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ANGIOPLASTY OR MEDICAL THERAPY IMMEDIATELY AFTER HEART ATTACK? (p 814, 825 )
September 11, 2002Authors of a study in this week’s issue of THE LANCET suggest that there is no difference in treatment outcome of pre-hospital medical therapy with anti-clotting drugs or emergency angioplasty after severe heart attack.
Although the use of anti-clotting drugs before hospital admission (prehospital fibrinolysis) and primary angioplasty (widening of the coronary arteries with balloon inflation) provide a clinical benefit over the use of anti-clotting drugs given to patients in hospital, these two strategies for the treatment of severe heart attack have not been directly compared.
Eric Bonnefoy and colleagues from University Hospital, Lyon, France, did a randomised multicentre trial of 840 patients who had experienced a severe heart attack; usually this had occurred at home or at work. Patients were randomly allocated to receive pre-hospital fibrinolysis (with the anti-clotting drug alteplase), or were given emergency angioplasty on arrival at hospital. All patients were transferred to a centre with access to emergency angioplasty. Patients assigned to pre-hospital fibrinolysis were scheduled to undergo complementary emergency angioplasty (“rescue”) if the initial treatment was suspected to have failed.
There were no statistically significant differences between the two treatment strategies in the main outcome measures of the study (death, recurrence of heart attack, or disabling stroke, within one month of treatment); although there were trends suggesting increased risk of heart-attack recurrence and stroke among patients given fibrinolytic therapy. As expected, it took longer to administer angioplasty (just over three hours on average) than fibrinolytic therapy (two hours). Around a quarter of patients randomised to receive fibrinolytic therapy underwent subsequent emergency “rescue” angioplasty.
Despite no difference in mortality outcome in Bonnefoy and colleagues’ study, Greg Stone from Lenox Hill Heart and Vascular Institute, New York, USA, in an accompanying Commentary (p 814) asserts that, taken together, all the available evidence is a ‘wake-up call’ for early intervention. He concludes: “…the best therapy for most patients with evolving AMI [acute myocardial infarction] should no longer be debated: administer antiplatelet therapy (aspirin, a thienopyridine and possibly abciximab), withhold thrombolytic therapy, and transfer the patient for primary PTCA [angioplasty], regardless of whether the nearest catheterisation suite is three floors or 3 h away. To do less should no longer be considered standard care. Strong words, yes, but it is time for a wake-up call.”
Lancet
There were no statistically significant differences between the two treatment strategies in the main outcome measures of the study (death, recurrence of heart attack, or disabling stroke, within one month of treatment); although there were trends suggesting increased risk of heart-attack recurrence and stroke among patients given fibrinolytic therapy. As expected, it took longer to administer angioplasty (just over three hours on average) than fibrinolytic therapy (two hours). Around a quarter of patients randomised to receive fibrinolytic therapy underwent subsequent emergency “rescue” angioplasty.
Despite no difference in mortality outcome in Bonnefoy and colleagues’ study, Greg Stone from Lenox Hill Heart and Vascular Institute, New York, USA, in an accompanying Commentary (p 814) asserts that, taken together, all the available evidence is a ‘wake-up call’ for early intervention. He concludes: “…the best therapy for most patients with evolving AMI [acute myocardial infarction] should no longer be debated: administer antiplatelet therapy (aspirin, a thienopyridine and possibly abciximab), withhold thrombolytic therapy, and transfer the patient for primary PTCA [angioplasty], regardless of whether the nearest catheterisation suite is three floors or 3 h away. To do less should no longer be considered standard care. Strong words, yes, but it is time for a wake-up call.”
Lancet
Angioplasty Current Events and Angioplasty News RSSYour Own Stem Cells Can Treat Heart Disease
The largest national stem cell study for heart disease showed the first evidence that transplanting a potent form of adult stem cells into the heart muscle of subjects with severe angina results in less pain and an improved ability to walk. The transplant subjects also experienced fewer deaths than those who didn't receive stem cells.
Vitamin B niacin offers no extra benefit to statin therapy in seniors already diagnosed with CAD
The routine prescription of extended-release niacin, a B vitamin (1,500 milligrams daily), in combination with traditional cholesterol-lowering therapy offers no extra benefit in correcting arterial narrowing and diminishing plaque buildup in seniors who already have coronary artery disease, a new vascular imaging study from Johns Hopkins experts shows.
The heart attack myth: Study establishes that women do have same the heart attack symptoms as men
The gender difference between men and women is a lot smaller than we've been led to believe when it comes to heart attack symptoms.
Lifestyle changes remain important in fighting peripheral arterial disease
Modifying the risk of peripheral arterial disease (or PAD)-with healthy lifestyle changes-remains vital to one's health, note researchers in a recent issue of the Journal of Vascular and Interventional Radiology.
Study questions need for routine intervention in patients with renovascular disease
Some invasive procedures that are becoming increasingly common as a first line of treatment for patients diagnosed with narrowed arteries in and around the kidneys may not be necessary.
Designing drugs and their antidotes together improves patient care
Imagine a surgical patient on a blood-thinning drug who starts bleeding more than expected, and an antidote that works immediately - because the blood thinner and antidote were designed to work together.
Pre-hospital organization: The first links in the chain of survival for heart attack patients
Mortality rate following a heart attack has fallen by more than 50% in Europe over the past 25 years. However, because only minor advances in the medical treatment of AMI are expected over the next decade, it is through organisational changes in the pre-hospital phase that mortality rate will continue this decline to below 5%.
Stent for life initiative
Primary angioplasty (with stent implantation) is the most effective therapy for acute myocardial infarction (AMI), but it is not available to many patients, even though most European countries have sufficient resources (ie, catheterisation laboratories) for its wider use.
Otamixaban for the treatment of patients with non-ST-elevation acute coronary syndromes
Data from a phase II trial of an investigational intravenous drug designed to block the formation of blood clots shows potential to reduce the risk of death, a second heart attack, or other coronary complications compared with the current standard of care in patients presenting with acute coronary syndromes (heart attacks or unstable angina).
New strategies for reperfusion therapy
A new trial has begun in order to ascertain once and for all whether the best strategy for patients who cannot receive P-PCI is early fibrinolysis, together with mandated angiography.
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