The effectiveness of primary PTCA: does patient risk matter?

Ever since the introduction of primary angioplasty as a method for reperfusion in the setting of acute myocardial infarction in 1982, controversy has surrounded its appropriate use. Taken as a group, modest-sized randomized clinical trials comparing primary angioplasty with thrombolytic therapy in acute myocardial infarction (AMI) patients eligible for either therapy have shown clinically meaningful and statistically significant reduction in death or recurrent myocardial infarction (MI) in patients treated with primary percutaneous transluminal coronary angioplasty (PTCA) (1–4). Although substantial growth has occurred in the use of this procedure in patients presenting with AMI and ST-segment elevation left bundle branch block controversy remains about the optimal use of primary angioplasty. Although it is clear that in expert hands and in expert centers, primary PTCA appears to be the treatment of choice, use outside of these expert centers may not replicate these excellent results. Nonrandomized comparisons of primary PTCA and thrombolytic therapy in the Myocardial Infarction Triage and Intervention (MITI) Registry, National Registry of Myocardial Infarction (NRMI) and Cooperative Cardiovascular Project (CCP) databases have