OUTCOME OF DIFFERENT REPERFUSION STRATEGIES IN PATIENTS WITH FORMER CONTRAINDICATIONS TO THROMBOLYTIC THERAPY - A COMPARISON OF PRIMARY ANGIOPLASTY AND TISSUE-PLASMINOGEN ACTIVATOR

High-risk patients have been excluded from most thrombolytic trials be cause of concern over hemorrhagic complications or lack of efficacy. H owever, based on several recent studies suggesting that patients with relative thrombolytic contraindications may also benefit from reperfus ion, recommendations have been made to broadly expand the eligibility criteria for thrombolytic therapy, despite higher absolute complicatio n rates. Primary percutaneous transluminal coronary angioplasty (PTCA) may be an attractive alternative for patients presenting at appropria tely equipped hospitals who would otherwise remain at high risk after thrombolytic therapy. In the Primary Angioplasty in Myocardial Infarct ion (PAMI) trial, 395 patients with acute myocardial infarction were r andomized to tissue plasminogen activator (t-PA) or primary PTCA Condi tions were present in 151 patients (38%) which formerly would have con traindicated thrombolytlc therapy (age >70 yr, symptom duration >4 hr, or prior bypass surgery). In-hospital mortality was 4.3-fold higher i n patients with former thrombolytic contraindications compared to lyti c-eligible patients (8.6% vs. 2.0%, P = .002). Lytic-eligible patients treated with t-PA and PTCA had similar in-hospital mortality (1.7% vs . 2.4%, P = NS). In contrast, both in-hospital (2.9% vs. 13.2%, P = .0 25) and 6-mo mortality (2.9% vs. 15.7%, P = .009) were significantly r educed in patients with former thrombolytic contraindications treated by primary PTCA compared to t-PA. By logistic regression analysis, tre atment by PTCA rather than t-PA was the strongest predictor of surviva l in patients with former thrombolytic contraindications. We conclude that patients with conditions formerly contraindicating thrombolytic t herapy constitute a high-risk group with significant morbidity and mor tality after lytic reperfusion. Our data suggest that patients with fo rmer contraindications to thrombolytic therapy may benefit by preferen tial management with primary PTCA without antecedent thrombolysis. (C) 1996 Wiley-Liss, Inc.