BMJ  2004;328:1256-1257 (22 May), doi:10.1136/bmj.328.7450.1256

Education and debate

For and against

Primary angioplasty should be first line treatment for acute myocardial infarction

AGAINST

Royal Hallamshire Hospital, Sheffield S10 2JF kevin.channer@sth.nhs.uk

The UK government is considering establishing a national primary angioplasty service for patients with acute myocardial infarction. David Smith and Kevin Channer debate whether moving away from first line thrombolysis is appropriate or practical

The first 150 words of the full text of this article appear below.

Thrombolysis is the established treatment for patients with an acute ST segment elevation myocardial infarction based on large trials in the past two decades.¹ Studies show that treatment within an hour after onset of symptoms results in a 6.5% absolute reduction in mortality compared with placebo; this benefit falls quickly with time to 3.7% at 1-2 hours, 2.6% at 2-3 hours, 2.9% at 3-6 hours, 1.8% at 6-12 hours, and 0.9% at 12-24 hours.² However, thrombolysis also causes an absolute increase in stroke of 0.4% (half of which are fatal), an absolute increase of 0.7% in major non-cerebral bleeds, and a 3% increase in early non-fatal reinfarction.¹

Although thrombolysis saves lives in hospital, it has no later benefits; the survival curves of patients given placebo or thrombolysis exactly superimpose after 35 days, or even after discharge from hospital.^{3 4} The mechanism for the reduction in hospital mortality is unclear since all . . . [Full text of this article]

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