CLINICAL STUDY
A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction
The air primary angioplasty in myocardial infarction study
Cindy L. Grines, MD, FACC*,*,
Donald R. Westerhausen, Jr, MD, FACC  ,
Lorelei L. Grines, PhD*,
J. Timothy Hanlon, MD, FACC,
Timothy L. Logemann, MD, FACC ,
Matti Niemela, MD||,
W. Douglas Weaver, MD, FACC¶,
Marianne Graham, RN*,
Judith Boura, MS*,
William W. O’Neill, MD, FACC*,
Carlos Balestrini, MD# Air PAMI Study Group
* Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan, USA
Division of Cardiology, St. Joseph Medical Center, South Bend, Indiana, USA
Division of Cardiology, St. Charles Hospital, Bend, Oregon, USA
Division of Cardiology Wausau Hospital, Wausau, Wisconsin, USA
|| Division of Cardiology, Oulu University Hospital, Oulu, Finland
¶ Division of Cardiology, Henry Ford Hospital, Detroit, Michigan, USA
# Division of Cardiology, Instituto Modelo de Cardiologia, Cordoba, Argentina
Manuscript received October 16, 2001;
revised manuscript received February 5, 2002,
accepted March 13, 2002.
* Reprint requests and correspondence: Dr. Cindy L. Grines, William Beaumont Hospital, Cardiology Administration, 3rd Floor, Heart Center, 3601 West Thirteen Mile Road, Royal Oak, Michigan, USA 48073-6769.
cgrines{at}beaumont.edu
OBJECTIVES: The Air Primary Angioplasty in Myocardial Infarction (PAMI) study was designed to determine the best reperfusion strategy for patients with high-risk acute myocardial infarction (AMI) at hospitals without percutaneous transluminal coronary angioplasty (PTCA) capability.
BACKGROUND: Previous studies have suggested that high-risk patients have better outcomes with primary PTCA than with thrombolytic therapy. It is unknown whether this advantage would be lost if the patient had to be transferred for PTCA, and reperfusion was delayed.
METHODS: Patients with high-risk AMI (age >70 years, anterior MI, Killip class II/III, heart rate >100 beats/min or systolic BP <100 mm Hg) who were eligible for thrombolytic therapy were randomized to either transfer for primary PTCA or on-site thrombolysis.
RESULTS: One hundred thirty-eight patients were randomized before the study ended (71 to transfer for PTCA and 67 to thrombolysis). The time from arrival to treatment was delayed in the transfer group (155 vs. 51 min, p < 0.0001), largely due to the initiation of transfer (43 min) and transport time (26 min). Patients randomized to transfer had a reduced hospital stay (6.1 ± 4.3 vs. 7.5 ± 4.3 days, p = 0.015) and less ischemia (12.7% vs. 31.8%, p = 0.007). At 30 days, a 38% reduction in major adverse cardiac events was observed for the transfer group; however, because of the inability to recruit the necessary sample size, this did not achieve statistical significance (8.4% vs. 13.6%, p = 0.331).
CONCLUSIONS: Patients with high-risk AMI at hospitals without a catheterization laboratory may have an improved outcome when transferred for primary PTCA versus on-site thrombolysis; however, this will require further study. The marked delay in the transfer process suggests a role for triaging patients directly to specialized heart-attack centers.
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Abbreviations and Acronyms
| | AMI | | acute myocardial infarction | | BP | | blood pressure | | CABG | | coronary artery bypass graft surgery | | CI | | confidence interval | | ECG | | electrocardiogram | | MACE | | major adverse cardiac events | | OR | | odds ratio | | PAMI | | Primary Angioplasty in Myocardial Infarction study | | PTCA | | percutaneous transluminal coronary angioplasty |
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Evolving strategies in the treatment of acute myocardial infarction in the community hospital setting
J. Am. Coll. Cardiol.,
August 20, 2003;
42(4):
642 - 645.
[Full Text]
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M. K. Natarajan and S. Yusuf
Primary angioplasty for ST-segment elevation myocardial infarction: Ready for prime time?
Can. Med. Assoc. J.,
July 8, 2003;
169(1):
32 - 35.
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C. L. Grines, P. Serruys, and W. W. O'Neill
Fibrinolytic Therapy: Is It A Treatment of the Past?
Circulation,
May 27, 2003;
107(20):
2538 - 2542.
[Full Text]
[PDF]
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E. J. Topol and D. J. Kereiakes
Regionalization of Care for Acute Ischemic Heart Disease: A Call for Specialized Centers
Circulation,
March 25, 2003;
107(11):
1463 - 1466.
[Full Text]
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C. L. Grines
Reply
J. Am. Coll. Cardiol.,
February 5, 2003;
41(3):
518 - 519.
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B. Silverman
Safety and benefits of transferring patients with acute myocardial infarction to interventional center for immediate angioplasty
J. Am. Coll. Cardiol.,
February 5, 2003;
41(3):
518 - 518.
[Full Text]
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C. Pechlaner and R. Bellmann
Patients with high-risk acute myocardial infarction randomized to one of two treatment strategies: delay and eligibility questions
J. Am. Coll. Cardiol.,
February 5, 2003;
41(3):
518 - 518.
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F Zijlstra
Angioplasty vs thrombolysis for acute myocardial infarction: a quantitative overview of the effects of interhospital transportation
Eur. Heart J.,
January 1, 2003;
24(1):
21 - 23.
[Full Text]
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Is It Best to Transfer AMI Patients for Angioplasty?
Journal Watch Emergency Medicine,
August 14, 2002;
2002(814):
6 - 6.
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Primary Angioplasty Beats Thrombolysis in High-Risk Acute-MI Patients
Journal Watch Cardiology,
August 2, 2002;
2002(802):
5 - 5.
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Treatment for Acute MI: Thrombolytic Therapy or Transfer for Primary Angioplasty?
Journal Watch (General),
June 28, 2002;
2002(628):
4 - 4.
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C. P. Cannon and D. S. Baim
Expanding the reach of primary percutaneous coronary intervention for the treatment of acute myocardial infarction
J. Am. Coll. Cardiol.,
June 5, 2002;
39(11):
1720 - 1722.
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