This Article  • Full text  • PDF  • Correction  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (149)  • Contact me when this article is cited  Related Content  • Related letters  • Related articles  • Similar articles in JAMA  Topic Collections  • Revascularization  • Thrombolysis  • Surgical Interventions  • Cardiovascular/ Cardiothoracic Surgery  • Randomized Controlled Trial  • Cardiovascular Disease/ Myocardial Infarction  • Cardiovascular Intervention  • Alert me on articles by topic

A Randomized Controlled Trial

Thomas Aversano, MD; Lynnet T. Aversano, RN, BSN; Eugene Passamani, MD; Genell L. Knatterud, PhD; Michael L. Terrin, MD; David O. Williams, MD; Sandra A. Forman, MA; for the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT)

JAMA. 2002;287:1943-1951.

Context  Trials comparing primary percutaneous coronary intervention (PCI) and thrombolytic therapy for treatment of acute myocardial infarction (MI) suggest primary PCI is the superior therapy, although they differ with respect to the durability of benefit. Because PCI is often limited to hospitals that have on-site cardiac surgery programs, most acute MI patients do not have access to this therapy.

Objective  To determine whether treatment of acute MI with primary PCI is superior to thrombolytic therapy at hospitals without on-site cardiac surgery and, if so, whether superiority is durable.

Design  The Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) trial, a prospective, randomized trial conducted from July 1996 through December 1999.

Setting  Eleven community hospitals in Massachusetts and Maryland without on-site cardiac surgery or extant PCI programs.

Patients  Four hundred fifty-one thrombolytic-eligible patients with acute MI of less than 12 hours' duration associated with ST-segment elevation on electrocardiogram.

Interventions  After a formal primary PCI development program was completed at all sites, patients were randomly assigned to receive primary PCI (n = 225) or accelerated tissue plasminogen activator (bolus dose of 15 mg and an infusion of 0.75 mg/kg for 30 minutes followed by 0.5 mg/kg for 60 minutes; n = 226). After initiation of assigned treatment, all care was determined by treating physicians.

Main Outcome Measures  Six-month composite incidence of death, recurrent MI, and stroke; median hospital length of stay.

Results  The incidence of the composite end point was reduced in the primary PCI group at 6 weeks (10.7% vs 17.7%; P = .03) and 6 months (12.4% vs 19.9%; P = .03) after index MI. Six-month rates for individual outcomes were 6.2% vs 7.1% for death (P = .72), 5.3% vs 10.6% for recurrent MI (P = .04), and 2.2% vs 4.0% for stroke (P = .28) for primary PCI vs thrombolytic therapy, respectively. Median length of stay was also reduced in the primary PCI group (4.5 vs 6.0 days; P = .02).

Conclusions  Compared with thrombolytic therapy, treatment of patients with primary PCI at hospitals without on-site cardiac surgery is associated with better clinical outcomes for 6 months after index MI and a shorter hospital stay.

Author Affiliations: The Johns Hopkins Medical Institutions, Baltimore, Md (Dr Aversano and Ms Aversano); and Suburban Hospital, Bethesda, Md (Dr Passamani); Maryland Medical Research Institute, Baltimore (Drs Knatterud and Terrin and Ms Forman); and Rhode Island Hospital and Brown University, Providence (Dr Williams).

RELATED LETTERS

Thrombolytic Therapy vs Primary Percutaneous Coronary Intervention for Myocardial Infarction in Patients Presenting to Hospitals Without On-site Cardiac Surgery: A Randomized Controlled Trial
Thomas Aversano, Lynnet T. Aversano, Eugene Passamani, Genell L. Knatterud, Michael L. Terrin, David O. Williams, Sandra A. Forman, and for the Atlantic Cardiovascular Patient Outcomes Research Team
JAMA. 2002;287(15):1943-1951.
ABSTRACT | FULL TEXT  

Thrombolytic Therapy vs Angioplasty in Acute Myocardial Infarction
Christoph Pechlaner, Romuald Bellmann, Aynna Yee, Arash Gabayan, Enrique V. Carbajal, and Thomas Aversano
JAMA. 2002;288(18):2263-2264.
EXTRACT | FULL TEXT  

RELATED ARTICLES

Primary Percutaneous Coronary Intervention for All?
Christopher P. Cannon
JAMA. 2002;287(15):1987-1989.
EXTRACT | FULL TEXT  

April 17, 2002
JAMA. 2002;287(15):2009-2010.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Angioplasty Strategies in ST-Segment-Elevation Myocardial Infarction: Part I: Primary Percutaneous Coronary Intervention
Stone
Circulation 2008;118:538-551.
FULL TEXT  

The Danish multicentre randomized study of fibrinolytic therapy vs. primary angioplasty in acute myocardial infarction (the DANAMI-2 trial): outcome after 3 years follow-up
Busk et al.
Eur Heart J 2008;29:1259-1266.
ABSTRACT | FULL TEXT  

Thrombolysis or primary angioplasty? Reperfusion therapy for myocardial infarction in the UK
Ratcliffe and Pepper
Postgrad. Med. J. 2008;84:73-77.
ABSTRACT | FULL TEXT  

Time to Treatment in Primary Percutaneous Coronary Intervention
Nallamothu et al.
NEJM 2007;357:1631-1638.
FULL TEXT  

Transfer with GP IIb/IIIa inhibitor tirofiban for primary percutaneous coronary intervention vs. on-site thrombolysis in patients with ST-elevation myocardial infarction (STEMI): a randomized open-label study for patients admitted to community hospitals
Dobrzycki et al.
Eur Heart J 2007;28:2438-2448.
ABSTRACT | FULL TEXT  

Has thrombolysis lost its mojo?
Brophy
Heart 2007;93:1167-1169.
FULL TEXT  

Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis
Asseburg et al.
Heart 2007;93:1244-1250.
ABSTRACT | FULL TEXT  

Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review of Contemporary Management Options
Boden et al.
J Am Coll Cardiol 2007;50:917-929.
ABSTRACT | FULL TEXT  

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: Executive Summary
Jacobs et al.
Circulation 2007;116:217-230.
FULL TEXT  

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients: The Non-Percutaneous Coronary Intervention-Capable (ST-Elevation Myocardial Infarction Referral) Hospital Perspective
Ellrodt et al.
Circulation 2007;116:e49-e54.
FULL TEXT  

Primary Percutaneous Coronary Intervention Compared With Fibrinolysis for Myocardial Infarction in Diabetes Mellitus: Results From the Primary Coronary Angioplasty vs Thrombolysis-2 Trial
Timmer et al.
Arch Intern Med 2007;167:1353-1359.
ABSTRACT | FULL TEXT  

Facilitated percutaneous coronary intervention: current concepts, promises, and pitfalls
Kiernan et al.
Eur Heart J 2007;28:1545-1553.
ABSTRACT | FULL TEXT  

Differences in Mortality and Use of Revascularization in Black and White Patients With Acute MI Admitted to Hospitals With and Without Revascularization Services
Popescu et al.
JAMA 2007;297:2489-2495.
ABSTRACT | FULL TEXT  

Primary percutaneous coronary intervention.
Brown et al.
NEJM 2007;356:1588-1589.
FULL TEXT  

On-site surgical standby for percutaneous coronary intervention: a thing of the past?
de Belder
Heart 2007;93:281-283.
ABSTRACT | FULL TEXT  

Primary PCI for Myocardial Infarction with ST-Segment Elevation
Keeley and Hillis
NEJM 2007;356:47-54.
FULL TEXT  

The Cardiovascular Disease Continuum Validated: Clinical Evidence of Improved Patient Outcomes: Part II: Clinical Trial Evidence (Acute Coronary Syndromes Through Renal Disease) and Future Directions
Dzau et al.
Circulation 2006;114:2871-2891.
FULL TEXT  

Narrative review: reperfusion strategies for ST-segment elevation myocardial infarction.
Ting et al.
ANN INTERN MED 2006;145:610-617.
ABSTRACT | FULL TEXT  

Recommendation to Develop Strategies to Increase the Number of ST-Segment-Elevation Myocardial Infarction Patients With Timely Access to Primary Percutaneous Coronary Intervention
The American Heart Association's Acute Myocardial et al.
Circulation 2006;113:2152-2163.
ABSTRACT | FULL TEXT  

A Total of 1,007 Percutaneous Coronary Interventions Without Onsite Cardiac Surgery: Acute and Long-Term Outcomes
Ting et al.
J Am Coll Cardiol 2006;47:1713-1721.
ABSTRACT | FULL TEXT  

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients
Boersma and The Primary Coronary Angioplasty vs. Thrombolysis
Eur Heart J 2006;27:779-788.
ABSTRACT | FULL TEXT  

Trends in mortality from coronary heart and cerebrovascular diseases in the Americas: 1970-2000.
Rodriguez et al.
Heart 2006;92:453-460.
ABSTRACT | FULL TEXT  

Driving Times and Distances to Hospitals With Percutaneous Coronary Intervention in the United States: Implications for Prehospital Triage of Patients With ST-Elevation Myocardial Infarction
Nallamothu et al.
Circulation 2006;113:1189-1195.
ABSTRACT | FULL TEXT  

Door-to-Balloon Time in Primary Percutaneous Coronary Intervention: Is the 90-Minute Gold Standard an Unreachable Chimera?
Moscucci and Eagle
Circulation 2006;113:1048-1050.
FULL TEXT  

Reducing the Risk of Emergency Bypass Surgery for Failed Percutaneous Coronary Interventions
Bittl
J Am Coll Cardiol 2005;46:2010-2012.
FULL TEXT  

A Community-Based Study of Stroke Incidence after Myocardial Infarction
Witt et al.
ANN INTERN MED 2005;143:785-792.
ABSTRACT | FULL TEXT  

Recent advances in primary percutaneous intervention for acute myocardial infarction
Smith et al.
Heart 2005;91:1533-1536.
FULL TEXT  

The Case for Community Hospital Angioplasty
Wharton et al.
Circulation 2005;112:3509-3534.
FULL TEXT  

Part 5: Acute Coronary Syndromes
Circulation 2005;112:III-55-III-72.
FULL TEXT  

The declining prevalence of ST elevation myocardial infarction in patients presenting with acute coronary syndromes
Kleiman and White
Heart 2005;91:1121-1123.
ABSTRACT | FULL TEXT  

Acute Coronary Syndromes and Regionalization of Care
Haynes
JAMA 2005;294:304-304.
FULL TEXT  

Acute Coronary Syndromes and Regionalization of Care--Reply
Rathore et al.
JAMA 2005;294:304-305.
FULL TEXT  

Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology
Authors/Task Force Members et al.
Eur Heart J 2005;26:804-847.
FULL TEXT  

Should all patients with an acute myocardial infarction be referred for direct PTCA?
de Jaegere et al.
Heart 2004;90:1352-1357.
FULL TEXT  

Outcomes of Percutaneous Coronary Interventions Performed at Centers Without and With Onsite Coronary Artery Bypass Graft Surgery
Wennberg et al.
JAMA 2004;292:1961-1968.
ABSTRACT | FULL TEXT  

Is Onsite Surgery Backup Necessary for Percutaneous Coronary Interventions?
Weaver
JAMA 2004;292:2014-2016.
FULL TEXT  

Primary Percutaneous Coronary Intervention for Every Patient with ST-Segment Elevation Myocardial Infarction: What Stands in the Way?
Keeley and Grines
ANN INTERN MED 2004;141:298-304.
ABSTRACT | FULL TEXT  

ACC/AHA guidelines for the management of patients with ST-Elevation myocardial infarction--executive summary: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction)
Writing Committee Members et al.
J Am Coll Cardiol 2004;44:671-719.
FULL TEXT  

ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction)
Antman et al.
Circulation 2004;110:588-636.
FULL TEXT  

Rationale and strategies for implementing community-based transfer protocols for primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction
Waters et al.
J Am Coll Cardiol 2004;43:2153-2159.
ABSTRACT | FULL TEXT  

Primary Angioplasty in Acute Myocardial Infarction at Hospitals With No Surgery On-Site (the PAMI-No SOS study) versus transfer to surgical centers for primary angioplasty
Wharton et al.
J Am Coll Cardiol 2004;43:1943-1950.
ABSTRACT | FULL TEXT  

Primary percutaneous coronary intervention at hospitals without on-site cardiac surgery: Expanding the use of mechanical reperfusion for acute myocardial infarction
Brodie
J Am Coll Cardiol 2004;43:1951-1953.
FULL TEXT  

Summary of recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction
Montalescot et al.
Heart 2004;90:676-677.
FULL TEXT  

Recommendations on percutaneous coronary intervention for the reperfusion of acute ST elevation myocardial infarction
Montalescot et al.
Heart 2004;90:e37-e37.
ABSTRACT | FULL TEXT  

Pharmacoinvasive Therapy: The Future of Treatment for ST-Elevation Myocardial Infarction
Antman and Van de Werf
Circulation 2004;109:2480-2486.
FULL TEXT  

Stroke after percutaneous coronary interventions
Bittl and Caplan
J Am Coll Cardiol 2004;43:1168-1169.
FULL TEXT  

A randomized trial comparing myocardial salvage achieved by coronary stenting versus balloon angioplasty in patients with acute myocardial infarction considered ineligible for reperfusion therapy
Kastrati et al.
J Am Coll Cardiol 2004;43:734-741.
ABSTRACT | FULL TEXT  

Update in Hospital Medicine
Auerbach and Kleinbart
ANN INTERN MED 2004;140:363-369.
FULL TEXT  

Primary Coronary Intervention for Acute Myocardial Infarction
Keeley and Grines
JAMA 2004;291:736-739.
FULL TEXT  

Impact of Time to Treatment on Mortality After Prehospital Fibrinolysis or Primary Angioplasty: Data From the CAPTIM Randomized Clinical Trial
Steg et al.
Circulation 2003;108:2851-2856.
ABSTRACT | FULL TEXT  

Hospitalization Costs of Primary Stenting Versus Thrombolysis in Acute Myocardial Infarction: Cost Analysis of the Canadian STAT Study
Le May et al.
Circulation 2003;108:2624-2630.
ABSTRACT | FULL TEXT  

Interventional therapy for acute myocardial infarction: respect the microvasculature
Dangas
J Am Coll Cardiol 2003;42:1403-1405.
FULL TEXT  

Mortality Benefit of Immediate Revascularization of Acute ST-Segment Elevation Myocardial Infarction in Patients With Contraindications to Thrombolytic Therapy: A Propensity Analysis
Grzybowski et al.
JAMA 2003;290:1891-1898.
ABSTRACT | FULL TEXT  

The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis
Birnbaum and Drew
Postgrad. Med. J. 2003;79:490-504.
ABSTRACT | FULL TEXT  

A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction
Andersen et al.
NEJM 2003;349:733-742.
ABSTRACT | FULL TEXT  

Evolving strategies in the treatment of acute myocardial infarction in the community hospital setting
McKay
J Am Coll Cardiol 2003;42:642-645.
FULL TEXT  

Decline in Out-of-Hospital Coronary Heart Disease Deaths Has Contributed the Main Part to the Overall Decline in Coronary Heart Disease Mortality Rates Among Persons 35 to 64 Years of Age in Finland: The FINAMI Study
Salomaa et al.
Circulation 2003;108:691-696.
ABSTRACT | FULL TEXT  

Primary angioplasty for ST-segment elevation myocardial infarction: Ready for prime time?
Natarajan and Yusuf
CMAJ 2003;169:32-35.
FULL TEXT  

Rising to the challenge: transforming the treatment of ST-segment elevation myocardial infarction
Ghali et al.
CMAJ 2003;169:35-37.
FULL TEXT  

Determinants of treatment strategies and survival in acute myocardial infarction: a population-based study in the Florence district, Italy: Results of the acute myocardial infarction Florence registry (AMI-Florence),
Buiatti et al.
Eur Heart J 2003;24:1195-1203.
ABSTRACT | FULL TEXT  

Fibrinolytic Therapy: Is It A Treatment of the Past?
Grines et al.
Circulation 2003;107:2538-2542.
FULL TEXT  

Regionalization of Care for Acute Ischemic Heart Disease: A Call for Specialized Centers
Topol and Kereiakes
Circulation 2003;107:1463-1466.
FULL TEXT  

Angioplasty vs thrombolysis for acute myocardial infarction: a quantitative overview of the effects of interhospital transportation
Zijlstra
Eur Heart J 2003;24:21-23.
FULL TEXT  

Transfer for primary angioplasty: who and how?
Dalby and Montalescot
Heart 2002;88:570-572.
ABSTRACT | FULL TEXT  

Thrombolytic Therapy vs Angioplasty in Acute Myocardial Infarction
Pechlaner et al.
JAMA 2002;288:2263-2264.
FULL TEXT  

ADDITIONAL ARTICLES ABSTRACTED IN ACP JOURNAL CLUB
Evid. Based Med. 2002;7:131-131.
FULL TEXT  

PCI Superior to Thrombolytic Therapy at Community Hospitals
JWatch Emergency Med. 2002;2002:4-4.
FULL TEXT  

Rationale for on-site cardiac surgery for primary angioplasty: a time for reappraisal
Singh et al.
J Am Coll Cardiol 2002;39:1881-1889.
ABSTRACT | FULL TEXT  

Reperfusion for ST-Segment Elevation Myocardial Infarction: An Overview of Current Treatment Options
Van de Werf and Baim
Circulation 2002;105:2813-2816.
FULL TEXT  

Primary PCI vs. Thrombolysis at Hospitals Without On-Site Cardiac Surgery
Journal Watch Cardiology 2002;2002:2-2.
FULL TEXT  

A randomized trial of transfer for primary angioplasty versus on-site thrombolysis in patients with high-risk myocardial infarction: The air primary angioplasty in myocardial infarction study
Grines et al.
J Am Coll Cardiol 2002;39:1713-1719.
ABSTRACT | FULL TEXT  

Expanding the reach of primary percutaneous coronary intervention for the treatment of acute myocardial infarction
Cannon and Baim
J Am Coll Cardiol 2002;39:1720-1722.
FULL TEXT  

More on Primary Percutaneous Coronary Interventions in Acute MI
JWatch General 2002;2002:6-6.
FULL TEXT  

Primary Percutaneous Coronary Intervention for All?
Cannon
JAMA 2002;287:1987-1989.
FULL TEXT