Primary percutaneous coronary angioplasty: A protagonist's view

Abstract

The wide variety of reperfusion strategies now available has led to confusion regarding the optimal therapy of patients with acute myocardial infarction. In assessing the comparative efficacy of reperfusion strategies, safety factors, recanalization rates, reocclusion rates, myocardial salvage and improvement in survival must be compared. In this analysis, primary percutaneous transluminal coronary angioplasty (PTCA) compares favorably to intravenous thrombolytic therapy or combination PTCA and thrombolytic therapy as a reperfusion strategy. Primary PTCA has not been reported to cause intracerebral hemorrhage, whereas thrombolytic strategies are associated with an incidence of a 0.2 to 1.4% rate of intracerebral bleeding. Strategies using PTCA have recanalization rates of only 33 to 75%. Disappointingly, a major failure of all reperfusion strategies (including primary PTCA) is a high rate of reocclusion and reinfarction. Primary PTCA is associated with a 7 to 16% increase in global ejection fraction. Similar improvement in ejection fraction has not been demonstrated in patients treated with thrombolytic therapy alone. Although in-hospital mortality is improved, a substantial 1-year mortality persists for intravenous thrombolytic therapy. Long-term survival is greater when PTCA therapy is used. In addition, PTCA does favorably improve survival in high-risk patients with cardiogenic shock. Although it is unlikely that most patients with acute myocardial infarction will have primary PTCA as a treatment option, this therapy remains extremely attractive for centers where primary PTCA is readily available.