Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study

Abstract

BACKGROUND: Primary coronary angioplasty is an effective reperfusion strategy in acute myocardial infarction. However, its availability is limited, and transporting patients to an angioplasty centre in the acute phase of myocardial infarction has not yet been proved safe. METHODS: The PRAGUE study (PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis) compared three reperfusion strategies in patients with acute myocardial infarction, presenting within 6 h of symptom onset at community hospitals without a catheterization laboratory: group A - thrombolytic therapy in community hospitals (n=99), group B - thrombolytic therapy during transportation to angioplasty (n=100), group C - immediate transportation for primary angioplasty without pre-treatment with thrombolysis (n=101). RESULTS: No complications occurred during transportation in group C. Two ventricular fibrillations occurred during transportation in group B. Median admission-reperfusion time in transported patients (group B 106 min, group C 96 min) compared favourably with the anticipated >90 min in group A. The combined primary end-point (death/reinfarction/stroke at 30 days) was less frequent in group C (8%) compared to groups B (15%) and A (23%, P<0. 02). The incidence of reinfarction was markedly reduced by transport to primary angioplasty (1% in group C vs 7% in group B vs 10% in group A, P<0.03). CONCLUSIONS: Transferring patients from community hospitals to a tertiary angioplasty centre in the acute phase of myocardial infarction is feasible and safe. This strategy is associated with a significant reduction in the incidence of reinfarction and the combined clinical end-point of death/reinfarction/stroke at 30 days when compared to standard thrombolytic therapy at the community hospital.