Primary angioplasty should be first line treatment for acute myocardial infarctionFOR

doi:10.1136/bmj.328.7450.1254

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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

FOR

David Smith, consultant cardiologist (dagobert@eurobell.co.uk)

Royal Devon and Exeter Hospital, Exeter EX2 5DW

There seems little doubt that acute ST elevation myocardial infarction is the result of coronary arterial occlusion and that myocardial necrosis can be limited by early restoration of normal antegrade blood flow. The relation between normal coronary artery blood flow and mortality after myocardial infarction is well documented. A meta-analysis of angiographic infarct trials showed normal flow was associated with a mortality of 3.7% compared with 6.6% (P = 0.0001) in patients with impaired flow and 9.2% (P = 0.0003) in patients with occluded or nearly occluded infarct related arteries.1 This relation extends to microvascular reperfusion so that mortality after myocardial infarction can be reduced to less than 1% if normal epicardial blood flow and myocardial perfusion are restored.2 The mortality benefits of restoring normal flow have been shown to extend up to 12 years.3 Early restoration of normal myocardial blood flow must therefore be the therapeutic goal of the management of acute myocardial infarction.

Angioplasty is more widely applicable

For the past 20 years there have been two methods for restoring blood flow. Thrombolysis (the current first line treatment) is pharmacological, can be applied to only 60-80% …