The history of angioplasty therapy for acute myocardial infarction: buried alive but still kicking?

Angioplasty therapy for acute myocardial infarction (direct or primary coronary angioplasty) has been a hot issue of the medical literature since 1982. It was first presented as a rescue therapy in the case of failed intracoronary thrombolysis. Later it was described as a useful complement to thrombolysis before it emerged as a formidable alternative. For a number of years in the late 1980s, the advent of clot-specific intravenous thrombolysis swayed the spotlight from direct angioplasty on to the non-invasive active drug treatment. This was reversed by the appearance of several randomized studies demonstrating superiority of angioplasty in 1992. Later studies have put this advantage of angioplasty over thrombolysis in perspective again. It was found that the superior results of the randomized studies on selected patients could not be reproduced in everyday cases. Nonetheless, a small but significant advantage of primary angioplasty remains when all available literature is scrutinized carefully. Even if the results in terms of mortality and acute events during the initial hospital stay are quite comparable for thrombolysis and primary angioplasty, the latter removes the culprit clot, treats the underlying lesion, and informs about the general state of the coronary vasculature and the myocardium with unsurpassed details. Moreover, most patients with intravenous thrombolysis will undergo cardiac catheterization within the first year after their infarction. Thus, the facts that the initial savings of foregoing cardiac catheterization is lost and the cost of the thrombolytic drug can be spared with primary angioplasty may tilt the scale in favour of primary catheter intervention. As direct angioplasty establishes patency earlier and more completely than thrombolysis, a slightly better hospital course and markedly better long-term course with improved longevity, myocardial function, and fewer cardiac events can be achieved. This is not necessarily associated with a higher investment, because the initial surplus in cost of primary angioplasty tends to revert into savings over time. All patients amenable to direct angioplasty within 30-60 min after initial diagnosis should be offered the procedure. In the remaining cases, thrombolysis is the preferred treatment. The role of primary angioplasty is the more important the larger the infarction. However, in small infarctions but also in protracted cardiogenic shock it may be wasted, but so is any other aggressive treatment.