ORIGINAL INVESTIGATION

Primary Percutaneous Coronary Intervention

Compared With Fibrinolysis for Myocardial
Infarction in Diabetes Mellitus
Results From the Primary Coronary Angioplasty vs Thrombolysis–2 Trial
Jorik R. Timmer, MD, PhD; Jan Paul Ottervanger, MD, PhD; Menko-Jan de Boer, MD, PhD; Eric Boersma, PhD;
Cindy L. Grines, MD; Cynthia M. Westerhout, MD; R. John Simes, MD, FRACP; Christopher B. Granger, MD;
Felix Zijlstra, MD, PhD; for the Primary Coronary Angioplasty vs Thrombolysis–2 Trialists Collaborators Group

Background: There is growing evidence for a clinical
benefit of primary percutaneous coronary intervention
(PCI) compared with fibrinolysis; however, whether the
treatment effect is consistent among patients with dia-
betes mellitus is unclear. We compared PCI with fibri-
nolysis for treatment of ST-segment elevation myocar-
dial infarction in patients with diabetes mellitus.
Methods: A pooled analysis of individual patient data
from 19 trials comparing primary PCI with fibrinolysis
for treatment of ST-segment elevation myocardial infarc-
tion was performed. Trials that enrolled at least 50 pa-
tients with ST-segment elevation myocardial infarction
and randomized patients to receive either primary PCI
or fibrinolysis were considered for inclusion in our study.
Clinical end points were total deaths, recurrent infarc-
tion, death or nonfatal recurrent infarction, and stroke,
measured 30 days after randomization.
Results: Of 6315 patients, 877 (14%) had diabetes.
Thirty-day mortality (9.4% vs 5.9%; P⬍.001) was higher
in patients with diabetes. Mortality was lower after pri-
mary PCI compared with fibrinolysis in both patients with
diabetes (unadjusted odds ratio, 0.49; 95% confidence
interval, 0.31-0.79; P =.004) and without diabetes (un-
adjusted odds ratio, 0.69; 95% confidence interval, 0.54-
0.86, P=.001), with no evidence of heterogeneity of treat-
ment effect (P=.24 for interaction). Recurrent infarction
and stroke were also reduced after primary PCI in both
patient groups. After multivariable analysis, primary PCI
was associated with decreased 30-day mortality in pa-
tients with and without diabetes, with a point estimate
of greater benefit in diabetic patients.
Conclusions: Diabetic patients with ST-segment eleva-
tion myocardial infarction treated with reperfusion therapy
have increased mortality compared with patients with-
out diabetes. The beneficial effects of primary PCI com-
pared with fibrinolysis in diabetic patients are consis-
tent with effects in nondiabetic patients.
Arch Intern Med. 2007;167(13):1353-1359

Author Affiliations are listed at
the end of this article.
Group Information: The
members of the Primary
Coronary Angioplasty vs
Thrombolysis–2 Trialists
Collaborators Group are listed
at the end of the article.
P
ROGNOSIS IN PATIENTS WITH
ST-segment elevation myo-
cardial infarction (STEMI) has
improved markedly since the
introduction of reperfusion
therapy, either primary percutaneous coro-
nary intervention (PCI) or fibrinolysis.1,2
Prognosis in patients with diabetes melli-
tus and coronary artery disease is worse,
and these patients may have different
CME course available at
www.archinternmed.com
responses to various treatment regimens.3-5
Although there is growing evidence for a
clinical benefit of primary PCI compared
with fibrinolysis insofar as short-term and
long-term outcomes in general are con-
cerned,1,6 data comparing primary PCI with
fibrinolysis in diabetic patients are contra-
dictory and describe only a limited num-
ber of patients.7-10 Although primary PCI
has been suggested as the treatment of
choice in patients at high risk,6,11 it re-
mains unclear whether diabetic patients
benefit equally. Diabetic patients have in-
creased platelet agreeability and adhesive-
ness that may influence response to throm-
bolytic therapy,12 and angiographic and
electrocardiographic success of fibrinoly-
sis in diabetic patients has been de-
bated.13-15 However, PCI may result in a less
favorable outcome in diabetic patients. Dia-
betic patients generally have more diffuse
and extensive coronary artery disease with
smaller reference diameters.16 Restenosis
rates after angioplasty with or without stent-
ing are significantly higher in diabetic pa-
tients.17,18 Furthermore, diabetic patients are
more prone to experience life-threatening
adverse events such as subacute stent

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 Randomized clinical trials of primary PCI vs fibrinolysis in
patients with STEMI published between January 1990 and
December 2002 in peer-reviewed journals or international
scientific meetings abstract listings

25 Trials (7743 patients)

Excluded trials

Bonnefoy et al 21 (840 patients)

Prehospital fibrinolysis

DeWood22 (90 patients) and Morais et al 23 (50 patients)

No individual patient data available

Grinfeld et al 24 (112 patients), Widimský et al 25 (200 patients),

and Aoki et al 26 (121 patients)
Diabetes status unknown

Excluded individuals (15 patients)

Diabetes status unknown

Included in the pooled analysis

19 Trials (6315 patients)

Figure 1. Flow diagram of the trial selection process. PCI indicates percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.

thrombosis.19 We compared primary PCI with fibrinoly-
sis in diabetic patients with STEMI based on individual
patient data derived from randomized trials.
METHODS
viously published results were queried and resolved. Clinical end
points were total deaths, recurrent infarction, death or recurrent
infarction, and stroke, measured 30 days after randomization. We
compared clinical outcomes between patients with and without
diabetes and the interaction of the method of reperfusion therapy
and diabetes on outcome.

TRIAL SELECTION STATISTICAL ANALYSIS

Details of trial selection criteria and primary data analysis have
been published previously.20 If a trial enrolled at least 50 pa-
tients with evolving STEMI and randomized patients to either treat-
ment with fibrinolysis (streptokinase or tissue plasminogen ac-
tivator) or primary PCI (without fibrinolytic therapy; with or
without stenting), it was considered for inclusion in our study.
To identify eligible trials, a MEDLINE search was performed using
a broad range of key terms including “(acute) myocardial infarc-
tion,” “fibrinolysis,” “fibrinolytic,” “thrombolysis,” “thrombo-
lytic,” “primary,” “angioplasty,” “stent,” and “percutaneous coro-
nary intervention.” We considered all articles published between
January 1990 and December 2002. References from identified ar-
ticles and abstracts presented at annual international meetings of
the American Heart Association (Circulation), American Col-
lege of Cardiology (Journal of the American College of Cardiol-
ogy), and European Society of Cardiology (European Heart Jour-
nal) were also examined. Each trial identified in this search was
then critically evaluated by 3 investigators (E.B., C.M.W., and
R.J.S.) for inclusion in the pooled analysis.
A flowsheet of the trial selection process is shown in Figure 1.
Nineteen trials were included in the pooled analysis. Design char-
acteristics of included trials are given in Table 1. Each trial was
reviewed to determine whether treatment allocation was truly ran-
domized, that there were no exclusions from the analysis, and
for the extent to which outcome adjudication was blinded. Any
discrepancies between analyses of these data provided and pre-
Continuous data were summarized and are given as median val-
ues with corresponding interquartile range or as mean values
with corresponding SD, whereas dichotomous data are given
as counts and percentages. Wilcoxon rank sum, Kruskal-
Wallis, or ␹2 tests were used as appropriate. To pool trial- or
diabetes-specific outcome data, the Cochran–Mantel-
Haenszel method was used, and odds ratios (ORs) and 95% con-
fidence intervals (CIs) for 30-day mortality are given. In addi-
tion, the Breslow-Day test was used to assess heterogeneity of
treatment effect according to diabetes status or among the trial-
specific ORs. Odds ratios were further adjusted for other base-
line characteristics, including age, sex, time to randomization,
treatment delay, systolic blood pressure, anterior myocardial
infarction (MI), previous MI, heart rate, and randomized treat-
ment, using multiple logistic regression. Statistical signifi-
cance for all analyses was defined as P ⬍.05. The number of
patients needed to treat was calculated as the inverse of the ab-
solute risk difference in outcome. The 95% CI of the patients
needed to treat was estimated using the 95% CI associated with
the absolute risk difference.
RESULTS
Individual patient data were collected for 6763 patients with
STEMI enrolled in 22 randomized clinical trials as part of

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 Table 1. Characteristics of Trials Included in the Meta-analysis

No. of Patients/ Symptom No. (%) of Patients

Source (Trial) Mean Age, y Onset, h With Diabetes Mellitus Primary End Point
Zijlstra et al,27 1993 294/59.7 ⬍6 26 (9) Recurrent ischemia, LVEF, or vessel patency
Ribeiro et al,28 1993 100/56.1 ⬍6 11 (11) Infarct-related artery patency
Zijlstra et al,29 1997 100/60.7 ⬍6 6 (6) Death, recurrent MI, or stroke
Akhras et al,30 1997 87/57.2 ⬍12 43 (49) Coronary flow after TIMI
Kedev et al,31 1997 135/58.0 ⬍12 0 Death, recurrent ischemia, or LVEF
de Boer et al,32 2002 87/81.0 ⬍6 17 (20) Death, recurrent MI, or stroke
Widimský et al (PRAGUE-2),33 2003 850/63.4 ⬍12 189 (22) Death
Gibbons et al,34 1993 103/60.7 ⬍12 12 (12) Perfusion detected at radionuclide imaging
Grines et al,35 1993 395/59.9 ⬍12 50 (13) Death or recurrent ischemia
GUSTO-IIb,36 1997 1138/61.5 ⬍12 176 (16) Death, recurrent MI, or disabling stroke
Ribichini et al,37 1998 110/61.8 ⬍6 15 (14) Not specified, death, recurrent MI, or recurrent ischemia
Garcı́a et al,38 1999 189/60.6 ⬍5 28 (15) Death
Vermeer et al (LIMI),39 1999 150/58.7 ⬍6 7 (5) Death, recurrent MI
Le May et al (STAT),40 2001 123/60.4 ⬍12 27 (22) Death, recurrent MI, stroke, or repeat TVR
Schömig et al (STOPAMI-1),41 2000 140/61.1 ⬍12 28 (20) Salvage index
Grines et al (Air PAMI),42 2002 138/63.0 ⬍12 29 (21) Death, nonfatal recurrent MI, or disabling stroke
Aversano et al (C-PORT),43 2002 451/63.8 ⬍12 70 (16) Death, recurrent MI, or stroke
Andersen et al (DANAMI-2),44 2003 1572/63.1 ⬍12 113 (7) Death, recurrent MI, or disabling stroke
Kastrati et al (STOPAMI-2),45 2002 162/61.3 ⬍12 30 (19) Salvage index

Abbreviations: C-PORT, Cardiovascular Patient Outcomes Research Team Trial; DANAMI-2, Second Danish Trial of Acute Myocardial Infarction;
GUSTO-IIb, Second Global Utilization of Strategies to Open Occluded Coronary Arteries substudy; LIMI, Limburg Myocardial Infarction Trial; LVEF, left ventricular
ejection fraction; MI, myocardial infarction; PAMI, Primary Angioplasty in Acute Myocardial Infarction Study; PRAGUE-2, Second PRimary Angioplasty in patients
transferred from General community hospitals to specialized percutaneous transluminal angioplasty Units with or without Emergency thrombolysis study;
STAT, Stenting vs Thrombolysis in Acute Myocardial Infarction Trial; STOPAMI, Stent vs Thrombolysis for Occluded Coronary Arteries in Patients With Acute
Myocardial Infarction Study; TIMI, thrombolysis in myocardial infarction; TVR, target vessel revascularization.

the PCAT-2 (Primary Coronary Angioplasty vs Throm-
bolysis–2) trial. Of the 6763 patients, complete data on dia-
betes status were available for 6315 patients (93.4%) on
which the following analyses are based. Of these patients,
877 (14%) had diabetes. Patients with diabetes were older,
were more often female, more often had previous MI, and
had longer ischemic time. Baseline characteristics of pa-
tients with and without diabetes are given in Table 2.
After 30 days, 401 patients (6.3%) had died. Mortality
after 30 days was significantly higher in patients with dia-
betes compared with patients without diabetes (9.4% vs
5.9%; P⬍.001; unadjusted OR, 1.64; 95% CI, 1.26-2.13;
P⬍.001). This finding was consistent across the trials
(Breslow-Day test, P=.39). Recurrent MI after 30 days was
comparable between patients with and without diabetes
(4.4% vs 4.5%; P=.87). Death or recurrent MI was signifi-
cantly higher in patients with diabetes (13.2% vs 9.7%;
P = .001). Stroke data were available for 6085 patients
(96.3%). The occurrence of stroke after admission was
comparable between patients with and without diabetes
(2.6% vs 2.0%; P=.29). After baseline adjustment, dia-
betes was associated with a trend for an increase in
30-day mortality (OR, 1.29; 95% CI, 0.99-1.68; P=.06)
and death or recurrent MI (OR, 1.25; 95% CI, 1.00-
2.01; P=.054) but not with an increase in recurrent MI
only (OR, 0.98; 95% CI, 0.69-1.40; P=.92).
tients with diabetes according to the method of reperfu-
sion therapy are summarized in Table 3. There were no
significant differences between diabetic patients random-
ized to receive primary PCI or fibrinolysis. Unadjusted
mortality, recurrent MI, and stroke in patients with and
without diabetes according to the method of reperfu-
sion therapy are given in Table 4. Primary PCI was as-
sociated with a reduction in 30-day mortality in pa-
tients with and without diabetes. This reduction was most
pronounced in diabetic patients. To save 1 life at 30 days,
48 patients without diabetes (95% CI, 37-60) had to be
treated with primary PCI compared with 17 patients with
diabetes (95% CI, 11-28). No interaction between type
of fibrinolytic agent, mortality, and presence of diabetes
was found.
After adjusting for potential confounders, including
age, sex, time to randomization, treatment delay, sys-
tolic blood pressure, anterior MI, previous MI, heart rate,
and randomized treatment, primary PCI was indepen-
dently associated with improved 30-day survival (OR,
0.64; 95% CI, 0.52-0.79; P ⬍ .001), which was evident
in patients both with diabetes (OR, 0.50; 95% CI, 0.31-
0.80; P=.003) and those without diabetes (OR, 0.68; 95%
CI, 0.54-0.86; P=.001; interaction P=.24; Figure 2). This
treatment effect was consistent across the pooled trials
(Breslow-Day test, P=.52).

ASSOCIATIONS AMONG DIABETIC STATUS,

COMMENT
TREATMENT, AND 30-DAY MORTALITY

Of patients without diabetes, 2700 (50%) were random- This analysis showed no difference in relative mortality
ized to receive primary PCI, compared with 456 (52%) reduction after primary PCI in patients with and with-
patients with diabetes. Baseline characteristics of pa- out diabetes. Because diabetes was associated with in-

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 Table 2. Baseline Characteristics of Patients With STEMI Table 3. Baseline Characteristics of Patients With Diabetes
Without vs With Diabetes a According to Randomized Method of Reperfusion Therapy:
Fibrinolysis vs Primary PCI a
Patients Patients
Without With Fibrinolysis Primary PCI P
Diabetes Diabetes P Characteristic (n = 421) (n = 456) Value
Characteristic (n = 5438) (n = 877) Value
Age, y 65 ± 11 65 ± 11 .92
Age, y 62 ± 12 65 ± 11 ⬍.001 Male sex 268 (64) 292 (64) .89
Male sex 4043 (74) 560 (64) ⬍.001 Systolic blood pressure, 136 ± 24 134 ± 24 .17
Systolic blood pressure, 133 ± 24 135 ± 24 .004 mm Hg
mm Hg Heart rate, beats/min 80 ± 17 79 ± 17 .26
Heart rate, beats/min 76 ± 17 79 ± 17 ⬍.001 Weight, kg 81 ± 12 80 ± 12 .93
Weight, kg 79 ± 12 80 ± 12 .001 Previous MI 63 (15) 80 (18) .59
Previous MI 701 (13) 143 (16) .02 Previous PCI 13 (3) 14 (3) .98
Previous PCI 227 (4) 27 (3) ⬍.001 Previous CABG 8 (2) 8 (2) .97
Previous CABG 96 (2) 16 (2) .56 Time from symptom onset .80
Time from symptom onset to ⬍.001 to randomization, h
randomization, h 0-1 44 (11) 39 (9)
0-1 635 (12) 83 (10) ⬎1-2 94 (22) 102 (22)
⬎1-2 1772 (32) 196 (22) ⬎2-3 102 (24) 122 (27)
⬎2-3 1346 (5) 224 (26) ⬎3-6 119 (28) 122 (27)
⬎3-6 1228 (23) 241 (28) ⬎6 62 (15) 71 (16)
⬎6 507 (9) 133 (15) Median percentile 160 (105-280) 164 (110-270) .64
Median percentile 137 (90-212) 163 (110-272) ⬍.001 (25th-75th percentile)
(25th-75th percentile) PCI-related delay, min b .92
PCI-related delay, min b ⬍.001 0-35 81 (19) 89 (20)
0-35 1125 (21) 170 (19) 36-50 83 (20) 84 (18)
36-50 1011 (19) 167 (19) 51-62 81 (19) 93 (20)
51-62 1222 (23) 174 (20) 63-79 65 (15) 63 (14)
63-79 1026 (19) 128 (15) ⱖ80 111 (26) 127 (28)
ⱖ80 1054 (19) 238 (27) Median percentile 58 (37-80) 58 (37-80) .86
Median percentile 55 (38-74) 58 (37-80) .01 (25th-75th percentile)
(25th-75th percentile) Anterior infarction 212 (50) 203 (45) .18
Anterior infarction 2490 (46) 415 (48) .35
Randomized to primary PCI 2700 (50) 456 (52) .20 Abbreviations: CABG, coronary artery bypass grafting; MI, myocardial
infarction; PCI, percutaneous coronary intervention.
a Data are given as mean ± SD or number (percentage) unless otherwise
Abbreviations: CABG, coronary artery bypass grafting; MI, myocardial
infarction; PCI, percutaneous coronary intervention; STEMI, ST-segment indicated.
b Calculated at each hospital site.
elevation myocardial infarction.
a Data are given as mean ± SD or number (percentage) unless otherwise
indicated.
b Calculated at each hospital site.

significant benefit of primary PCI in major cardiac events

creased 30-day mortality, the absolute benefit of pri-
mary PCI can be expected to be greater in patients with
diabetes.
The negative influence of diabetes on outcome after
STEMI has been described previously.10 In addition to
differences in baseline patient characteristics, including
age, sex, previous MI, longer ischemic time, or a higher
prevalence of multivessel disease, prothrombotic de-
rangement and unfavorable lipid metabolism might pre-
dispose diabetic patients to future coronary events.12,46,47
Because mortality remains particularly high in patients
with diabetes after STEMI, it is important to define op-
timal treatment strategies, including method of reperfu-
sion therapy, in this population.
In a general patient population, primary PCI im-
proves outcome when compared with fibrinolysis.1,6 How-
ever, effects of reperfusion therapy may be different in
patients with diabetes. Percutaneous coronary interven-
tion in patients with diabetes may be more complex, with
higher complication rates.17-19,48 Fibrinolysis may also be
less effective in diabetic patients.13-15 Previous trials com-
paring primary PCI with fibrinolysis for STEMI in dia-
betic patients are few and conflicting. Hsu et al8 found a
in 202 diabetic patients in a registry study. A subanaly-
sis of the CAPTIM (Comparison of Angioplasty and Pre-
hospital Thrombolysis in Acute Myocardial Infarction)
study also revealed a possible beneficial effect of pri-
mary PCI in 103 diabetic patients.9 An analysis of the
GUSTO-IIb Angioplasty Substudy (Second Global Use
of Strategies to Open Occluded Coronary Arteries in Acute
Coronary Syndromes), which included only 177 dia-
betic patients, showed a consistent treatment effect (with
wide confidence intervals) of primary PCI in patients with
and without diabetes.10 In our analysis including a large
number of patients, it was more clearly demonstrated that
primary PCI is associated with improved survival after
30 days in both patients with and without diabetes.
The point estimate of the benefit of primary PCI
compared with fibrinolysis was greater in diabetic
patients, and because the absolute risk is higher in this
population, the absolute benefit was greater. This obser-
vation may be the result of delay in initiation of therapy
and longer ischemic time in diabetic patients, which
may be related in part to atypical symptoms.49,50 In par-
ticular, thrombolytic therapy seems to be negatively
influenced by longer time to initiation of therapy.51
Also, microvascular flow seems to be decreased in dia-

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 Table 4. Thirty-Day Clinical End Points in Patients According to Diabetes Status and Randomized Method of Reperfusion Therapy a

End Point PCI Fibrinolysis OR (95% CI) P Value

Death
Without diabetes 130 (4.8) 189 (6.9) 0.69 (0.54-0.86) .001
With diabetes 30 (6.6) 52 (12.4) 0.49 (0.31-0.79) .004
Recurrent MI
Without diabetes 62 (2.3) 182 (6.7) 0.33 (0.25-0.44) .001
With diabetes 15 (3.4) 23 (5.5) 0.60 (0.30-1.16) .12
Death or recurrent MI
Without diabetes 182 (6.7) 343 (12.5) 0.51 (0.42-0.61) ⬍.001
With diabetes 44 (9.6) 72 (17.1) 0.52 (0.35-0.77) .001
Stroke
Without diabetes 38 (1.5) 66 (2.5) 0.58 (0.39-0.86) .007
With diabetes 7 (1.5) 16 (3.7) 0.40 (0.16-0.99) .04

Abbreviations: CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention.
a Data are given as number (percentage) unless otherwise indicated.

Total No. of patients, 6315

No. of patients with diabetes, 877
No. of patients without diabetes, 5438

Total

DM

Non-DM

0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6

PCI Better Fibrinolysis Better

Figure 2. Adjusted odds ratios and 95% confidence intervals for the risk of 30-day mortality according to the method of reperfusion therapy in patients with and
without diabetes. DM indicates diabetes mellitus; PCI, percutaneous coronary intervention.

betic patients after fibrinolysis.14 Possibly, this is associ-
ated with increased platelet aggregation and reduced
ability to induce endothelium-mediated vasodilation.12
In addition to the superiority of primary PCI compared
with fibrinolysis in restoring optimal epicardial flow,
percutaneous intervention is associated with improved
microvascular flow.52
It is not known whether the clinical benefit of pri-
mary PCI compared with fibrinolysis is sustained with
time because no long-term follow-up data are yet avail-
able. No data on the type of treatment of diabetes (insu-
lin or no insulin) were present. Furthermore, the effect
of long-term glycometabolic control in diabetic patients
according to method of reperfusion therapy could not
be assessed because glycosylated hemoglobin levels
were unavailable. Most patients in the fibrinolysis
group in the current analysis were not treated with pre-
hospital fibrinolysis. Selection is a potential limitation
of randomized controlled trials. Indeed, the prevalence
of diabetes in the present patients is somewhat lower
when compared with registries.53,54 Also, the relatively
young age of our patient group may suggest some bias
resulting from the inclusion process. However, the
demonstration of a clear benefit of primary PCI com-
pared with fibrinolysis in these patients only strength-
ens our conclusions.
CONCLUSIONS
Diabetic patients with STEMI treated with reperfusion
therapy have higher mortality compared with nondia-
betic patients. The beneficial effect of primary PCI com-
pared with fibrinolysis is consistent in patients with and
without diabetes. Wider application of timely primary PCI
could be an important strategy to improve outcomes in
the high-risk population of diabetic patients.
Accepted for Publication: March 4, 2007.
Author Affiliations: Department of Cardiology, Isala
Klinieken, Zwolle, the Netherlands (Drs Timmer,
Ottervanger, and de Boer); Clinical Epidemiology Unit,
Thoraxcenter, Erasmus Medical Center, Rotterdam, the
Netherlands (Drs Boersma and Westerhout); William
Beaumont Hospital, Royal Oak, Michigan (Dr Grines);
Department of Medicine, University of Alberta, Edmon-

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ton (Dr Westerhout); National Health and Medical
Research Counsel Clinical Trials Centre, University of
Sydney, Sydney, Australia (Dr Simes); Duke Clinical Re-
search Institute, Durham, North Carolina (Dr Granger);
and Department of Cardiology, Thoraxcenter, Univer-
sity Medical Center Groningen, Groningen, the Nether-
lands (Dr Zijlstra).
Correspondence: Jan Paul Ottervanger, MD, PhD, De-
partment of Cardiology, Isala Klinieken, Groot Wezen-
land 20, 8011 JW Zwolle, the Netherlands (v.r.c.derks
@isala.nl).
Author Contributions: Dr Ottervanger had full access to
all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analy-
sis. Study concept and design: Timmer, Ottervanger,
de Boer, Grines, Granger, and Zijlstra. Acquisition of data:
Grines, Westerhout, and Granger. Analysis and interpre-
tation of data: Timmer, Ottervanger, Boersma, Grines,
Westerhout, Simes, and Granger. Drafting of the manu-
script: Timmer, Ottervanger, de Boer, and Simes. Criti-
cal revision of the manuscript for important intellectual con-
tent: Ottervanger, Boersma, Grines, Westerhout, Granger,
and Zijlstra. Statistical analysis: Timmer, Ottervanger,
Boersma, and Westerhout. Obtained funding: Granger. Ad-
ministrative, technical, and material support: Timmer,
Ottervanger, Simes, and Zijlstra. Study supervision:
Ottervanger and de Boer.
Financial Disclosure: None reported.
PCAT-2 Collaborative Group: Study Chairs: Eric Boersma,
PhD, Erasmus Medical Center, Rotterdam, the Nether-
lands; R. John Simes, MD, FRACP, National Health and
Medical Research Counsel Clinical Trials Centre, Uni-
versity of Sydney, Sydney, Australia; Cindy L. Grines, MD,
Beaumont Hospital, Royal Oak, Michigan. Trialists: Zwolle
studies: Menko-Jan de Boer, MD, PhD, Isala Klinieken,
Zwolle, the Netherlands; Felix Zijlstra, MD, PhD, Uni-
versity Medical Center Groningen, Groningen, the Neth-
erlands; Expedito Ribeiro, MD, PhD, Heart Institute of
the University of São Paulo, São Paulo, Brazil; Liliana
Grinfeld, MD, Hospital Italiano, Buenos Aires, Argen-
tina; Fawaz Akhras, MD, Cromwell Hospital, London, En-
gland; and Sahko Kedev, MD, Skopje Clinic Center,
Skopje, Macedonia. PRAGUE (PRimary Angioplasty in pa-
tients transferred from General community hospitals to spe-
cialized percutaneous coronary angioplasty Units with or
without Emergency thrombolysis) Study: Petr Widimský,
MD, PhD, Cardiocenter Vinohrady, Prague, Czech Re-
public; and Marcus A. DeWood, MD, Deaconess Medi-
cal Center, Spokane Heart Research Foundation, Spo-
kane, Washington. Mayo Trial: Raymond J. Gibbons, MD,
Mayo Clinic, Rochester, Minnesota. PAMI (Primary An-
gioplasty in Myocardial Infarction) and Air PAMI studies:
Cindy L. Grines, MD. GUSTO-IIb (Global Utilization of
Strategies to Open Occluded Coronary Arteries) Study:
Christopher B. Granger, MD, and Robert Califf, MD, Duke
University Medical Center, Durham, North Carolina; Paul
W. Armstrong, MD, University of Alberta, Edmonton; and
R. John Simes, MD, FRACP, University of Sydney. JIMI
(Japanese Intervention Trial in Myocardial Infarction): Hi-
dehiko Aoki, MD, Iwate Medical University, Morioka, Ja-
pan; Joao Morais, MD, Santo André’s Hospital, Leiria, Por-
tugal; Flavio Ribichini, MD, University of Verona, Cuneo,
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Italy; and Eulogica Garcia, MD, University Hospital Gre-
gorio Maranon, Madrid, Spain. Limburg Myocardial In-
farction Trial: Fritz Bär, MD, PhD, University of Maas-
tricht, Maastricht, the Netherlands. STAT (Stenting vs
Thrombolysis in Acute Myocardial Infarction Trial): Michel
R. LeMay, MD, Ottawa Heart Institute, Ottawa, On-
tario. STOPAMI (Stent vs Thrombolysis for Occluded Coro-
nary Arteries in Patients With Acute Myocardial Infarc-
tion) studies: Adnan Kastrati, MD, and Albert Schömig,
MD, Deutsches Herzzentrum München, Munich, Ger-
many. C-PORT (Cardiovascular Patient Outcomes Re-
search Team) Trial: Thomas Aversano, MD, The Johns
Hopkins School of Medicine, Baltimore, Maryland.
DANAMI-2 (Second Danish Trial of Acute Myocardial In-
farction): Henning Rud Andersen, MD, and Torsten T.
Nielsen, MD, Aarhus University Hospital, Aarhus,
Denmark.
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