.The forgotten “Gem of a study” from lancet 2002 .
The fight between Primary angioplasty and thrombolysis was actually over in 2002 itself. But the cardiology community failed to ,( rather reluctant ) to accept the truth. The issue is being dragged without any useful purpose (for the patient !) still trying to keep up the non existing superiority of pPCI.
A bolus thrombolytic agent (TPA/RPA) or even streptokinase can do almost the same if not better than a highly complex procedure called Primary PCI with lots of logistics issues and most important an unacceptable early procedure related hazard.
Timely lysis can kick pPCI out of the ring . . . in three aspects with 100% certainty !
1.If symptom to TIMI 2/3 flow in IRA is the true parameter of success .pPCI can never ever come closer to pre hospital lysis.
2.The poor lytics do not differentiate in the efficacy . It simply acts whoever administer it. While results of pPCI are never reproducible and lots of expertise involved.
3.Thrombolytic agents never need to bother about the complexity of lesions , (or where is the IRA dilemma ? Is it a CTO or ATO confusion etc ) for the simple reason it doesn’t need to think before acting. It does its job fast.
What did CAPTIM prove ?
- It proved pPCI has no mortality advantage over pre hospital lysis.
- Perhaps the most Important conclusion from CAPTIM is pre hospital lysis significantly reduced number of new onset cardiogenic shock . This alone nullifies the self inflicted pseudoscientific delay wasting the golden hour in the process ! (By the way who fixed the arbitrary acceptable delay conferred to pPCI of I hour .The whole evidence base for this delay to be scrutinised in view of CAPTIM !)
Final message
It is an irony, a simple intravenous push of a drug (Thrombolytic agent) very early after an STEMI can save many patients and reduce complication rate .But because it is simple ,it is considered inferior .
Probably the only role for pPCI is high risk complicated STEMI at presentation or after an attempt of lysis has not stabilised the patient.(Where its referred to as Pharamco Invasive strategy )
2018 update
This post was originally posted in 2008. Now as I see this in 2018 . It is shocking to know we haven’t learnt any lesson from this study for 16 years since its published.
In this era of medical commerce and simple ,cheap ,and effective treatment can never compete with sophisticated , glamorous , less effective treatment modalities !
Read the full version of CAPTIM and comments
Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction (CAPTIM) study group, are published in the September 14, 2002 issue of theLancet.
London, UK – In a finding that would appear to go against the swelling tide of support for primary angioplasty as the treatment of choice for acute MI, investigators comparing primary angioplasty with prehospital administration of alteplase with rescue angioplasty have concluded that the 2 strategies are comparable. The results, from the Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction(CAPTIM) study group, are published in the September 14, 2002 issue of theLancet.1
“Our findings indicate that primary angioplasty is no better than prehospital fibrinolysis followed by transfer for possible emergency coronary angioplasty in patients presenting within 6 hours of an acute myocardial infarction,” the researchers, led by Dr Eric Bonnefoy and Dr Paul Touboul(Hopital Louis Pradel, Hospices Civils de Lyon, Lyon, France), write.
However, they point out that cessation of funding during the trial resulted in a lower-than-expected enrollment, 840 of 1200 planned patients, reducing their statistical power. “The CI (confidence interval) for the primary end point shows that there could be a real difference in the treatment effects,” they write.
Still, the researchers feel their conclusion is valid. “This was and is for us a very pragmatic question for our care system in France,” Bonnefoy told heartwire. “Is our current management, with prehospital thrombolysis with transfer, in a time when primary angioplasty is promoted as the best-of-the-best treatment, still sufficient? Even if the power of the study is lower than expected, we think that we have our answer, and we can go on with that practice.”
The strategy also means less strain on their cath labs, Bonnefoy added, since only 1 in 4 patients underwent rescue angioplasty. A cost analysis comparing the 2 strategies is currently being carried out.
Time to treatment, as expected, was longer in the primary angioplasty group: the median delay between onset of symptoms and treatment was 130 minutes in the prehospital fibrinolysis group, and time to first balloon inflation was 190 minutes in the angioplasty group.
At 30 days, there was no significant difference in the primary end point between groups. Overall mortality was lower than expected, they note. Deaths were fewer in the prehospital thrombolysis group, but mortality was not significantly different between groups. There was a trend toward less reinfarction and less disabling stroke favoring the primary angioplasty strategy.
CAPTIM: Primary end point
| Outcome
|
Prehospital fibrinolysis
|
Primary angioplasty
|
Risk difference (95% CI)
|
p
|
| Composite end point | 8.2% | 6.2% | 1.96 (-1.53-5.46) |
0.29 |
| Mortality | 3.8% | 4.8% | -0.93 (-3.67-1.81) |
0.61 |
| Reinfarction | 3.7% | 1.7% | 1.99 (-0.27-4.24) |
0.13 |
| Disabling stroke | 1.0% | 0 | 1.00 (0.02-1.97 |
0.12 |
To download table as a slide, click on slide logo below
Among secondary end points, the researchers noted a nonsignificant trend toward a higher frequency of cardiogenic shockthe most common cause of death in this studyin the primary angioplasty group, noting that cardiogenic shock between randomization and hospital admission occurred only in that group.
The CAPTIM results were first presented at the European Society of Cardiology Congress in September 2001 and reported by heartwire.
“Thus, until the large trials of facilitated PTCA are completed (none of which have even begun enrolling), the best therapy for most patients with evolving AMI should no longer be debated; administer antiplatelet therapy (aspirin, a thienopyridine, and possibly abciximab), withhold thrombolytic therapy, and transfer the patient for primary PTCA, regardless of whether the nearest catheterization suite is 3 floors or 3 hours away,” Stone concludes.
“To do less should no longer be considered standard care. Strong words, yes, but it is time for a wake-up call.”
Dr.S.Venkatesan MD 