Christopher Nunn

Long-term outcome after primary angioplasty: report from the Primary Angioplasty in Myocardial Infarction (PAMI-I) trial

OBJECTIVES This study sought to compare the two-year outcome after primary percutaneous coronary angioplasty or thrombolytic therapy for acute myocardial infarction. BACKGROUND Primary angioplasty, that is, angioplasty without antecedent thrombolytic therapy, has been shown to be an effective reperfusion modality for patients suffering an acute myocardial infarction. This report reviews the two-year clinical outcome of patients randomized in the Primary Angioplasty in Myocardial Infarction trial. METHODS At 12 clinical centers, 395 patients who presented within 12 h of the onset of myocardial infarction were randomized to undergo primary angioplasty (195 patients) or to receive tissue-type plasminogen activator (t-PA) (200 patients) followed by conservative care. Patients were followed by physician visits, phone call, letter and review of hospital records for any hospital admission at one month, six months, one year and two years. RESULTS At two years, patients undergoing primary angioplasty had less recurrent ischemia (36.4% vs. 48% for t-PA, p = 0.026), lower reintervention rates (27.2% vs. 46.5% for t-PA, p < 0.0001) and reduced hospital readmission rates (58.5% vs. 69.0% for t-PA, p = 0.035). The combined end point of death or reinfarction was 14.9% for angioplasty versus 23% for t-PA, p = 0.034. Multivariate analysis found angioplasty to be independently predictive of a reduction in death, reinfarction or target vessel revascularization (p = 0.0001). CONCLUSIONS The initial benefit of primary angioplasty performed by experienced operators is maintained over a two-year follow-up period with improved infarct-free survival and reduced rate of reintervention.

Long-term mortality after primary percutaneous coronary intervention for high-risk myocardial infarction.

BACKGROUND Primary percutaneous coronary intervention (PPCI) has evolved, including the introduction of stents and platelet glycoprotein IIb/IIIa receptor inhibitors (GPI). The effects of these changes and other variables on long-term survival for a single-centre service were studied. METHODS A prospective database of clinical and angiographic variables were kept for patients treated with PPCI in Waikato Hospital from 1996 to 2006 (n=527). This was analysed with long-term mortality data. Survival was recorded using Kaplan-Meier curves. Multivariate analysis of factors at presentation, including ethnicity was performed. RESULTS 5, 8 & 10-year survival rates were 76.5% (n=274), 72.7% (n=125) & 71.0% (n=19) respectively. Increased stent (42.8% vs. 84.1%, p<0.001) and GPI (39.6% vs. 73.3%, p<0.001) use was seen between early and late stages of the study. Stent use was associated with greater 5-year survival (80.5% vs. 70.8%, p=0.02), but GPI use was not. Multivariate analysis showed stent use independently predicted reduced mortality. Age, Maori ethnicity, renal failure and cardiogenic shock predicted higher mortality. CONCLUSIONS Survival after PPCI remains high long-term. Stent and GPI use significantly increased. Stent, but not GPI, use was associated with improved survival. Maori ethnicity was under-represented in the study and is associated with worse long-term outcomes after myocardial infarction (MI).

Percutaneous transluminal coronary angioplasty: refining standards for good practice

Highly competent doctors often differ on what constitutes good medical practice. This is especially true in areas where clinical trial data are scanty. The problem of selecting the best treatment is exacerbated by pressures created by conflicting interests. On the one hand demanding patients, optimistic industry projections, and financial incentives encourage overuse of high-tech equipment. Alternatively, doctors may be overly timid due to overzealous peer review, threat of litigation, cost-containment or plain ignorance. Quite appropriately, cardiologists look to their professional societies for guidance. For more than a decade, the American College of Cardiology and the American Heart Association have combined to generate a series of Task Force reports setting out guidelines on a wide range of topics. Acknowledged experts, from various cardiology backgrounds, write a consensus opinion on the current standard of practice. Speculation, personal interest, and marketing issues are avoided. These reports are regularly updated. The first set of Guidelines for Percutaneous Transluminal Coronary Angioplasty were published in 1988 [I]. There was then no area more in need of consensus development because a lack of trial data had led to widely differing practice habits affecting large numbers of high-risk patients, costly procedures and repercussions involving the whole healthcare system. These first guidelines detailed areas where there was general agreement on coronary angioplasty being indicated (Class I) and contraindicated (Class III) as well as areas where there was lesser agreement (Class II). The panelists considered these indications as falling into categories of single vessel disease, multivessel disease and during hospitalization for acute myocardial infarction. While appropriately leaving some issues unanswered (e.g., prevention of restenosis, need for complete revascularization), the panel was unequivocally clear on the need for in-house surgical backup and valid peer review within each institution performing coronary angioplasty. Since 1988, coronary angioplasty use has doubled in the United States and now exceeds 300 000 cases per year. It is being widely applied around the world, not only in the so-called developed countries, but also in lesser developed but highly populated countries such as India and China.