Thomas Aversano, M.D., and colleagues conducted a multi-center, randomized trial (the Atlantic C-PORT study) from July 1996 through December 1999 to determine whether treatment of acute myocardial infarction with primary percutaneous coronary intervention results in better outcomes than thrombolytic therapy at hospitals that do not have on-site cardiac surgery.

According to background information, trials comparing primary percutaneous interventions with thrombolytic therapy suggest primary percutaneous coronary intervention is the superior therapy, although the studies differ with respect to durability of benefit. Because the invasive procedure is usually limited to hospitals that have on-site cardiac surgery programs, many patients with acute myocardial infarctions do not have access to the procedure.

The Atlantic C-PORT trial began by implementing primary percutaneous intervention training programs at 11 hospitals without on-site cardiac surgical facilities. "Primary percutaneous coronary intervention, rather than being simply a procedure performed by an expert interventionist, is instead a strategy of care involving a team of health care personnel in multiple care areas, including the emergency department, coronary care unit, cardiac catheterization laboratory, and ideally, the pre-hospital transport system," the authors write.

After the training program was completed, 226 patients with acute myocardial infarction were randomly assigned to receive tissue plasminogen activator and 225 were assigned to undergo primary percutaneous intervention. The authors evaluated the composite endpoint of death, recurrent infarction, or stroke at six months following treatment.

"The incidence of the composite end point was reduced in the primary percutaneous intervention group at six weeks (10.7 percent vs. 17.7 percent) and six months (12.4 percent vs. 19.9 percent) after index myocardial infarction," the authors write.

"Six-month rates for individual outcomes were 6.2 percent vs. 7.1 percent for death, 5.3 percent vs. 10.6 percent for recurrent infarction, and 2.2 percent vs. 4.0 percent for stroke for primary percutaneous coronary intervention versus thrombolytic therapy, respectively," they report.

"Median length of stay was also reduced in the primary percutaneous coronary intervention group (4.5 days vs. 6.0 days)," they write. "This trial demonstrates that, after an extensive development program, primary percutaneous coronary intervention can be performed safely, promptly, and effectively in the community hospital without an elective percutaneous intervention or cardiac surgery program," the authors conclude.

"Compared with thrombolytic therapy, treatment of patients with primary percutaneous coronary intervention at hospitals without on-site cardiac surgery is associated with better clinical outcomes for six months after index myocardial infarction and a shorter hospital stay."

In an accompanying editorial, Christopher P. Cannon, M.D., of Brigham and Women's Hospital and Harvard Medical School, Boston, writes that more than 15 trials now show a clear benefit of percutaneous coronary intervention over thrombolytic therapy.

"The implications of these trials are profound. The first is that if a community hospital makes a strong institutional commitment to establishing a comprehensive program, performance of primary percutaneous coronary intervention is beneficial to patients," he writes. "This commitment must involve all levels of caregivers, including the emergency medical services, nurses, physicians, and cardiac catheterization laboratory personnel, such that the overall program can be implemented with as high a quality as was conducted in the Atlantic C-PORT study."

"Second, the related positive data on transfer of patients for primary percutaneous coronary intervention suggest that it is time to change the approach of the emergency medical response system for acute myocardial infarction," he continues. "It has been the practice that patients with acute myocardial infarction should be transported to the nearest acute care hospital so that they can be stabilized and treated appropriately. However, given the results of these 5 recent trials, and the 12 that preceded them, this approach may need to be modified so that patients should be transferred to a cardiac center that offers primary percutaneous coronary intervention as the optimal reperfusion strategy."

"The time is now to re-evaluate the optimal approach to treatment of patients with acute myocardial infarction, with an interventional approach appearing to be the optimal strategy. The task for cardiologists and other physicians is to make the best possible therapy available to every patient with acute myocardial infarction," he concludes.