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.