Transfer of patients with acute myocardial infarction for primary or acute angioplasty from hospitals without the facilities to perform angioplasty. Results from the pooled data of the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) Registry and the Myocardial Infarction Registry (MIR)

In patients with acute myocardial infarction (AMI) admitted at hospitals without angioplasty facilities there are some subgroups of patients which seem to profit from a transfer to primary or acute angioplasty. However, current clinical practice at such hospitals is unknown. We analyzed the pooled data of the German acute myocardial infarction registries MITRA and the MIR. Angioplasty was not available at 221/271 hospitals (81.5%). Out of 14,487 patients with acute myocardial infarction admitted to these hospitals, 50.1% (7,259/14,487) received thrombolysis at the initial hospital and 3.6% (523/14,487) were transferred. Out of the transferred patients, 55.3% (289/523) were treated with primary angioplasty and 44.7% (234/523) received a combination of thrombolysis and angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998 (p for trend = 0.001). One hundred and four hospitals (47.1%) never transferred patients. Patients transferred for primary angioplasty (289 patients) were compared to patients treated with thrombolysis at the initial hospitals (7,259 patients). Multivariate analysis showed the following independent predictors for transfer of patients for primary angioplasty: contraindications for thrombolysis (OR = 17.9), a non-diagnostic first ECG (OR = 4.0), pre-hospital delay > 6 hours (OR = 2.5), unknown symptom onset of the acute myocardial infarction (OR = 2.0) and anterior wall acute myocardial infarction (OR = 1.6). Heart failure at admission was the only independent predictor not to transfer patients (OR = 0.40). In Germany only 47.1% of hospitals without angioplasty facilities transfer patients with acute myocardial infarction to primary or acute angioplasty. The proportion of transferred patients increased from 1.1% in 1994 to 5.5% in 1998. Contraindications for thrombolysis were the strongest predictor to transfer patients to primary angioplasty.     

Type of treatment and short-term outcome in elderly patients with acute myocardial infarction admitted to hospitals with a primary coronary angioplasty facility. The TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry

INTRODUCTION AND OBJECTIVES: The nature and outcome of treatment for acute myocardial infarction in elderly patients admitted to Spanish hospitals with primary angioplasty facilities are not well documented. PATIENTS AND METHOD: Prospective analysis of registry data on patients > or =75 years old with ST-segment-elevation acute myocardial infarction admitted between April and July 2002 to Spanish hospitals with an active primary angioplasty program. RESULTS: We followed up 410 consecutive patients for 1 month. Their mean age was 80 (4.3) years and 46% were female. The median delay between symptom onset and arrival at hospital was 190 minutes. Around 42% of patients received no reperfusion therapy, 35% were treated by thrombolysis, and 22% by primary angioplasty. Patients who underwent reperfusion therapy were younger, were more frequently male, had a shorter delay from symptom onset to hospital arrival, and had a better initial hemodynamic status (Killip Class). However, they were more likely to have extensive anterior infarctions. Overall, 30-day mortality was 24.9%. Independent predictors of death were age, systolic blood pressure, and Killip class >1, but not use of thrombolysis or primary angioplasty. CONCLUSIONS: Over 42% of elderly patients with myocardial infarction admitted to Spanish hospitals with angioplasty facilities did not receive reperfusion therapy. Thrombolysis was the most frequently used reperfusion therapy. However, neither thrombolysis nor primary angioplasty improved 30-day mortality.     

Relation of interhospital delay and mortality in patients with ST-segment elevation myocardial infarction transferred for primary coronary angioplasty

The aim of the present study was to evaluate the impact of interhospital delay on mortality in 616 patients with ST-segment elevation myocardial infarction transferred for primary angioplasty to our hospital. Longer interhospital delay was associated with impaired perfusion, larger infarct size, and higher 1-year mortality (adjusted RR 1.5, 95% confidence interval 1.07 to 2.12; p = 0.019). These results suggest that in patients with ST-segment elevation myocardial infarction transferred for primary angioplasty, all efforts should be made to reduce time to treatment.     

Direct Angioplasty for Myocardial Infarction: One-Year Experience in a Center with Surgical Back-up 220 Miles Away

AIMS: To report the outcome of patients undergoing angioplasty for myocardial infarction in a general hospital in a city without cardiac surgery serving an extended population of 500,000. The nearest cardiac surgical facilities are 220 miles away. METHODS AND RESULTS: Consecutive, unselected patients with myocardial infarction associated/complicated by: cardiogenic shock (n=10), a contraindication to thrombolysis (n=16), anterior site (n=27), stent or vein graft thrombosis (n=7) or failed thrombolysis (n=11) comprised the study group (n=71) who underwent angioplasty as a reperfusion strategy. In patients presenting without cardiogenic shock, the primary procedural success rate (absence of complications, TIMI 3 flow and a residual diameter stenosis <50%) was 93.4%. In those presenting in cardiogenic shock (CGS) the procedural success rate was 40%. Seven patients (6 with CGS) died prior to hospital discharge for reasons unrelated to the angioplasty procedure (6 progressive shock, one neurological sequelae because of delayed resuscitation). Four additional patients had recurrent infarctions, all were successfully treated by repeat PTCA. Two patients were transferred emergently, by air, to the regional cardiothoracic unit in a stable state in case surgery was required. In neither instance was this the result of a direct complication of angioplasty. CONCLUSIONS: Direct angioplasty for myocardial infarction may be safely performed by trained operators in centers without nearby surgical backup.     

Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial.

AIMS: In patients with acute myocardial infarction and ST-segment elevation (STEMI), primary angioplasty is frequently not available or performed beyond the recommended time limit. We designed a non-inferiority, randomized, controlled study to evaluate whether lytic-based early routine angioplasty represents a reasonable reperfusion option for victims of STEMI irrespective of geographic or logistical barriers. METHODS AND RESULTS: A total of 212 STEMI patients were randomized to full tenecteplase followed by stenting within 3-12 h of randomization (early routine post-fibrinolysis angioplasty; 104 patients), or to undergo primary stenting with abciximab within 3 h of randomization (primary angioplasty; 108 patients). The primary endpoints were epicardial and myocardial reperfusion, and the extent of left ventricular myocardial damage, determined by means of the infarct size and 6-week left ventricular function. The secondary endpoints were the acute incidence of bleeding and the 6-month composite incidence of death, reinfarction, stroke, or revascularization. Early routine post-fibrinolysis angioplasty resulted in higher frequency (21 vs. 6%, P = 0.003) of complete epicardial and myocardial reperfusion (TIMI 3 epicardial flow and TIMI 3 myocardial perfusion and resolution of the initial sum of ST-segment elevation > or = 70%) following angioplasty. Both groups were similar regarding infarct size (area under the curve of CK-MB: 4613 +/- 3373 vs. 4649 +/- 3632 microg/L/h, P = 0.94); 6-week left ventricular function (ejection fraction: 59.0 +/- 11.6 vs. 56.2 +/- 13.2%, P = 0.11; endsystolic volume index: 27.2 +/- 12.8 vs. 29.7 +/- 13.6, P = 0.21); major bleeding (1.9 vs. 2.8%, P = 0.99) and 6-month cumulative incidence of the clinical endpoint (10 vs. 12%, P = 0.57; relative risk: 0.80; 95% confidence interval: 0.37-1.74). CONCLUSION: Early routine post-fibrinolysis angioplasty safely results in better myocardial perfusion than primary angioplasty. Despite its later application, this approach seems to be equivalent to primary angioplasty in limiting infarct size and preserving left ventricular function.     

Sex-based differences in clinical and angiographic outcomes after primary angioplasty or stenting for acute myocardial infarction

A paucity of data exists on the importance of gender in contributing to the mortality rate after primary angioplasty, although it is has been shown that women with acute myocardial infarction (AMI) are less likely than men to undergo reperfusion treatments. This study analyzes gender-related differences in 6-month clinical and angiographic outcomes in nonselected patients with AMI who underwent primary angioplasty or stenting. We compared clinical and angiographic outcomes of 230 women and 789 men who underwent primary angioplasty or stenting from January 1995 to August 1999. The women were older than the men, and had a greater incidence of diabetes and cardiogenic shock. The 6-month mortality rate was 12% in women and 7% in men (p = 0.028). Nonfatal reinfarction occurred in 3% of the women and in 1% of the men (p = 0.010). There were no differences in repeat target vessel revascularization rates. After multivariate analysis, gender did not emerge as a significant variable in relation to 6-month mortality or to the combined end point of death, reinfarction, and repeat target vessel revascularization. Both women and men with stented infarct arteries had lower restenosis rates (29% and 26%, respectively) than patients without stents (52% and 39%, repectively). The results of outcome analysis in nonselected patients suggest that sex is not an independent predictor of mortality after primary angioplasty for AMI, and that the benefit of primary stenting is similar in men and women.     

One-year clinical and angiographic follow-up after primary stenting

INTRODUCTION AND OBJECTIVES: The late reocclusion or restenosis rate of the infarct related artery is frequent after primary angioplasty. An implanted stent may be able to improve the coronary angioplasty results and long-term outcome of these patients. We present the clinical and angiographic outcome of a cohort of patients treated with primary stenting. PATIENTS AND METHODS: A group of 74 consecutive patients with acute myocardial infarction treated with primary angioplasty and stenting were followed for one year. An angiographic control was performed at the 6th month of follow-up in 91% of patients to assess the restenosis and reocclusion rates of the infarct-related artery. RESULTS: There were eight in-hospital deaths and three during follow-up (mortality rate 14.8%) and one non-fatal reinfarction (1.5%). The cumulative rate of recurrent ischemia was 6% at 3 months and 15% at 6 months, without any further increment at one-year follow-up. A new angioplasty was performed in 7 patients and three patients underwent surgical revascularization. Thus 80% of patients after discharge were free of events. The angiographic control showed only one reocclusion of the infarct related artery and a restenosis rate of 27%. CONCLUSIONS: These results show that primary stenting is an effective procedure in treating non-selected patients with acute myocardial infarction with a low long-term incidence of adverse events and a low restenosis rate.     

Impact of vessel size on distal embolization, myocardial perfusion and clinical outcome in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction

Background Mounting interest has emerged on the role of distal embolization as a major explanation of poor myocardial perfusion among patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. The aim of the current study was to evaluate the relationship between vessel size, distal embolization, myocardial perfusion and clinical outcome in patients with STEMI treated by primary angioplasty. Methods Our population is represented by 1969 patients with STEMI undergoing primary stenting from 1997 to 2002. All clinical, angiographic, and follow-up data were prospectively collected. Results Vessel size was linearly associated with gender, diabetes, anterior infarction location, shorter time-delay, the rate of stenting and glycoprotein IIb-IIIa inhibitors. Small vessel size was associated with poor perfusion, despite lower rates of distal embolization. These data were confirmed after correction for confounding factors. The higher risk profile and poor myocardial perfusion contribute to explain the worse outcome observed in patients with smaller vessel size. Conclusions This study shows that in patients undergoing primary angioplasty for STEMI, small vessel size is associated with poor myocardial perfusion, despite less distal embolization, that contributes to explain the worse outcome observed among patients with small infarct related arteries.     

Absence of seasonal variation in myocardial perfusion, enzymatic infarct size, and mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty

The present study investigated any seasonal variation in myocardial perfusion, enzymatic infarct size, and 1-year mortality in 1,548 patients who underwent primary angioplasty for ST-segment elevation myocardial infarction. No seasonal variation was observed in patients' demographic and clinical characteristics. No difference was observed in the prevalence of heart failure at presentation and in myocardial perfusion, enzymatic infarct size, and 1-year mortality.     

Relation of pain-to-balloon time and myocardial infarct size in patients transferred for primary percutaneous coronary intervention

The paradigm of a shorter pain-to-balloon time decreasing extent of infarct size may be not completely true in transferred patients. This study evaluated the influence of pain-to-balloon time on infarct size as assessed by delayed enhancement magnetic resonance imaging in patients transferred from a peripheral hospital to a tertiary center for primary coronary angioplasty (percutaneous coronary intervention [PCI]). Sixty patients (40 men, 64 +/- 3 years of age) with first acute myocardial infarction were treated within <168, 168 to 222, 223 to 300, and >300 minutes. A presentation score system including clinical, laboratory, and echocardiographic data was used to classify severity of presentation at admission. Magnetic resonance imaging was performed 6 +/- 3 days after PCI. Group 1 had a higher presentation score than did group 2 (p <0.02) and group 3 (p <0.02). Group 1 had a significantly longer delayed enhancement than did group 2 (p <0.002) and group 3 (p <0.03). In conclusion we found that patients with worse presentation are transferred sooner for primary PCI. This approach in these patients does not decrease infarct size likely because of unavoidable delay to reperfusion. This finding suggests a different therapeutic strategy in these patients.     

The effect of blockade of the CD11/CD18 integrin receptor on infarct size in patients with acute myocardial infarction treated with direct angioplasty: the results of the HALT-MI study

OBJECTIVE: The purpose of this study was to determine whether Hu23F2G (LeukoArrest), an antibody to the CD11/CD18 integrin receptors, would reduce infarct size in patients undergoing primary angioplasty for an acute myocardial infarction. BACKGROUND: Reperfusion injury in acute myocardial infarction has been shown experimentally to be related to neutrophil accumulation. Inhibitors of the CD11/CD18 or CD18 integrin receptors have been shown to reduce infarct size in experimental models. METHODS: Patients within 6 h of onset of chest pain with ST-segment elevation were randomized to receive either 0.3 mg/kg or 1.0 mg/kg of Hu23F2G or placebo just before angioplasty of occluded arteries (Thrombolysis in Myocardial Infarction TIMI flow grade 0 or 1). The primary end point was infarct size as measured by sestamibi single-photon emission computed tomography (SPECT) scan five to nine days later. RESULTS: Four-hundred and twenty patients were enrolled and received a placebo or the study drug. The groups did not differ in baseline or angiographic characteristics or angioplasty results. Infarct size was 16%, 17.2% and 16.6%, for placebo, 0.3 mg/kg and 1.0 mg/kg, respectively, of the left ventricle (p = NS). No differences were evident in those patients with anterior myocardial infarction or those presenting within 2 h of onset of chest pain. Corrected TIMI frame count was also not different between groups. Clinical events at 30 days were very low, with a mortality of 0.8%, 1.4% and 3.3%, respectively. The drug was well tolerated, with a slight increase in minor infections in the high dose group. CONCLUSIONS: The results of this multicenter, double-blind, placebo-controlled, randomized clinical trial demonstrated that an antibody to CD11/CD18 leukocyte integrin receptor did not reduce infarct size in patients who underwent primary angioplasty.     

Fibrinogen and C-reactive protein on admission as markers of final infarct size after primary angioplasty for acute myocardial infarction.

BACKGROUND: In acute myocardial infarction (AMI) treated conservatively or with thrombolysis, marked increases of C-reactive protein (CRP) and fibrinogen have been observed. No data are however available concerning a possible relation between CRP and fibrinogen levels on admission and markers of infarct size after obtaining thrombolysis in myocardial infarction (TIMI) flow III by primary angioplasty. METHODS: We studied 34 patients with a first AMI (29 men, mean age 54+/-11 years) who were treated with primary angioplasty (TIMI flow III in all patients, no concomitant treatment with glycoprotein IIb-IIIa antagonists) within 6 h of onset of pain. CRP and fibrinogen levels on admission were determined and related to the following markers of infarct size: peak creatine kinase MB (CKMB) levels, radionuclide left ventricular ejection fraction (LVEF) at discharge and thallium-201 single-photon emission computed tomography (SPECT) infarct size at 1 month. RESULTS: Median CRP levels were 0.4 mg/dl (range 0.09-3 mg/dl), median fibrinogen levels 412 mg/dl (range 198-679 mg/dl), mean CKMB was 178+/-151 U/l, mean LVEF 52+/-8% and mean thallium-201 infarct size 7+/-6%. Although CRP levels were related to fibrinogen levels on admission (r=0.56, P=0.002), only fibrinogen levels were related to markers of infarct size (r=0.58, P=0.001 for CKMB, r=-0.44, P=0.01 for LVEF and r=0.64, P=0.001 for thallium-201 infarct size). No relation was found between CRP or fibrinogen levels on admission and the extent of coronary artery disease or the myocardial area at risk. In multiple regression analysis, the relation between fibrinogen and markers of infarct size was independent of CRP levels and the duration of pain on admission. CONCLUSIONS: These findings indicate a relation between fibrinogen levels on admission and myocardial infarct size in patients treated with primary angioplasty for AMI. This relation seems to be independent of CRP levels and the duration of pain on admission. If confirmed in larger patient populations, fibrinogen levels on admission could have an important value for risk stratification and more aggressive reduction of infarct size in patients who are treated with primary angioplasty.     

Early reperfusion strategies after acute ST-segment elevation myocardial infarction: the importance of timing

Acute ST-segment elevation myocardial infarction is estimated to occur in more than 500,000 people in the US every year. With the introduction of reperfusion therapy by fibrinolysis or primary angioplasty, mortality has significantly fallen. Although fibrinolysis is more readily available than primary angioplasty, the latter is more effective and results in better short-term and long-term outcomes if performed in a timely manner by an experienced operator and hospital team. The ischemic time, door-to-balloon time and clinical risk are important determinants of favorable outcome. Primary angioplasty is the preferred reperfusion strategy when symptom onset is longer than 3 h, in high-risk patients, such as those with cardiogenic shock, congestive heart failure or elderly age, and those with contraindications for fibrinolysis. Primary angioplasty is the preferred strategy in interventional facilities, with a goal door-to-balloon time of less than 90 min. For patients who present to noninterventional facilities, transfer to a hospital capable of primary angioplasty is safe and effective if the additional treatment delay is less than 90 min. Facilitated percutaneous coronary intervention has been shown in several small trials to offer early vessel patency and improve outcomes compared with fibrinolysis alone, but has not been shown to reduce mortality. Larger trials are ongoing to evaluate the benefit of this approach. The establishment of an effective and efficient system for the rapid transport of patients to centers capable and experienced in primary angioplasty is severely needed to provide optimum treatment and outcomes to patients with ST-segment elevation acute myocardial infarction.     

Appropriate invasive and conservative treatment strategies for patients with ST elevation myocardial infarction

PURPOSE OF REVIEW: The goal of treatment strategies for patients with ST elevation myocardial infarction is to reperfuse the occluded coronary artery, as rapidly and safely as possible. This review discusses evidence regarding the appropriate treatment strategy for patients with ST elevation myocardial infarction taking into consideration geographical and logistical barriers. RECENT FINDINGS: Primary percutaneous coronary intervention is considered the gold standard of myocardial reperfusion. As therapy is time dependent, logistical barriers limit its use to no more than 29% of ST elevation myocardial infarction patients worldwide. Most patients with ST elevation myocardial infarction who undergo primary angioplasty achieve mechanical reopening of the infarct-related artery beyond the established time limit from which left ventricular preservation and clinical benefit are less probable. In contrast, early administration of newer fibrin-specific thrombolytics is at least as effective as primary angioplasty, and can abort infarction and dramatically reduce mortality when given during the first 1-2 hours of onset. Consequently, key elements from the current guidelines recommend that patients with ST elevation myocardial infarction should be reperfused either by primary percutaneous coronary intervention performed 90 minutes after the first medical contact or by thrombolysis within 30 minutes of presentation to hospital. These advantages and disadvantages should generate distinct viewpoints on reperfusion strategies for patients with infarction. For patients admitted in a hospital with primary percutaneous coronary intervention facilities, this should be considered the reperfusion strategy. Options for patients admitted to community hospitals without percutaneous coronary intervention facilities include administration of fibrinolysis or transfer to a tertiary care center for primary percutaneous coronary intervention. SUMMARY: Implementation of reperfusion strategies should vary based on the mode of transportation of the patient and capabilities at the receiving hospital.     

Danish multicenter randomized study on fibrinolytic therapy versus acute coronary angioplasty in acute myocardial infarction: rationale and design of the DANish trial in Acute Myocardial Infarction-2 (DANAMI-2)

Background

Randomized trials have indicated that primary coronary angioplasty performed in patients admitted directly to highly-experienced angioplasty centers offers certain advantages over intravenous fibrinolytic therapy. However, the large majority of patients with acute myocardial infarction are submitted to hospitals without a catheterization laboratory. This means that additional transportation will be necessary for many patients if a strategy of acute coronary angioplasty is to be introduced as routine treatment. The delay of treatment caused by transportation might negate (part of) the benefits of primary angioplasty compared to fibrinolytic therapy given immediately at the local hospital.

Study design

The DANish trial in Acute Myocardial Infarction-2 (DANAMI-2) is the first large-scale study to clarify, in a whole community, which of the 2 treatment strategies is best. A total of 1900 patients with ST-elevation myocardial infarction are to be randomized: 800 patients will be admitted to invasive hospitals and 1100 patients will be admitted to referral hospitals. Half of the 1100 patients admitted to referral hospitals will immediately be transferred to an invasive center to be treated with primary angioplasty.

Implications

If acute transfer from a local hospital to an angioplasty center is the superior strategy, primary angioplasty should be offered to all patients as routine treatment on a community basis.     

Coronary angioplasty in the treatment of threatening extension of myocardial infarction

Recurrent angina with reversible ECG changes within days of a myocardial infarction is a serious clinical entity associated with a high incidence of reinfarction and death. In this study, we report a one-year experience of the treatment and outcome of patients presenting early post-myocardial infarction angina. Out of 32 patients who underwent coronary angiography, 3 were treated medically, 4 were operated upon and 25 had coronary angioplasty at the same time as coronary angiography with a 100 p. 100 immediate success rate. Four early reocclusions were redilated successfully. While in hospital 3 of these 32 patients had myocardial infarct extension (very moderate in 2 cases with CPK less than 500 and a patent artery), and there was no death. During an 8-month follow-up period there were 3 late deaths and 2 reinfarctions; 4 patients were operated upon and 4 were redilated. Thus, angioplasty has a high success rate in early post-myocardial infarction angina, enabling most patients to get through an unstable phase. In some patients, however, the course of the disease is marred by secondary adverse events.     

A randomized double-blind trial of intravenous trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction

BACKGROUND: Despite high patency rates, primary angioplasty for myocardial infarction does not necessarily result in optimal myocardial reperfusion and limitation of infarct size. Experimentally, trimetazidine limits infarct size, decreases platelet aggregation, and reduces leukocyte influx into the infarct zone. To assess trimetazidine as adjunctive therapy to primary angioplasty for acute myocardial infarction a prospective, double-blind, placebo-controlled pilot trial was performed. METHODS: 94 patients with acute myocardial infarction were randomized to receive trimetazidine (40 mg bolus followed by 60 mg/day intravenously for 48 h) (n=44) or placebo (n=50), starting before recanalization of the infarct vessel by primary angioplasty. Patients underwent continuous ST-segment monitoring to assess return of ST-segment deviation to baseline and presence of ST-segment exacerbation at the time of vessel recanalization. Infarct size was measured enzymatically from serial myoglobin measurements. Left ventricular angiography was performed before treatment and repeated at day 14. RESULTS: Blinded ST segment analysis showed that despite higher initial ST deviation from baseline in the trimetazidine group (355 (32) vs. 278 (29) microV, P=0.07), there was an earlier and more marked return towards baseline within the first 6 h than in the placebo group (P=0.014) (change: 245 (30) vs. 156 (31) microV respectively, P=0.044). There was a trend towards less frequent exacerbation of ST deviation at the time of recanalization in the trimetazidine group (23.3 vs. 42.2%, P=0.11). There was no difference in left ventricular wall motion at day 14, or in enzymatic infarct size. There was no side effect from treatment. Clinical outcomes were similar between groups. CONCLUSION: Trimetazidine was safe and led to earlier resolution of ST-segment elevation in patients treated by primary angioplasty for acute myocardial infarction.     

Program of coronary angioplasty in acute myocardial infarction in the region of Murcia (Spain). APRIMUR Registry

INTRODUCTION AND OBJECTIVES: The geographic characteristic and healthcare facilities of the region of Murcia, Spain, are enough to assure that coronary angioplasty can be carried out in acute myocardial infarction according to current guidelines. The development of a regional program for coronary intervention in acute myocardial infarction may increase the number of patients who would benefit from reperfusion therapy in general and primary angioplasty in particular. MATERIAL AND METHODS: The program was initiated in April 2000 and had four steps: 1) Establishment of primary angioplasty as the treatment of choice of acute myocardial infarction in the regional reference hospital. 2) Application of phase 1 to a second hospital located 10 kilometers away from the reference hospital. 3) Extension of phase 1 to the entire city of Murcia. 4) Provision of facilities for coronary angioplasty in acute myocardial infarction to all patients in the region. RESULTS: Between January 2000 and August 2001, 392 angioplasties were performed for acute myocardial infarction. Primary angioplasty was performed in 92% and 85% of the patients with an indication for reperfusion therapy in phase 1 and 2, respectively. The median delay (indication to beginning of procedure) was 25 and 35 minutes in phases 1 and 2, respectively. Total mortality was 11,5% (5,2% in patients without shock at admission). CONCLUSIONS: The design of a regional program of primary angioplasty may increase the number of patients who receive reperfusion therapy in compliance with current recommendations for the treatment of acute myocardial infarction.     

Percutaneous transluminal coronary angioplasty for acute myocardial infarction

Studies have suggested that intracoronary and intravenous thrombolysis and emergency PTCA result in decreased infarct size, improved left ventricular function, and decreased in-hospital mortality. Significant problems remain with all three treatment modalities. Thrombolysis is associated with significant bleeding, especially if acute catheterization also is performed. The intracoronary method of thrombolysis requires cardiac catheterization facilities and entails a significant delay in reperfusion. Lower rates of reperfusion initially were found with intravenous than intracoronary streptokinase, but the intravenous administration of t-PA has been associated with a reperfusion rate (75 per cent) similar to that of intracoronary streptokinase. Significant bleeding complications occur with t-PA just as with streptokinase. Furthermore, there are patients in whom thrombolysis is contraindicated because of the high risk of life-threatening hemorrhagic complications. Once thrombolysis is achieved, an underlying significant coronary artery lesion usually is present so that a significant risk of recurrent ischemia and/or reinfarction still exists. In controlled studies, the addition of cardiac catheterization and angioplasty after thrombolytic therapy is associated with a further increase in significant bleeding episodes. Also, in low-risk subgroups of patients randomized to emergency angioplasty versus elective angioplasty or noninvasive treatment after thrombolytic therapy, the complications of angioplasty may outweigh the benefits of further reduction in lesion severity. Potential problems of emergency angioplasty following thrombolytic therapy include: (1) hemorrhage into ischemic myocardium, which may have a deleterious effect on ultimate muscle recovery; (2) hemorrhage at the angioplasty site caused by thrombolytic therapy, with a resultant increased chance of occlusion of the vessel post-angioplasty, and (3) production of reperfusion arrhythmias and hypotension, predisposing to vessel reclosure and infarct extension. With primary angioplasty therapy, the reperfusion success rate is 85 to 90 per cent. This is higher than the approximately 75 per cent success rate with thrombolytic therapy alone. If angioplasty can be performed expeditiously, within 6 hours of the onset of ischemia, potential advantages of this technique include: (1) rapid reperfusion, possibly comparable to thrombolytic therapy alone; (2) higher success rate for reperfusion than thrombolytic therapy; (3) alleviation of underlying stenosis usually present after thrombolytic therapy alone; (4) avoidance of systemic thrombolysis, with a concomitant decrease in hemorrhagic risk; (5) possible avoidance of hemorrhagic infarction, which may have a deleterious effect on ultimate muscle recovery; and (6) applicability to patients in cardiogenic shock, who presently respond poorly to thrombolytic therapy alone. No large controlled randomized study exists comparing primary angioplasty with thr     

Prospective randomised comparison between thrombolysis, rescue PTCA, and primary PTCA in patients with extensive myocardial infarction admitted to a hospital without PTCA facilities: a safety and feasibility study

OBJECTIVE—To assess the safety and feasibility of acute transport followed by rescue percutaneous transluminal coronary angioplasty (PTCA) or primary PTCA in patients with acute myocardial infarction initially admitted to a hospital without PTCA facilities.
DESIGN—In a multicentre randomised open trial, three regimens of treatment of acute large myocardial infarction were compared for patients admitted to hospitals without angioplasty facilities: thrombolytic treatment with alteplase (75 patients), alteplase followed by transfer to the PTCA centre and (if indicated) rescue PTCA (74 patients), or transfer for primary PTCA (75 patients).
RESULTS—Between 1995 and 1997 224 patients were included. Baseline characteristics were distributed evenly. Transport to the PTCA centre was without severe complications in all patients. Mean (SD) delay from onset of symptoms to randomisation was 130 (75) minutes and from randomisation to angiography 90 (25) minutes. Death or recurrent infarction within 42 days occurred in 12 patients in the thrombolysis group, in 10 patients in the rescue PTCA group, and in six patients in the primary PTCA group. These differences were not significant.
CONCLUSIONS—Acute transfer for rescue PTCA or primary PTCA in patients with extensive myocardial infarction is feasible and safe. Efficacy of rescue PTCA or primary PTCA in this setting will have to be tested in larger series before this approach can be implemented as "routine treatment" for patients with extensive myocardial infarction.


Keywords: myocardial infarction; percutaneous transluminal coronary angioplasty; primary PTCA; rescue PTCA; reperfusion