DANAMI-2: Is primary angioplasty superior to thrombolysis in acute MI when the patient has to be transferred to an invasive centre?

Primary angioplasty is superior to thrombolysis in acute myocardial infarction when performed in a timely manner but the benefits are unknown when inter-hospital transfer is required for angioplasty. On the 20th March 2002 at the American College of Cardiology 51st Annual Scientific Session, the results of the Danish Multicentre Randomized Trial on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2) were presented. 1572 patients were randomized to front loaded tPA or angioplasty on presentation within 12 h of acute myocardial infarction; 1129 from hospitals requiring transfer for up to 3 h for angioplasty. The trial was stopped early since there was a 40% relative reduction in the composite primary end-point of death, disabling stroke or reinfarction within 30 days (absolute reduction 13,7 to 8%. p=0.0003) with primary angioplasty. This appeared to be driven by a significant reduction of reinfarction from 6.3 to 1.6%. Ambulance transfer was shown to be safe but time to angioplasty was approximately 60 min longer than time to thrombolysis. No data are as yet available on the relative infarct sizes or left ventricular function in the two groups. The management of acute myocardial infarction is an area of missed opportunities. Patients present late to hospital, up to 30% of eligible patients do not receive reperfusion therapy and door to needle time is longer than is ideal. Whilst we await the full details of the trial and long term follow-up, we should not forget the challenges of conventional management of acute myocardial infarction. (C) 2002 Elsevier Science Ireland Ltd. All rights reserved.