Angioplasters and thrombolysers

“Paper will surely take over from screens. It's attractive, highly portable, flexible, smells good, and is easy to notate. Within a year, we hope, the BMJ should be available not just electronically but also on paper.” History, of course, worked the other way round, and paper preceded electronic communication by centuries—but sometimes the race to be historically first may be close. Thrombolysis arrived as a routine treatment for patients with acute myocardial infarction just before primary angioplasty, but there are now enthusiasts arguing that primary angioplasty should become the first line treatment. Peter Bogarty and James Brophy have imagined a world in which primary angioplasty came first and the enthusiasts are arguing for thrombolysis (p 1257).

There are strong arguments for both treatments, and these are well displayed in a “For and against” by David Smith and Kevin Channer (p 1255). Sometimes we have difficulty urging the combatants to argue their case as strongly as possible. This week—perhaps because both protagonists are cardiologists—there is no such problem. If you were to read either piece alone you would, I suggest, be convinced. Reading them together, you will probably be grateful that it's somebody else's decision on whether to make primary angioplasty available to all.

Smith presents incontrovertible evidence that if normal myocardial blood flow can be restored then mortality can be dramatically reduced—to perhaps less than 1%. Of 100 patients with infarcts about a quarter are not eligible for thrombolysis. Of those treated, a third to a half will have normal blood flow restored, but this would have happened in 10% anyway. Some patients are thus exposed to the hazards of thrombolysis but for no benefit. In contrast, argues Smith, angioplasty can be offered to everybody, needn't be done on those who spontaneously reperfuse, and can achieve normal blood flow in 90-97% of those treated. A meta-analysis of 23 trials shows substantial benefits over thrombolysis in mortality, non-fatal infarction, and haemorrhagic stroke. Surely, you'll think after reading this, the case is made.

But, argues Channer, you must be careful in extrapolating from the results of trials done in selective patients, mostly in the United States, to the real world and most other countries. A large Dutch trial in which patients were transferred from district general hospitals to regional centres found no improvement in all cause mortality. Even in the United States, registry data show less benefit than was expected from trials. The problem is the inevitable delay that occurs with angioplasty.

Perhaps the answer is yet another strategy—possibly home thrombolysis followed by rescue angioplasty. We also need some evidence on costs and benefits and on what it would be like to live in a world full of angioplasters. What will they all do when, as predicted by our heart tsar, deaths from heart disease disappear?