for the Primary Angioplasty in Myocardial Infarction (PAMI) Investigators High-risk patients have been excluded from most thrombolytic trials because of concern over hemorrhagic complications or lack of efficacy. However, based on several recent studies suggesting that patients wlth relative thromboiytic contraindications may also benefit from reperfusion, recommendations have been made to broadly expand the eligibility criteria for thromboiytic therapy, despite higher absolute complication rates. Primary percutaneous transluminai coronary angioplasty (PTCA) may be an attractive alternative for patients presenting at appropriately equipped hospitals who would otherwise remain at high risk after thrombolytic therapy. In the Primary Angioplasty in Myocardial infarction (PAMI) trial, 395 patients with acute myocardial infarction were randomized to tissue piasminogen activator (t-PA) or primary PTCA. Conditions were present in 151 patients (38%) which formerly would have contraindicated thromboiytic therapy (age >70 yr, symptom duration >4 hr, or prior bypass surgery). in-hospital mortality was 4.3-fold higher in patients wlth former thromboiytlc contraindications compared to iytic-eiigible patients (8.6Oh vs. 2.00/, P = .002). Lytic-eligibie patients treated with t-PA and PTCA had similar in-hospital mortality (1.7% vs. 2.4%, P = NS). in contrast, both in-hospital (2.9% vs. 13.2%, P = .025) and 6-mo mortality (2.9% vs. 15.7%, P = .009) were significantly reduced in patients with former thrombolytic contraindications treated by primary PTCA compared to t-PA. By logistic regression analysis, treatment by PTCA rather than t-PA was the strongest predictor of survival in patients with former thromboiytic contraindications. We conclude that patients with conditions formerly contraindicating thrombolytic therapy constitute a high-risk group wlth significant morbidity and mortality after lytic reperfusion. Our data suggest that patients with former contraindications to thromboiytic therapy may benefit by preferential management with primary PTCA without antecedent thromboiysis. Q im wii~y-~its, Inc.