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Fibrinolytic Therapy and Coronary Revascularization

Am Fam Physician. 2003 Feb 15;67(4):809-810.

Most patients with acute myocardial infarction (MI) are treated at community hospitals that do not have coronary revascularization capabilities. Recent studies suggest that patients with acute MI who are admitted to tertiary-care hospitals have better clinical outcomes. In addition, small randomized trials have found that percutaneous transluminal coronary angioplasty (PTCA) is superior to thrombolytic therapy in the treatment of patients with acute MI. Based on these results, the ability to care for patients with acute MI would be limited to facilities that have these capabilities. Other studies have found no substantial survival benefit with PTCA when compared with thrombolytic therapy. Mehta and colleagues conducted a retrospective evaluation of clinical outcomes in patients with acute MI who were treated with fibrinolytic therapy in hospitals with and without coronary artery revascularization capabilities.

The authors analyzed the outcomes of patients enrolled in the Global Use of Streptokinase and TPA (alteplase) for Occluded Coronary arteries (GUSTO-1) trial. Patients with acute MI who presented to the 660 hospitals participating in the study were randomly assigned to receive one of four different thrombolytic regimens. Data were collected concerning the patients' medical history, family history, other treatments received, complications, procedures performed, and clinical events. Patients also were divided into those who received care at a hospital with coronary artery revascularization capabilities and those at hospitals without such capabilities. In addition, data were collected on patients who received initial care at hospitals without these capabilities but were transferred to such a facility, and at hospitals without these capabilities who did not transfer patients with acute MI.

Of the patients who met the inclusion criteria, 25,515 were enrolled in the study. The baseline characteristics of the two patient groups were similar, with no difference in complication rates. Patients admitted to hospitals with coronary artery revascularization capabilities underwent substantially more procedures, but the 30-day and one-year survival rates were similar between the two groups. Also, the rates of recurrent ischemia, reinfarction, congestive heart failure, shock, and stroke did not differ between the two hospital types.

The authors conclude that similar outcomes occur in patients with acute MI treated with fibrinolytic therapy regardless of whether the hospital has coronary artery revascularization capabilities, provided that appropriate candidates receive aspirin and beta-blocker therapy. Hospitals without revascularization capabilities must have the capacity to immediately transfer patients who need angiography or revascularization.

Mehta RH, et al. Patient outcomes after fibrinolytic therapy for acute myocardial infarction at hospitals with and without coronary revascularization capability. J Am Coll Cardiol. September 18, 2002;40:1034–40.


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