Haifa, Israel -Provocative results from the Acute Coronary Syndromes Israel Survey (ACSIS) suggest the best mortality results for patients with ST-segment-elevation acute myocardial infarction (STEAMI) and renal failure were obtained with thrombolysis, while primary angioplasty appeared to increase crude mortality figures over levels seen with no reperfusion therapy.

"Our results suggest that thrombolysis is feasible and effective and may represent the preferred mode of reperfusion therapy in patients with STEAMI and renal failure," the authors, led by Dr Robert Dragu (Rambam Medical Center, Haifa, Israel), conclude.

They concede their results are observational and the cohort studied relatively small but conclude, "There is a need for a prospective, large trial to confirm our provocative results and solve the therapeutic dilemma that clinicians are faced with at the bedside of patients with renal failure and STEAMI."

The study is published in the April 15, 2006 issue of the American Journal of Cardiology.

Many studies have shown a decrease in life expectancy after the procedure associated with elective percutaneous coronary intervention (PCI) in patients with renal failure and coronary disease, the authors write. Because patients with renal insufficiency have coagulopathies and platelet dysfunction, there is a tendency to undertreat these patients with thrombolysis when they present with STEAMI, they note. Since these patients were not analyzed as a subgroup in the large thrombolysis trials like GUSTO and GISS-2, information about thrombolysis outcomes when renal failure is present is "deficient," they write.

In this study, Dragu et al used the ACSIS database, a national prospective study of 2047 patients with acute coronary syndromes admitted to 26 cardiac centers in Israel, to look at outcomes among 132 patients with STEAMI and renal failure defined by history and/or an admission serum creatinine level of >1.5 mg/dL.

The decision to treat and the reperfusion modality were at the discretion of the staff at the participating institution. Of the 132 patients with renal failure, most did not receive reperfusion therapy; among those who did, more underwent primary PCI (65% using a stent) than thrombolysis, the bulk of whom received streptokinase (87.5%).

The authors report that crude overall mortality was significantly lower in those treated with thrombolysis than either PCI or no reperfusion therapy.

Relative to the thrombolytic group, crude and adjusted mortality odds ratios observed at seven, 30, and 365 days were 3.1 to 8.1 in the PCI group and 1.5 to 4.6 with no reperfusion therapy.