A Prospective, Randomized Evaluation of Prophylactic Intraaortic Balloon Counterpulsation in High Risk Patients With Acute Myocardial Infarction Treated With Primary Angioplasty

Objectives. A large, international, multicenter, prospective, randomized trial was performed to determine the role of prophylactic intraaortic balloon pump (IABP) counterpulsation after primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI).

Background. Previous studies have suggested that routine IABP use after primary PTCA reduces infarct-related artery reocclusion, augments myocardial recovery and improves clinical outcomes.

Methods. Cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 clinical centers. Clinical and angiographic variables were used to stratify patients undergoing primary PTCA into high and low risk groups. High risk patients were then randomized to 36 to 48 h of IABP (n = 211) or traditional care (n = 226). The study had 80% power to detect a reduction in the primary end point from 30% to 20%.

Results. There was no significant difference in the predefined primary combined end point of death, reinfarction, infarct-related artery reocclusion, stroke or new-onset heart failure or sustained hypotension in patients treated with an IABP versus those treated conservatively (28.9% vs. 29.2%, p = 0.95). The IABP strategy conferred modest benefits in reduction of recurrent ischemia (13.3% vs. 19.6%, p = 0.08) and subsequent unscheduled repeat catheterization (7.6% vs. 13.3%, p = 0.05) but did not reduce the rate of infarct-related artery reocclusion (6.7% vs. 5.5%, p = 0.64), reinfarction (6.2% vs. 8.0%, p = 0.46) or mortality (4.3% vs. 3.1%) and was associated with a higher incidence of stroke (2.4% vs. 0%, p = 0.03). IABP use did not result in enhanced myocardial recovery as assessed by paired admission to predischarge and 6-week rest and exercise left ventricular ejection fraction.

Conclusions. In contrast to previous studies, a prophylactic IABP strategy after primary PTCA in hemodynamically stable high risk patients with AMI does not decrease the rates of infarct-related artery reocclusion or reinfarction, promote myocardial recovery or improve overall clinical outcome.

(J Am Coll Cardiol 1997;29:1459–67)     

Prognostic value of predischarge radionuclide ventriculography at rest and exercise after acute myocardial infarction treated with thrombolytic therapy or primary coronary angioplasty

Background: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modern reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited. Hypothesis: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty. Methods: A total of 272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during follow-up. Results: During a mean follow-up of 30 ± 10 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients with an ejection fraction <40%, cardiac death occurred in 16% compared with 2% in those with an ejection fraction ≥ 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (11 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris or ST-segment depression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and 10%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI. Conclusion: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables reflecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost effectiveness of reperfusion therapies.     

Decreased prevalence of late potentials with mechanical versus thrombolysis-induced reperfusion in acute myocardial infarction

Objectives. We sought to evaluate the influence of the method used to achieve early coronary reperfusion (i.e., intravenous thrombolysis or percutaneous transluminal coronary angioplasty) on the prevalence of late potentials after acute myocardial infarction.Background. After myocardial infarction, late potentials are associated with an increased risk of ventricular tachyarrhythmia and sudden death. Although their prevalence is lower in patients with coronary reperfusion, the influence of the method used to achieve reperfusion remains debated.Methods. We retrospectively analyzed 109 patients with acute myocardial infarction who were treated within 6 h of symptom onset and had angiographically proved early reperfusion. A signal-averaged electrocardiogram was recorded ≥5 days after infarction.Results. Reperfusion was successfully achieved by intravenous thrombolysis alone in 37 patients (34%), by “rescue” coronary angioplasty in 26 (24%) and by primary angioplasty in 46 (42%). There was no significant difference between groups in terms of gender ratio, infarct location, time to admission or to reperfusion, peak creatine kinase value or left ventricular ejection fraction. The prevalence of late potentials was similar in the two groups in which patency was achieved by primary and rescue coronary angioplasty (17.4% and 7.7%, respectively [p = NS]) but higher in patients who had successful thrombolysis (35.1%, p < 0.05). Multivariate analysis showed that the use of thrombolysis instead of angioplasty as the reperfusion method was the only variable significantly associated with the presence of late potentials.Conclusions. This study suggests that after acute myocardial infarction the prevalence of late potentials is lower when reperfusion is achieved by angioplasty (either primary or as a rescue procedure after failed thrombolysis) than by thrombolysis.     

Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy

OBJECTIVES: This study sought to determine the short- and long-term outcome of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) in patients older than 75 years of age. BACKGROUND: The benefit of reperfusion therapy in elderly patients with AMI is uncertain, although elderly people account for a large proportion of deaths. METHODS: We randomly assigned a total of 87 patients with an AMI who were older than 75 years to treatment with angioplasty or intravenous (IV) streptokinase. Clinical outcome was measured by taking the end points of death and the combination of death, reinfarction or stroke during follow-up. RESULTS: The primary end point, a composite of death, reinfarction or stroke, at 30 days had occurred in 4 (9%) patients in the angioplasty group as compared with 12 (29%) in the thrombolysis group (p = 0.01, relative risk [RR]: 4.3, 95% confidence interval [CI]: 1.2 to 20.0). At one year the corresponding figures were 6 (13%) and 18 (44%), respectively (p = 0.001, RR: 5.2, 95% CI: 1.7 to 18.1). CONCLUSIONS: In this series of patients with AMI who were older than 75 years, primary coronary angioplasty had a significant clinical benefit when compared with IV streptokinase therapy.     

Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE study.

BACKGROUND: Primary coronary angioplasty is an effective reperfusion strategy in acute myocardial infarction. However, its availability is limited, and transporting patients to an angioplasty centre in the acute phase of myocardial infarction has not yet been proved safe. METHODS: The PRAGUE study (PRimary Angioplasty in patients transferred from General community hospitals to specialized PTCA Units with or without Emergency thrombolysis) compared three reperfusion strategies in patients with acute myocardial infarction, presenting within 6 h of symptom onset at community hospitals without a catheterization laboratory: group A - thrombolytic therapy in community hospitals (n=99), group B - thrombolytic therapy during transportation to angioplasty (n=100), group C - immediate transportation for primary angioplasty without pre-treatment with thrombolysis (n=101). RESULTS: No complications occurred during transportation in group C. Two ventricular fibrillations occurred during transportation in group B. Median admission-reperfusion time in transported patients (group B 106 min, group C 96 min) compared favourably with the anticipated >90 min in group A. The combined primary end-point (death/reinfarction/stroke at 30 days) was less frequent in group C (8%) compared to groups B (15%) and A (23%, P<0. 02). The incidence of reinfarction was markedly reduced by transport to primary angioplasty (1% in group C vs 7% in group B vs 10% in group A, P<0.03). CONCLUSIONS: Transferring patients from community hospitals to a tertiary angioplasty centre in the acute phase of myocardial infarction is feasible and safe. This strategy is associated with a significant reduction in the incidence of reinfarction and the combined clinical end-point of death/reinfarction/stroke at 30 days when compared to standard thrombolytic therapy at the community hospital.     

Long-term outcome after primary angioplasty: report from the primary angioplasty in myocardial infarction (PAMI-I) trial

OBJECTIVES: This study sought to compare the two-year outcome after primary percutaneous coronary angioplasty or thrombolytic therapy for acute myocardial infarction. BACKGROUND: Primary angioplasty, that is, angioplasty without antecedent thrombolytic therapy, has been shown to be an effective reperfusion modality for patients suffering an acute myocardial infarction. This report reviews the two-year clinical outcome of patients randomized in the Primary Angioplasty in Myocardial Infarction trial. METHODS: At 12 clinical centers, 395 patients who presented within 12 h of the onset of myocardial infarction were randomized to undergo primary angioplasty (195 patients) or to receive tissue-type plasminogen activator (t-PA) (200 patients) followed by conservative care. Patients were followed by physician visits, phone call, letter and review of hospital records for any hospital admission at one month, six months, one year and two years. RESULTS: At two years, patients undergoing primary angioplasty had less recurrent ischemia (36.4% vs. 48% for t-PA, p = 0.026), lower reintervention rates (27.2% vs. 46.5% for t-PA, p < 0.0001) and reduced hospital readmission rates (58.5% vs. 69.0% for t-PA, p = 0.035). The combined end point of death or reinfarction was 14.9% for angioplasty versus 23% for t-PA, p = 0.034. Multivariate analysis found angioplasty to be independently predictive of a reduction in death, reinfarction or target vessel revascularization (p = 0.0001). CONCLUSIONS: The initial benefit of primary angioplasty performed by experienced operators is maintained over a two-year follow-up period with improved infarct-free survival and reduced rate of reintervention.     

Interhospital transport for primary angioplasty improves the long-term outcome of acute myocardial infarction compared with immediate thrombolysis in the nearest hospital (one-year follow-up of the PRAGUE-1 study)

OBJECTIVE: Comparison of the long-term outcomes of three reperfusion strategies in patients with acute ST elevation myocardial infarction presenting to community hospitals. METHODS: One-year clinical outcomes were compared for 300 patients randomized in the PRimary Angioplasty in patients transferred from General community hospitals to specialized percutaneous coronary intervention Units with or without Emergency thrombolysis (PRAGUE-1) study to one of three treatment strategies: thrombolysis in a community hospital (group A, n=99); thrombolysis during immediate transportation for coronary angioplasty (group B, n=100); and immediate transportation for coronary angioplasty without thrombolysis (group C, n=101). RESULTS: Total mortality rates in group A, B and C patients were 18%, 12% and 13%, respectively (not significant). Nonfatal reinfarction occurred in 12%, 6% and 3% of patients, respectively (P<0.05). The combined endpoint (total mortality and nonfatal reinfarction rate) was reported in 30%, 18% and 16% of patients, respectively (P<0.05). In patients randomized within 2 h of the onset of symptoms, mortality rates were 18%, 3% and 8%, respectively (P<0.05). Additional revascularization procedures (percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery) were performed in 35%, 14% and 15% of patients, respectively (P<0.001). CONCLUSIONS: Primary angioplasty (even if delayed due to patient transportation to an interventional centre) is associated with better short- and long-term clinical outcomes than thrombolysis. The combination of the two strategies did not prove superior to coronary angioplasty alone. However, it may be superior in a subset of patients with early admission. The coronary angioplasty strategy decreases the need for revascularization procedures during the subsequent one-year follow-up.     

Stenting versus thrombolysis in acute myocardial infarction trial (STAT)

OBJECTIVES: We sought to directly compare primary stenting with accelerated tissue plasminogen activator (t-PA) in patients presenting with acute ST-elevation myocardial infarction (AMI). BACKGROUND: Thrombolysis remains the standard therapy for AMI. However, at some institutions primary angioplasty is favored. Randomized trials have shown that primary angioplasty is equal or superior to thrombolysis, while recent studies demonstrate that stent implantation improves the results of primary angioplasty. METHODS: Patients presenting with AMI were randomly assigned to primary stenting (n = 62) or accelerated t-PA (n = 61). The primary end point was the composite of death, reinfarction, stroke or repeat target vessel revascularization (TVR) for ischemia at six months. RESULTS: The primary end point was significantly reduced in the stent group compared with the accelerated t-PA group, 24.2% versus 55.7% (p < 0.001). The event rates for other outcomes in the stent group versus the t-PA group were as follows: mortality: 4.8% versus 3.3% (p = 1.00); reinfarction: 6.5% versus 16.4% (p = 0.096); stroke: 1.6% versus 4.9% (p = 0.36); recurrent unstable ischemia: 9.7% versus 26.2% (p = 0.03) and repeat TVR for ischemia: 14.5% versus 49.2% (p < 0.001). The median length of the initial hospitalization was four days in the stent group and seven days in the t-PA group (p < 0.001). CONCLUSIONS: Compared with accelerated t-PA, primary stenting reduces death, reinfarction, stroke or repeat TVR for ischemia. In centers where facilities and experienced interventionists are available, primary stenting offers an attractive alternative to thrombolysis.     

Combined angioplasty and pharmacological intervention versus thrombolysis alone in acute myocardial infarction (CAPITAL AMI study)

OBJECTIVES: We compared a strategy of tenecteplase (TNK)-facilitated angioplasty with one of TNK alone in patients presenting with high-risk ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Previous trials show that thrombolysis followed by immediate angioplasty for the treatment of STEMI does not improve ischemic outcomes compared with thrombolysis alone and is associated with excessive bleeding complications. Since the publication of these trials, however, significant pharmacological and technological advances have occurred. METHODS: We randomized 170 patients with high-risk STEMI to treatment with TNK alone (84 patients) or TNK-facilitated angioplasty (86 patients). The primary end point was a composite of death, reinfarction, recurrent unstable ischemia, or stroke at six months. RESULTS: At six months, the incidence of the primary end point was 24.4% in the TNK-alone group versus 11.6% in the TNK-facilitated angioplasty group (p = 0.04). This difference was driven by a reduction in the rate of recurrent unstable ischemia (20.7% vs. 8.1%, p = 0.03). There was a trend toward a lower reinfarction rate with TNK-facilitated angioplasty (14.6% vs. 5.8%, p = 0.07). No significant differences were observed in the rates of death or stroke. Major bleeding was observed in 7.1% of the TNK-alone group and in 8.1% of the TNK-facilitated angioplasty group (p = 1.00). CONCLUSIONS: In patients presenting with high-risk STEMI, TNK plus immediate angioplasty reduced the risk of recurrent ischemic events compared with TNK alone and was not associated with an increase in major bleeding complications.     

DANAMI-2: is primary angioplasty superior to thrombolysis in acute MI when the patient has to be transferred to an invasive centre?

Primary angioplasty is superior to thrombolysis in acute myocardial infarction when performed in a timely manner but the benefits are unknown when inter-hospital transfer is required for angioplasty. On the 20th March 2002 at the American College of Cardiology 51st Annual Scientific Session, the results of the Danish Multicentre Randomized Trial on Thrombolytic Therapy versus Acute Coronary Angioplasty in Acute Myocardial Infarction (DANAMI-2) were presented. 1,572 patients were randomized to front loaded tPA or angioplasty on presentation within 12 h of acute myocardial infarction; 1,129 from hospitals requiring transfer for up to 3 h for angioplasty. The trial was stopped early since there was a 40% relative reduction in the composite primary end-point of death, disabling stroke or reinfarction within 30 days (absolute reduction 13.7 to 8%, p=0.0003) with primary angioplasty. This appeared to be driven by a significant reduction of reinfarction from 6.3 to 1.6%. Ambulance transfer was shown to be safe but time to angioplasty was approximately 60 min longer than time to thrombolysis. No data are as yet available on the relative infarct sizes or left ventricular function in the two groups. The management of acute myocardial infarction is an area of missed opportunities. Patients present late to hospital, up to 30% of eligible patients do not receive reperfusion therapy and door to needle time is longer than is ideal. Whilst we await the full details of the trial and long term follow-up, we should not forget the challenges of conventional management of acute myocardial infarction.     

Retrospective comparative study of primary intracoronary stenting versus balloon angioplasty for acute myocardial infarction

Balloon angioplasty has been shown to be an effective therapy for the treatment of acute myocardial infarction but is associated with a high restenosis rate, substantial early recoil, persistent thrombus and need for intracoronary thrombolysis, and a high rate of reclosure. Because many of the limitations of balloon angioplasty in the noninfarction setting are addressed by intracoronary stenting, we examined the results of primary stenting of 18 consecutive patients treated for acute myocardial infarction, and compared the results to those achieved with primary balloon angioplasty in 18 prior cases. Despite the presence of thrombus prior to angioplasty in 13 of the stented patients, no intracoronary thrombolytic therapy was required. Mean percent stenosis using quantitative coronary angiography was 17.7 ± 10.2% after primary stenting compared with 43.7 ± 20.3% after primary balloon angioplasty (P < .001). One stent patient who had all anticoagulant and antiplatelet therapy withdrawn early suffered subacute thrombosis. Patients were followed up to 3 yr. Complications were similar in the two groups. We conclude that primary stenting for acute myocardial infarction results in superior angiographic appearance as well as resolution of thrombus without the need for routine thrombolysis, and is associated with a low complication rate and excellent short-term clinical patency. Cathet. Cardiovasc. Diagn. 40:235–239, 1997. © 1997 Wiley-Liss, Inc.     

Does diabetes mellitus abolish the beneficial effect of primary coronary angioplasty on long-term risk of reinfarction after acute ST-segment elevation myocardial infarction compared with fibrinolysis? (A DANAMI-2 substudy)

Little is known about the effect of diabetes mellitus on long-term clinical outcome after primary percutaneous coronary intervention (pPCI) compared with fibrinolysis in patients who have acute ST-elevation myocardial infarction. We analyzed 3-year clinical outcome in diabetic patients and nondiabetic patients who had been randomized to fibrinolysis or pPCI in the DANAMI-2 trial to compare long-term clinical outcome. The primary end point was a composite of death, clinical reinfarction, or disabling stroke. Median follow-up was 3.8 years. Among 1,572 consecutive patients who had ST-elevation myocardial infarction and were randomized to pPCI or fibrinolysis, 173 (11.0%) had diabetes mellitus; 60 of these patients received metformin treatment and were excluded. After 3 years no difference was found between diabetic patients who underwent pPCI versus fibrinolysis (combined event p=0.37, reinfarction p=0.06 in favor of fibrinolysis), whereas pPCI was superior to fibrinolysis in nondiabetic patients (combined event p=0.002, clinical reinfarction p<0.001). Three-year incidence of clinical reinfarction analyzed with Cox's regression showed that pPCI compared with fibrinolysis increased the relative risk of clinical reinfarction in diabetic patients (relative risk 2.57, 95% confidence interval 1.48 to 4.46, p <0.001) but decreased the risk in nondiabetic patients (relative risk 0.52, 95% confidence interval 0.36 to 0.74, p<0.001). In conclusion, from the DANAMI-2 trial we hypothesize that diabetes may abolish the beneficial effect of pPCI on long-term risk of clinical reinfarction.     

Three-year follow-up of patients with silent ischemia in the subacute phase of myocardial infarction after thrombolysis and early coronary intervention

In order to assess the prognostic value of silent myocardial ischemia in acute myocardial infarction after thrombolysis and early coronary angiography (14-48 h after start of thrombolysis) including percutaneous transluminal coronary angioplasty, if indicated, 126 patients underwent 24 h-Holter-monitoring in the early postinfarction period. The 24 h-Holter-recording was initiated directly after early coronary intervention (40+/-11 h after onset of symptoms). Of the 126 patients initially eligible for the study 29 had to be excluded from further analysis for clinical or methodical reasons. Of the remaining 97 patients, 10 (10%) had silent ischemia (group A) and 87/97 (90%) patients showed no significant ST-segment alterations. Both groups did not significantly differ from each other with regard to baseline clinical characteristics, severity of coronary artery disease and frequency of successful percutaneous transluminal coronary angioplasty. The left ventricular ejection fraction showed a trend towards lower values in patients with than in those without silent ischemia (47+/-15% vs. 55+/-13%, p=0.07). When both silent ischemia and left ventricular ejection fraction <40% were present, a subset of patients at high risk for cardiac death could be identified (specificity: 98%, positive predictive accuracy: 75%). By Kaplan-Meier analysis, significantly more cardiac deaths occurred in group A than in group B (30% vs. 6%, p<0.01) during the three-year follow-up (950+/-392 days) after acute myocardial infarction. Regarding the cardiac events during long-term follow-up (emergency percutaneous transluminal coronary angioplasty, coronary artery bypass grafting, non-fatal reinfarction, and cardiac death) there was no significant difference between both groups (30% vs. 18%, NS). In conclusion, Holter monitor-detected silent ischemia in the subacute phase of myocardial infarction after thrombolysis followed by early delayed coronary intervention occurs in 10% of the patients indicating either a residual ischemia in the infarcted zone despite a combined reperfusion strategy or a remote ischemic potential in case of multivessel disease. In this small selected group of infarct patients too, silent ischemia is to be considered as an important non-invasive parameter to predict cardiac death during long-term follow-up and provides valuable complementary information to left ventricular dysfunction, a well established prognostic marker in the postinfarction period.     

Management of patients after thrombolytic therapy for acute myocardial infarction

The coronary artery thrombus that causes acute myocardial infarction can be lysed, and reperfusion can be achieved, in the first few hours after infarction. However, the infarct vessel will reocclude in 15-30% of patients, and this event is frequently associated with pain, reinfarction, arrhythmias, or death. The risk of reocclusion is greatest in patients with high-grade residual stenosis after thrombolysis. Percutaneous coronary angioplasty may be performed safely after thrombolytic therapy. Angioplasty effectively decreases the degree of residual stenosis, and may thereby reduce the risk of reocclusion and consequent ischemic events. However, a substantial proportion of patients with acute infarction are not suitable candidates for angioplasty. Coronary artery bypass surgery has also been safely performed within several days after thrombolytic therapy. Further studies are needed to determine which patients will benefit most from this aggressive approach to acute myocardial infarction.     

Limitation of myocardial infarct size after primary angioplasty: is a higher patency the only mechanism?

BACKGROUND: Several studies demonstrate a better outcome after primary angioplasty compared with thrombolysis. The mechanism is assumed to be a higher rate of open infarct-related vessels. METHODS AND RESULTS: We conducted a randomized trial of primary coronary angioplasty compared with thrombolysis. A total of 401 patients with acute myocardial infarction were randomly assigned to either primary angioplasty or thrombolytic therapy. Radionuclide left ventricular ejection fraction was performed before hospital discharge. Infarct size was estimated by measurement of serial lactate dehydrogenase activity (LDH Q72). Separate analyses were performed in patients with an open infarct-related vessel, either after thrombolysis or angioplasty. Baseline characteristics were comparable between the 2 treatment groups. Of the 197 patients treated with angioplasty, 176 (89%) had an open infarct-related vessel compared with 126 (62%) of the 204 patients treated with thrombolysis (P <.001). In patients with an open infarct-related vessel, those treated with primary angioplasty had a lower enzyme release compared with those treated with thrombolysis: LDH Q72 949 (748) and 1200 (1117), respectively (P <.05). Compared with angioplasty, patients treated with thrombolysis had a lower left ventricular ejection fraction. In the subgroup of patients with an open infarct-related vessel, after thrombolysis or angioplasty, patients treated with thrombolysis still had a lower ejection fraction (47% vs 50%, P <.05). Multivariate analysis, adjusting for differences in several clinical variables, did not change these results. Patients with an open infarct-related vessel and thrombolysis had a higher risk of an ejection fraction <40% compared with patients treated with primary angioplasty (relative risk 1.9, 95% confidence interval 1.0 to 2.7). CONCLUSIONS: Despite successful thrombolysis, with sustained patency of the infarct-related vessel, primary angioplasty remains superior to thrombolytic therapy with regard to left ventricular function and enzymatic infarct size. This may be caused by adverse effects of fibrinolytics on infarcted myocardium.     

Update on mechanical revascularization in acute myocardial infarction: which role and when?

Mechanical revascularization in the acute myocardial infarction by primary angioplasty has several advantages over thrombolytic therapy. The short-term patency rates of the infarct-related artery range from 95 to 99% and a normal flow is achieved in more than 90% of the cases. This prompt and effective reperfusion is probably responsible for the improved prognosis with primary angioplasty. The better outcome after primary angioplasty is observed both in low- and in high-risk patients, in all ages and in patients presenting late (>6 h) after the chest pain. Pooled analysis of randomized studies, show that primary angioplasty as compared to thrombolysis, has a lower incidence of death, stroke and reinfarction. Additional advantages of primary PTCA include the possibility of reperfusion in patients in whom lysis is contraindicated or less effective (e.g. patients in cardiogenic shock, or with prior coronary artery bypass surgery) and the ability to provide prognostic information helpful in the patient triage. Thus, primary PTCA results in better outcome than thrombolysis when performed in centers with success rates comparable to those achieved in the randomized trials. Further studies are still needed to assess its long-term efficacy. Several randomized trials are underway to assess the role of stents and the use of more potent antiplatelet drugs, as the GPIIb/IIIa receptor blockers, in adjunct to balloon angioplasty in the treatment of acute myocardial infarction.     

Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study.

AIMS: Direct angioplasty is an effective treatment for ST-elevation myocardial infarction. The role of very early angioplasty in non-ST-elevation infarction is not known. Thus, a randomized study of first day angiography/angioplasty vs early conservative therapy of evolving myocardial infarction without persistent ST-elevation was conducted. METHODS: One hundred and thirty-one patients with confirmed acute myocardial infarction without ST-segment elevations were randomized within 24 h of last rest chest pain: 64 in the first day angiography/angioplasty group and 67 in the early conservative group (coronary angiography only after recurrent or stress induced myocardial ischaemia). RESULTS: All patients in the invasive group underwent coronary angiography on the day of admission (mean randomization-angiography time 6.2 h). First day angioplasty of the infarct related artery was performed in 47% of the patients and bypass surgery in 35%. In the conservative group, 55% underwent coronary angiography, 10% angioplasty and 30% bypass surgery within 6 months. The primary end-point (death/reinfarction) at 6 months occurred in 6.2% vs 22.3% (P<0.001). Six month mortality in the first day angiography/angioplasty group was 3.1% vs 13.4% in the conservative group (P<0.03). Non-fatal reinfarction occurred in 3.1% vs. 14.9% (P<0.02). CONCLUSIONS: First day coronary angiography followed by angioplasty whenever possible reduces mortality and reinfarction in evolving myocardial infarction without persistent ST-elevation, in comparison with an early conservative treatment strategy.     

Acute myocardial infarction complicated by early onset of heart failure: safety and feasibility of interhospital transfer for coronary angioplasty. Subanalysis of Killip II-IV patients from the PRAGUE-1 study

OBJECTIVE: The objective of this study is to assess the feasibility and safety of interhospital transfer (within up to 60 minutes) for primary/rescue coronary angioplasty of patients with myocardial infarction (AMI) complicated by an early onset of acute heart failure (AHF) admitted to a community hospital without PCI facilities. DESIGN AND PATIENTS: From the multicenter randomized PRAGUE-1 study, a subgroup of 66 patients with AMI complicated by AHF on the first presentation to the community hospital were retrospectively analyzed. Group A patients (n = 21) were treated on site in community hospitals using thrombolysis (streptokinase), group B patients (n = 20) were transported with thrombolytic infusion to a PCI center for coronary angioplasty, and group C patients (n = 25) were immediately transported to a PCI center for primary angioplasty without thrombolysis. RESULTS: No patient died during transportation. One group B patient developed ventricular fibrillation during transfer. The time delay from the onset of chest pain to reperfusion was > 142 minutes, and 253 and 251 minutes in groups A, B, and C, respectively. Hospital stay (16 vs 11 vs 10 days, P = NS) was shorter in the angioplasty groups. Transported patients (groups B, C) displayed a significant decrease in heart failure progression within the first 24 hours after treatment (48% vs 15% vs 8%, P < 0.05). The combined end point, i.e., mortality + nonfatal reinfarction (43% vs 25% vs 8%, P < 0.05), was significantly less frequent in the coronary angioplasty group. CONCLUSIONS: Interhospital transfer for coronary angioplasty of patients with AMI complicated by an early onset of AHF is feasible and safe. Transport for angioplasty may even reduce the risk of heart failure progression and improve clinical outcome compared to immediate thrombolysis in the nearest community hospital.     

Reinfarction after thrombolytic therapy for acute myocardial infarction followed by conservative management: incidence and effect of smoking

A group of 456 consecutive patients seen less than or equal to 6 h after the onset of acute myocardial infarction associated with ST segment elevation received thrombolytic therapy and were followed up for 12 months. Intravenous streptokinase was given to 315 patients and recombinant tissue-type plasminogen activator (rt-PA) to 141 patients. Reinfarction rate and risk factors for reinfarction were assessed. Management after thrombolysis was conservative; revascularization procedures were reserved for patients with symptoms refractory to medical therapy or for those with left main coronary artery stenosis. Coronary artery surgery or angioplasty was performed in only 3.7% of patients during the first 30 days after thrombolysis and in only 8.6% by 1 year. Most patients (79%) underwent coronary arteriography. Twenty-six patients (5.7%) exhibited signs of threatened reinfarction at 1 month after thrombolytic therapy as did 43 patients (9.4%) by 1 year. Reinfarction was prevented in four of these patients by early readministration of thrombolytic therapy. Multivariate analysis of possible risk factors for reinfarction identified at the time of initial infarction showed current cigarette smoking to be the only predictive factor (reinfarction occurred in 12.5% of smokers versus 6.3% of nonsmokers, p = 0.04). A second analysis of risk factors identified 3 weeks after initial infarction, including the severity of residual stenosis at coronary arteriography and exercise test variables, again showed continued cigarette smoking to be the only factor predictive of reinfarction. Twenty percent of patients who continued to smoke developed reinfarction compared with 5.1% of those who stopped (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

A randomized trial of coronary stenting versus balloon angioplasty as a rescue intervention after failed thrombolysis in patients with acute myocardial infarction

OBJECTIVES: This study was conducted to assess whether coronary stenting produces better results compared with balloon angioplasty in patients with acute myocardial infarction (AMI) after failed thrombolysis. BACKGROUND: Little evidence exists on the value of rescue mechanical reperfusion after failed thrombolysis. METHODS: This open-label, randomized study enrolled 181 patients with AMI referred for failed thrombolysis performed within the previous 24 h. The patients had to have a Thrombolysis In Myocardial Infarction (TIMI) flow grade of 相似文献