Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction - CAPTIM

Description:

The authors sought to evaluate whether primary angioplasty was better than prehospital fibrinolysis in the treatment of acute myocardial infarction

Study Design

Study Design:

Drug/Procedures Used:

This study was a randomised multicentre trial of 840 patients who presented within 6 hr of acute ST-segment elevation myocardial infarction. Patients were assigned either to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and all patients were transferred to a centre with access to emergency angioplasty. The primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days.

Principal Findings:

The incidence of the primary endpoint was 8.2% (34 patients) in the prehospital-fibrinolysis group and 6.2% (26 patients) in the primary-angioplasty group (risk difference 1.96, 95% CI -1.53 to 5.46). There were sixteen (3.8%) deaths among patients assigned prehospital fibrinolysis and 20 (4.8%) among those assigned primary angioplasty (p=0.61).

Interpretation:

The authors concluded that a strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with acute myocardial infarction. The optimal treatment strategy for treatment of patients with acute ST-segment elevation myocardial infarction continues to evolve. In this study, the authors found a strategy of primary angioplasty was not statistically better than a strategy of prehospital fibrinolysis in the management of these patients. The CAPTIM trial actually compared the strategies of early fibrinolysis, transfer to a centre with interventional facilities, and liberal use of rescue angioplasty versus primary angioplasty. Of the patients treated with prehospital fibrinolysis, 26% underwent rescue PCI. The results of the trial are difficult to interpret because the trial ended before the planned recruitment of 1200 patients due to funding issues. Thus, the published analysis is significantly underpowered. Nevertheless, the results demonstrate a 24% relative reduction (a non-significant trend) in the occurrence of adverse events favoring the interventional strategy, driven by strong reductions in reinfarction and stroke. Based on available data including reports from DANAMI-2, PRAGUE-2, and now CAPTIM, the optimal treatment strategy for patients with acute ST-elevation MI appears to be appropriate initial antiplatelet and antithrombotic therapy and transfer to an interventional facility capable of PCI.

References:

Lancet 2002; 360 (9336):825-829

Clinical Topics: Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Lipid Metabolism

Keywords: Thrombolytic Therapy, Myocardial Infarction, Stroke, Fibrinolysis, Fibrinolytic Agents, Tissue Plasminogen Activator, Angioplasty


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