Reducing mortality in myocardial infarction

Editor—A short ambulance ride from the tertiary cardiac centre from where Townend and Doshi expound the virtues of prehospital thrombolysis plus early revascularisation lies a district hospital that has operated a policy of primary angioplasty for more than two years.¹

In this hospital, which is staffed by four cardiologists (see author list), more than 200 primary angioplasty procedures have been performed, with a 30 day mortality of 6.5%, reduced hospital lengths of stay, and a long term cost effectiveness that is comparable to thrombolysis. Although sometimes inconvenient, cases in truly unsocial hours (midnight to 8 00 am) represent only 20% of the total primary angioplasty burden.

Few now dispute the evidence for primary angioplasty.² As yet there are no robust data showing the superiority of prehospital thrombolysis over primary angioplasty. CAPTIM was not completed,³ and a quarter of the study population required rescue angioplasty for failed reperfusion. Townend and Doshi do not clearly state their position on the management of failed thrombolysis. GRACIA 1 merely shows that thrombolysed patients are probably better off with revascularisation before discharge rather than later, irrespective of whether ongoing ischaemia is shown (the open artery hypothesis).⁴ Several ongoing and planned trials will elucidate whether facilitated intervention (thrombolysis plus angioplasty within three to 12 hours) is superior to primary angioplasty.

Until the case for primary angioplasty is undermined in appropriate randomised trials perhaps we should be striving to introduce the optimal and proved strategy, concentrating on an evidence based rather than convenience based approach.