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David J. Magid, MD, MPH; B. Ned Calonge, MD, MPH; John S. Rumsfeld, MD, PhD; John G. Canto, MD, MSPH; Paul D. Frederick, MPH, MBA; Nathan R. Every, MD, MPH; Hal V. Barron, MD; for the National Registry of Myocardial Infarction 2 and 3 Investigators

JAMA. 2000;284:3131-3138.

Context  Institutional experience with primary angioplasty has been suggested as a factor in selecting a reperfusion strategy for patients with acute myocardial infarction (AMI). However, no large studies have directly compared outcomes of primary angioplasty vs thrombolytic therapy as a function of institutional experience.

Objective  To compare outcomes among patients with AMI who were treated with primary angioplasty vs thrombolytic therapy at hospitals with different volumes of primary angioplasty.

Design  Retrospective cohort.

Setting  A total of 446 acute care hospitals with 112 classified as low volume (16 procedures), 223 as intermediate volume (17-48 procedures), and 111 as high volume (49 procedures) based on their annual primary angioplasty volume.

Patients  A total of 62 299 patients with AMI treated with primary angioplasty or thrombolytic therapy from June 1, 1994, through July 31, 1999.

Main Outcome Measure  In-hospital mortality.

Results  Mortality was lower among patients who received primary angioplasty compared with those who received thrombolysis at hospitals with intermediate volumes (4.5% vs 5.9%; P<.001) and high volumes (3.4% vs 5.4%; P<.001) of primary angioplasty. At low-volume hospitals, there was no significant difference in mortality between patients treated with primary angioplasty vs those treated with thrombolysis (6.2% vs 5.9%; P = .58). Adjusting for differences in demographic, medical history, clinical presentation, treatment, and hospital characteristics did not significantly alter these findings.

Conclusions  In this study, patients with AMI treated at hospitals with high or intermediate volumes of primary angioplasty had lower mortality with primary angioplasty than with thrombolysis, whereas patients with AMI treated at hospitals with low angioplasty volumes had similar mortality outcomes with primary angioplasty or thrombolysis.

Author Affiliations: Clinical Research Unit, Colorado Permanente Medical Group, Denver (Drs Magid and Calonge); Department of Preventive Medicine and Biometrics (Drs Magid and Calonge), Division of Emergency Medicine (Dr Magid), Department of Family Medicine (Dr Calonge), and Division of Cardiology (Dr Rumsfeld), University of Colorado Health Sciences Center, Denver; Denver VA Medical Center (Dr Rumsfeld); University of Alabama Medical Center, Birmingham (Dr Canto); University of Washington Cardiovascular Outcomes Research Center, Seattle(Dr Every and Mr Frederick); VA Puget Sound Healthcare System, Seattle, Wash (Dr Every); University of California at San Francisco, and Genentech Inc, South San Francisco, Calif (Dr Barron).

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