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Little Difference Between Prehospital Fibrinolysis Or Emergency Angioplasty For MI

Little difference in treatment outcome for myocardial infarction between prehospital fibrinolysis or emergency angioplasty has been found in a multicentre trial by French clinicians.

Although prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis, these two strategies for the treatment of severe MI have not been directly compared, points out Dr. Eric Bonnefoy and colleagues from University Hospital, Lyon, France.

The trial was coordinated by the Hospices Civils de Lyon, among 27 French tertiary hospitals and their affiliated mobile emergency-care units. Each hospital was required to have experience in routine primary angioplasty for myocardial infarction and to have a 24 hour on-call angioplasty team available.

The randomized trial was among 840 patients who had experienced a severe MI, usually at home or at work. They had presented within six hours of acute myocardial infarction with ST-segment elevation and were initially managed by the mobile emergency-care units.

Patients were randomly allocated to receive pre-hospital fibrinolysis with alteplase, or emergency angioplasty on arrival at hospital. Patients assigned to pre-hospital fibrinolysis were scheduled to undergo complementary rescue emergency angioplasty if the initial treatment was suspected to have failed.

Dr. Bonnefoy and colleagues found no statistically significant differences between the two treatment strategies in the main outcome measures: death, recurrence of MI, or disabling stroke, within one month of treatment. Rescue angioplasty was done in 26 percent of the patients in the fibrinolysis group.

At the same time, the clinicians said they found trends suggesting increased risk of MI recurrence and stroke among patients given fibrinolytic therapy. As expected, it took longer to administer angioplasty--just over three hours on average--than fibrinolytic therapy which took two hours on average.

Dr. Bonnefoy and colleagues conclude that based on their data, the potential exists for further reductions in rates of mortality and recurrent infarction after both primary angioplasty and fibrinolysis. "The benefit of fibrinolysis might be increased by the association with low-molecular-weight heparin or glycoprotein IIb/IIIa receptor antagonists," they say.
Lancet 2002; 360: 825-29

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