Primary Angioplasty (POBA) vs Thrombolysis

Abstract

The reperfusion era for acute myocardial infarction (AMI) began when Rentrop and colleagues demonstrated in 1979 that an acutely occluded coronary artery could be successfully recanalized with the combination of mechanical intervention with a guidewire and pharmacologic intervention with the infusion of intracoronary streptokinase (1). Multiple clinical trials subsequently demonstrated the effectiveness and survival benefit of intravenous streptokinase, and thrombolytic therapy became the standard of care as reperfusion therapy for AMI in the late 1980s and 1990s (2–4). During the same time period, Hartzler and others demonstrated that mechanical reperfusion with primary angioplasty was also a highly effective strategy (5–7). While it was clear that primary angioplasty had certain advantages over thrombolytic therapy in achieving greater patency rates and avoiding the life-threatening complication of intracranial hemorrhage, primary angioplasty did not become a competitive reperfusion strategy until the early 1990s with the publication of the Primary Angioplasty in Myocardial Infarction (PAMI) and Zwolle trials (8,9). The 1990s have produced a number of randomized trials that provide meaningful comparisons between primary angioplasty (performed in the pre-stent era with plain old balloon angioplasty [POBA]) and first-and second-generation thrombolytic therapy (streptokinase, tissue plasminogen activator [t-PA], and accelerated t-PA).