Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction

Background As compared with thrombolytic therapy, primary coronary angiopla sty results in a higher rate of patency of the infarct-related coronary art ery, lower rates of stroke and reinfarction, and higher in-hospital or 30-d ay survival rates. However, the comparative long-term efficacy of these two approaches has not been carefully studied. Methods We randomly assigned a total of 395 patients with acute myocardial infarction to treatment with angioplasty or intravenous streptokinase. Clin ical information was collected for a mean (+/-SD) of 5+/-2 years, and medic al charges associated with the two treatments were compared. Results A total of 194 patients were assigned to undergo primary angioplast y, and 201 to receive streptokinase. Mortality was 13 percent in the angiop lasty group, as compared with 24 percent in the streptokinase group (relati ve risk, 0.54; 95 percent confidence interval, 0.36 to 0.87). Nonfatal rein farction occurred in 6 percent and 22 percent of the two groups, respective ly (relative risk, 0.27; 95 percent confidence interval, 0.15 to 0.52). The combined incidence of death and nonfatal reinfarction was also lower among patients assigned to angioplasty than among those assigned to streptokinas e, with a relative risk of 0.13 (95 percent confidence interval, 0.05 to 0. 37) for early events (within the first 30 days) and a relative risk of 0.62 (95 percent confidence interval, 0.43 to 0.91) for late events (after 30 d ays). The rates of readmission for heart failure and ischemia were also low er among patients in the angioplasty group than among patients in the strep tokinase group. Total medical charges per patient were lower in the angiopl asty group ($16,090) than in the streptokinase group ($16,813, P=0.05). Conclusions As compared with thrombolytic therapy with streptokinase, prima ry coronary angioplasty is associated with better clinical outcomes over fi ve years. (N Engl J Med 1999;341:1413-9.) (C)1999, Massachusetts Medical So ciety.