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When should patients with acute myocardial infarction be transferred for primary angioplasty?

The results of several randomised trials have shown superior outcomes with primary angioplasty for acute myocardial infarction compared to thrombolytic treatment.1-4 Primary angioplasty establishes TIMI-3 flow in the infarct artery in 93–97% of patients1 5 compared with 54% with accelerated t-PA.6 Pooled data from three randomised trials have shown lower hospital mortality (2.2% v 5.9%, p = 0.02) and less non-fatal re-infarction (1.9% v 8.1%, p = 0.001) in patients treated with primary angioplasty versus thrombolytic treatment.1-3 Intracranial haemorrhage, the most feared complication of thrombolysis, occurred significantly less often with primary angioplasty versus t-PA in both the PAMI-1 trial (0% v 2.0%, p = 0.05)1 and the GUSTO-IIB trial (0% v 1.4%, p = 0.008).4 In addition, several studies have documented shorter hospital stay and comparable or lower hospital costs with primary angioplasty.7-9 Because of these data, primary angioplasty has emerged as the preferred reperfusion strategy for acute myocardial infarction in institutions with interventional facilities and skilled operators.

The use of primary angioplasty is limited by the availability of facilities and technical staff to perform coronary interventional procedures. Fewer than 20% of hospitals in the United States, and fewer than 10% of hospitals in Europe have facilities to perform angioplasty, and not all of these institutions are prepared to perform the procedure …