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Angioplasty shows better long term results than drug treatment

Scott Gottlieb New York

Heart attack victims who received primary angioplasty had much better long term survival and less likelihood of a second heart attack than patients who got thrombolytic therapy with intravenous streptokinase, according to new study (New England Journal of Medicine 1999;341:1413-9).

Several recent studies have already suggested that angioplasty provides better short term results than thrombolytic drugs. But long term comparisons of the two treatments, the most common first line treatments for heart attacks, have not been done.

The present study, led by Dr Felix Zijlstra of Weezenlander Hospital in the Netherlands, looked at a total of 395 patients with acute myocardial infarction who were randomly assigned to treatment with either angioplasty or intravenous streptokinase. Researchers followed their progress over five years after their initial admission to hospital.

Of the group, 194 patients were assigned to undergo primary angioplasty and 201 received streptokinase. Mortality was 13% in the angioplasty group compared with 24% in the streptokinase group. Non-fatal reinfarction occurred in 6% and 22% of the two groups respectively. The combined incidence of death and non-fatal reinfarction was also lower among patients assigned to receive angioplasty than among those assigned to streptokinase.

"I wouldn't say this ends the debate, but it is a pretty strong statement that angioplasty is better," said David Rutlen, professor and chief of cardiovascular medicine at the Medical College of Wisconsin. "This is a very good study."

The use of thrombolytic drugs initially is less expensive, but the study also found that the total medical costs for the angioplasty group, including readmissions and drugs, was slightly less expensive—$16 090 (£10 056), compared with $16 813.

The lower cost was mainly a result of a marked decrease in hospital readmissions for ischaemia after angioplasty compared with the streptokinase group.

An estimated 482 000 angioplasty procedures were performed in the United States in 1996, a 211% increase from 1987, according to data from the American Heart Association. The study was done in the Netherlands.

Previous studies have shown that primary angioplasty, when performed by experienced clinicians, restores normal blood flow (grade 3 flow, according to the thrombolysis in myocardial infarction (TIMI) classification) in 80-95% of patients.

This result compares favourably with the 50-70% of patients in whom normal flow is restored after thrombolytic therapy.

This latest study is not expected to be the final word on whether angioplasty or thrombolytic therapy is the best treatment. Although some previous studies have found that intravenous thrombolytic therapy lowers early mortality by an estimated 20% to 30%, others have suggested that there is little difference between the two treatments when they are performed under real world conditions (New England Journal of Medicine 1993;328:673-9, 680-4).

There has also been a suggestion that a combination of both treatments may produce the best results. The key advantage of giving anticlotting drugs is that most hospitals can use them, treatment can begin rapidly, and the success rate is not as dependent on the skill of the doctor as it is for angioplasty.

The authors note that their study may have suffered from several limitations. In contrast to multicentre trials that have included thousands of patients undergoing reperfusion therapy for acute myocardial infarction, the present study included only 395 patients from a single institution.
 
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Rapid Responses:

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