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Am Fam Physician. 1998;57(8):1942-1945

Percutaneous transluminal coronary angioplasty (PTCA) is more widely used for revascularization following acute myocardial infarction than intravenous thrombolytic therapy, and PTCA seems to have the advantage of higher initial reperfusion rates. Weaver and associates combined data from trials of PTCA and thrombolytic therapy to determine each treatment's effect on death, rein-farction, major bleeding, total stroke and hemorrhagic stroke.

A literature search of MEDLINE and queries to principal investigators identified 10 randomized trials that compared PTCA and thrombolytic therapy. The only criterion for inclusion in the analysis was the use of PTCA or any course of intravenous thrombolytic therapy. These studies yielded data on 2,606 patients.

A total of 1,290 patients underwent PTCA. Of the 1,316 who received thrombolytic therapy, 307 received streptokinase, 300 received a three- or four-hour infusion of tissue-type plasminogen activator (t-PA), and 709 received a rapid infusion of t-PA.

The risk of death was significantly lower in patients undergoing PTCA (odds ratio: 0.66). The mortality rate at 30 days or less was 4.4 percent in the PTCA group, compared with 6.5 percent in the thrombolytic therapy group. The rate of nonfatal reinfarction was 5.4 percent for PTCA and 2.8 percent for thrombolytic therapy. The pooled rates of death or nonfatal reinfarction were 7.2 percent for PTCA and 11.9 percent for thrombolytic therapy. The total rate of stroke also was lower in the PTCA group, as was the rate of hemorrhagic stroke. The rate of hemorrhagic stroke was highest in patients receiving t-PA, although major bleeding rates were similar for PTCA and thrombolysis (8.8 percent and 8.4 percent, respectively).

The authors conclude that PTCA appears to be superior to thrombolytic therapy for treatment of acute myocardial infarction. They note that their retrospective meta-analysis has limitations because of differences, including the way PTCA was performed, in the treatments utilized in the trials they evaluated. The authors state that long-term assessment of outcomes is needed, and individual hospitals must examine their own results to determine if PTCA should be favored over thrombolytic therapy in their institution.

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Copyright © 1998 by the American Academy of Family Physicians.

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