Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial.

Abstract

The CAPTIM study randomized patients managed within 6 h of acute ST-segment elevation myocardial infarction to primary angioplasty or prehospital fibrinolysis (rt-PA), with immediate transfer to a centre with interventional facilities. It found a similar incidence of the primary endpoint of death, recurrent MI, or stroke at 30 days with both strategies. We report here the outcome in the diabetic subgroup. The relationship of diabetic status (diabetics, n=103, non-diabetics, n=731) and treatment strategy with the occurrence of the primary endpoint and of death was analysed. Compared with non-diabetics, diabetics had a higher baseline risk profile, a higher rate of the primary endpoint (14.6 vs. 5.6%; P=0.002), and a high rate of mortality (8.7 vs. 3.1%; P=0.01) at 30 days. The incidence of the primary endpoint tended to be higher in diabetics randomized to prehospital fibrinolysis compared with those randomized to primary angioplasty [21.7 vs. 8.8% (10/46 vs. 5/57); RR: 2.47 (0.91-6.74); P=0.09]. This difference was driven by the higher mortality in the fibrinolysis group [13.0 vs. 5.3% (6/46 vs. 3/57); RR: 2.47 (0.7-9.4); P=0.29]. For non-diabetics, no such trend was observed. Compared with non-diabetics, diabetics had a much higher rate of rescue angioplasty (41.4 vs. 23.5%; P=0.01) and a higher mortality after rescue angioplasty [17.4 vs. 0% (4/23 vs. 0/90); P=0.001]. These results suggest that diabetic patients presenting within 6 h of an acute myocardial infarction may derive particular benefit from a strategy of primary angioplasty. However, the small number of diabetic patients in this subgroup analysis does not allow a final conclusion and a specifically designed study is warranted.