Transfer for primary angioplasty: who and how? (Review).

Randomised trials have led to the conclusion that percutaneous coronary intervention (PCI) is the best reperfusion strategy for most patients with acute myocardial infarction (AMI). However, these trials have limited application to routine practice. Modern trials of mechanical reperfusion strategies need to take account of logistics, transfer times, and adjunctive drug treatment during transfer (facilitated PCI). Such PCI protocols need to be judged against very early thrombolysis with modern agents. This has been the thrust behind a series of recent studies addressing these "real world' issues in early AMI management

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At present, for most patients with acute myocardial infarction (AMI), percutaneous coronary intervention (PCI) is the best reperfusion strategy. (1) The randomised trials reaching this conclusion were conducted at experienced interventional centres, without long transfer times. However, even in the best resourced health care systems, only a minority of patients with AMI present initially to such centres. Furthermore, in these early trials patients were randomly assigned to PCI or thrombolysis at the interventional centres, thus precluding early domiciliary or ambulance thrombolysis and potentially therefore underestimating the benefit of expeditious pharmacological reperfusion. These factors limit the degree to which the trial conclusions can be applied in routine practice. Modern trials of mechanical reperfusion strategies need to take account of logistics, transfer times, and adjunctive drug treatment during transfer (facilitated PCI). Such PCI protocols need to be judged against very early thrombolysis wit h modern agents. This has been the thrust behind a series of recent studies addressing these "real world" issues in early AMI management (table 1).

TRANSFER FOR PRIMARY PCI OR LOCAL THROMBOLYSIS?

The PRAGUE (primary angioplasty in patients transferred from general community hospitals to specialised PTCA units with or without emergency thrombolysis) trial compared three reperfusion strategies for patients within six hours of myocardial infarction presenting at hospitals without PCI facilities: local thrombolytic treatment with streptokinase (n = 99), thrombolytic treatment during transfer for PCI (n = 100), and transfer for PCI without thrombolysis (n = 101). The combined end point of death/reinfarction/stroke at 30 days was reached by 23% of the local thrombolytic group, 15% of the thrombolysis during transfer group, and 8% of the transfer without thrombolysis group (p < 0.02). Reinfarction was greatly reduced in the latter group (1%) compared with the local thrombolytic group (10%) and the thrombolysis during transfer group (7%) (p < 0.03). (2) This study supports the superiority of PCI over thrombolysis in real world scenarios. It furthermore suggests that…