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The world of cardiology has been in turmoil ever since the first studies which showed that immediate angioplasty is superior to thrombolysis for acute myocardial infarction. Even on an overcrowded island like Britain, most people do not live within easy distance of a cardiac catheter facility, and even in a resource rich country like the USA, there aren’t enough cardiologists to provide a 24 hour immediate angiography service. A thorough systematic review and economic analysis in the British
finds that 6 month mortality is reduced by about one third, and reinfarction by a half, but that these benefits may be lost if door-to-balloon time is more than an hour longer than door-to-needle time. But a German trial published in
found a benefit even in patients presenting more than 12 hours from the first symptoms of myocardial infarction. Fortunately, there is growing evidence that thrombolysis followed by invasive treatment may achieve most of the benefits of …