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ACAD-AE-MED  September 2003

ACAD-AE-MED September 2003

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Subject:

Re: ECGs at the scene for thrombolysis

From:

Rowley Cottingham <[log in to unmask]>

Reply-To:

Accident and Emergency Academic List <[log in to unmask]>

Date:

Fri, 26 Sep 2003 13:21:00 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (68 lines)

I'm not sure I said it was superior, because as I explained,  they do different things. The clinical
picture of the patient is what matters. However, here is one snippet that show little benefit to
routine angioplasty, although it is not the specific article I was looking for:



BMJ 1996;313:1102 (2 November)

News
Angioplasty shows no benefit over thrombolysis
Angioplasty is no better than thrombolysis in acute myocardial infection, according to the
results from a major cohort study which look set to fuel the ongoing controversy about optimal
management.
US researchers found no difference in mortality during admission or long term follow up
between 1050 patients undergoing angioplasty and 2095 patients given thrombolysis (N Engl J
Med 1996;335:1253-60).

Patients were selected from a cohort of over 12 000 consecutive patients admitted with acute
myocardial infarction to 12 hospitals in Seattle between 1988 and 1994. Risk of death during
admission was 5.6% in patients given thrombolysis and 5.5% in those undergoing angioplasty.

Dr Nathan Every from the Northwest Health Services research and development field
programme at the Seattle Veterans Affairs Medical Center reported: "In a community setting, we
observed no benefit in terms of either mortality or the use of resources with a strategy of
primary angioplasty rather than thrombolytic therapy." He acknowledged that patients in the
study were not randomly assigned to treatment but argued that there were no substantial
differences in demographic or clinical characteristics between the two groups.

The primary therapeutic objective in a patient with an evolving Q wave myocardial infarction is
prompt restoration of blood flow in the occluded artery. Both immediate coronary angioplasty
and thrombolysis can restore flow in most occluded coronary arteries. In an accompanying
commentary Cindy Grines from the William Beaumont Hospital, Royal Oak, Michigan, argued
that angioplasty continues to have overwhelming advantages over thrombolysis. "Primary
angioplasty gives higher short and long term patency rates than those achieved with
thrombolysis, with reduced rates of recurrent ischaemia. It is also superior in reducing rates of
intracranial bleeding, reinfarction and death," she claimed.

However, in a second commentary, Richard Lange and David Hillis from the University of Texas
Southwestern Medical Center in Dallas argued that placebo controlled randomised trials in
almost 60 000 patients have shown that thrombolysis limits infarct size, improves left ventricular
function, and reduces mortality. Further studies in more than 100 000 subjects have confirmed
the efficacy and safety of thrombolytic agents, they said.

So what is the practical way forward for selecting the best management option for each patient
with a myocardial infarction? Dr Graham Jackson, consultant cardiologist at London's Guy's
Hospital, believes that a case cannot be made for primary angiography in the wider community.
"It seems an attractive idea that angioplasty should perhaps be better, and some studies have
shown benefits, but these have been in highly specialised units with low risk patients," he said.
"In contrast, this latest trial accurately reflects post-myocardial infarction management in the
real world."

> Dear Rowley,
>
> Would be grateful if you could provide the relevant references that
> thrombolysis is superior to primary angioplasty/PTCA.  Our colleagues in
> Japan and the US with whom we benchmark almost exclusively use
> angioplasty for management of their MIs.
>
> Anton

Best wishes,


Rowley Cottingham (currently laid up with coryza!)

[log in to unmask]
Visit the new and improved http://www.emergencyunit.com

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