Percutaneous transluminal coronary angioplasty after intracoronary streptokinase in evolving acute myocardial infarction

To achieve optimal myocardial revascularization and prevent rethrombosis of the infarct-related coronary artery, percutaneous transluminal coronary angioplasty (PTCA) was attempted in 18 patients with evolving acute myocardial infarction (9 anterior and 9 inferior) after administration of intracoronary streptokinase. PTCA was attempted 338 +/- 151 minutes after the onset of symptoms. After thrombolytic therapy, 11 patients had a severe residual stenosis and 7 a persistent total occlusion of the infarct-related coronary artery. PTCA was successful in 13 of 18 patients: in 9 of 11 with coronary stenoses and in 4 of 7 with total coronary occlusions. PTCA reduced the severity of the coronary lesion from 91 +/- 2% to 27 +/- 7% (p less than 0.001), and the transstenotic pressure gradient from 38 +/- 5 to 6 +/- 2 mm Hg (p less than 0.01). One patient in cardiogenic shock died during urgent coronary surgery after unsuccessful PTCA. After PTCA, all patients received heparin and antiplatelet agents. One patient had reinfarction with reocclusion of the infarct-related artery 5 days after PTCA. The other 12 patients had an uneventful hospital course, and cardiac catheterization before hospital discharge (8 to 17 days) revealed reocclusion of the infarct-related coronary artery in 3 and persistent patency in 9. Persistent patency of the infarct-related artery was associated with preservation of left ventricular end-diastolic volume (initial 86 +/- 6 ml/m2, follow-up 91 +/- 6 ml/m2), and improvement in left ventricular ejection fraction in some patients.     

Percutaneous transluminal coronary angioplasty in acute myocardial infarction

Percutaneous transluminal coronary angioplasty (PTCA) has, in general, been restricted to therapy for patients with angina pectoris. Thrombolytic therapy and guide wire recanalization have been used to recanalize coronary arteries in patients with evolving myocardial infarction. Recently we and others have examined the use of PTCA to recanalize the acutely occluded artery associated with the early evolving phase of myocardial infarction. PTCA was performed as definitive therapy in eight patients with acute myocardial infarction. Seven of these had totally occluded arteries to the region of infarct. The infarct-related artery was open within 20 minutes in each of these cases. PTCA recanalization resulted in evidence for reperfusion in each case. Residual stenoses either were not present or were minimal. The procedure was well tolerated. These preliminary results suggest that PTCA may be a reasonable alternative to intracoronary thrombolytic therapy in certain patients with acute evolving 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     

急性心肌梗死直接经皮腔内冠状动脉成形术治疗

临床上所说的急性心肌梗死(acutemyocardialinfarc tion,AMI)通常是指ST段抬高的心肌梗死(ST-seg mentelevationmyocardialinfarction,STEMI)。虽然有各种各样的药物和机械灌注治疗方法可供选择,包括溶栓和直接经皮腔内冠状动脉介入治疗(primarypercutaneouscoro naryintervent     

Percutaneous transluminal coronary angioplasty during acute myocardial infarction

Intravenous thrombolytic therapy with streptokinase in the setting of acute MI has been shown to be effective in improving left ventricular function, limiting infarct size, and improving early mortality. The benefit of this therapy is greatest when administered within 3 hours and is of minimal benefit when given more than 6 hours from symptom onset. Newer second generation thrombolytic agents such as intravenous r-TPA have been shown to be more effective at establishing patency of acutely thrombosed coronary arteries. TPA treatment produces patency rates similar to those observed with intracoronary administration of streptokinase (65 to 75 per cent). This agent will probably become standard therapy for patients with acute MI. Unfortunately, there are significant problems with systemic thrombolytic therapy. The potential for bleeding complications contraindicates the use of this therapy in patients with recent cerebrovascular events, recent surgery, or other possible bleeding problems. Acute angioplasty of the infarct-related artery has been shown to be effective in restoring blood flow in 85 per cent of patients with acute MI. Preliminary studies have suggested that this therapy, when administered within 4 hours from symptom onset, improves global and regional left ventricular function to a greater degree than intracoronary streptokinase. Patients receiving acute PTCA as a primary reperfusion modality have a lower incidence of post-infarction angina and provokable ischemia by exercise testing. If facilities and skilled personnel are available to perform PTCA within 4 hours from symptom onset, this therapy remains an alternative revascularization modality in patients with acute infarction and contraindications to systemic thrombolytic therapy. However, the benefit of PTCA with regard to reduction in mortality when used in this manner is unproven. PTCA can also be used as an adjunctive therapy administered at some time following systemic thrombolytic therapy. Performing PTCA acutely offers the potential to restore blood flow in 90 per cent of the patients that initially fail thrombolytic therapy. However, despite the use of PTCA in this subgroup, benefits with regard to improved ventricular function and decreased mortality have yet to be conclusively demonstrated. Performing acute PTCA following systemic thrombolytic therapy also incurs a high incidence of bleeding complications. If initial thrombolytic therapy reestablishes vessel patency, similar improvements in ventricular function can be expected even if PTCA is deferred until clinically indicated by evidence of recurrent ischemia.(ABSTRACT TRUNCATED AT 400 WORDS)     

稳妥开展急性心肌梗塞的经皮冠状动脉腔内成形术

稳妥开展急性心肌梗塞的经皮冠状动脉腔内成形术高润霖８０年代以来，急性心肌梗塞（ＡＭＩ）的治疗进入了再灌注治疗的年代，其中静脉溶栓治疗应用最为广泛。现已证明，溶栓治疗使冠状动脉再通，可明显改善ＡＭＩ近期及长期预后。据国家“八五”攻关课题研究组的报道，应...     

Percutaneous transluminal coronary angioplasty after non-Q-wave acute myocardial infarction

The value of percutaneous transluminal coronary angioplasty (PTCA) for ischemia after a non-Q-wave acute myocardial infarction (AMI) was assessed prospectively in 33 consecutive patients. In 30 patients the indication for the procedure was post-AMI angina and 3 patients underwent PTCA for silent ischemia. A total of 43 lesions were attempted at 63 +/- 94 days after the non-Q-wave AMI. Primary PTCA success was obtained in 30 (91%) patients and no major complications occurred. Angiographic evaluation was performed either for symptoms or for protocol (7 +/- 1 months after PTCA) in 28 (93%) of the 30 patients with successful PTCA, but 2 patients (7%) who were asymptomatic refused the repeat angiogram. Twenty (71%) had no restenosis and 8 (29%) had restenosis. Of these, 5 patients with restenosis underwent a successful repeat PTCA (6 +/- 1 months after the initial procedure). At the last clinical follow-up (17 +/- 8 months), 2 of the 30 (7%) patients successfully dilated presented with stable angina despite medical treatment, whereas the rest (93%) remained asymptomatic. During the study period no patient died, had an AMI or required coronary artery bypass grafting. Thus, selected patients with ischemia after a non-Q-wave AMI, a "high-risk population," can be effectively treated with PTCA with an initial success rate and angiographic restenosis rate similar to that of the general PTCA population and appear to have sustained symptomatic benefit remaining free of subsequent cardiac events.     

Percutaneous transluminal coronary angioplasty: Application for acute myocardial infarction

Seventy-eight of 1,000 consecutive PTCA procedures were performed in the setting of acute MI. Twenty-four of 26 patients with subtotal coronary occlusions underwent successful PTCA, including 9 patients with and 15 patients without previous intracoronary streptokinase infusions. Of 52 patients with total occlusions, PTCA was performed after reperfusion by streptokinase in 24 patients, after unsuccessful intracoronary streptokinase infusion in 6 patients and without previous thrombolytic therapy in 14 patients (27%). Six patients (7.7%) died. The immediate post-PTCA course was stable in 59 of 63 successfully dilated patients and 4 had coronary reocclusion. Late catheterization (mean 10 days) in 41 patients showed improved left ventricular function in most. At 6.5 months of follow-up, there were 9 restenoses that required PTCA, 1 reocclusion, 1 elective CABG and no deaths.     

Percutaneous transluminal coronary angioplasty versus thrombolysis in acute myocardial infarction: A meta-analysis

While percutaneous transluminal coronary angioplasty (PTCA) as a primary modality for treating acute myocardial infarction (MI) has been shown to have important advantages over thrombolysis, a survival benefit has not been demonstrated because of the small size of the individual trials. To increase the statistical power to detect a survival benefit, we performed a meta-analysis of trials of PTCA and thrombolysis. We pooled the data for all randomized, controlled trials; randomized, controlled trials stratified according to thrombolytic agent [streptokinase vs. tissue plasminogen activator (TPA)]; and all trials. Pooling was performed by calculating the Mantel-Haenszel odds ratio with the Robins, Greenland, and Breslow estimate of variance. Calculation of the Q statistic was performed to assess heterogeneity. For all four analyses, the odds ratio indicated a significant survival advantage of PTCA over thrombolysis: all randomized controlled trials [0.57,95% confidence index (CI): 0.48,0.68)]; streptokinase trials [0.61,95% CI: 0.43,0.87); TPA trials (0.52,95% CI: 0.36,0.76); all trials (0.51,95% CI: 0.43,0.61). The Q statistic was not significant for any of the analyses. The results of our meta-analysis support the hypothesis that PTCA is associated with a significant reduction in mortality compared with thrombolysis.     

Percutaneous transluminal coronary angioplasty for angina pectoris after a non-Q-wave acute myocardial infarction

Despite initially favorable prognosis in patients with non-Q-wave acute myocardial infarction (AMI), long-term mortality in this subset of patients appears to be similar to or even greater than that in patients with Q-wave AMI. The relatively poor late prognosis is primarily due to a high incidence of unstable angina and recurrent AMI. Between January 1982 and January 1987, 114 patients with suitable coronary narrowing underwent percutaneous transluminal coronary angioplasty (PTCA) for angina pectoris (present either at rest or during mild exertion, and despite optimal pharmacologic therapy), a median of 31 (range 2 to 362) days after a non-Q-wave AMI. Success was achieved in dilating the obstructed artery in 98 patients (113 of the 129 dilated arteries). Emergency bypass surgery was performed in 7 patients. Mean clinical follow-up of 20 (range 3 to 59) months was obtained in all patients and revealed no deaths. Of the 98 patients with successful PTCAs, 6 (6%) developed a nonfatal recurrent AMI and 62 (63%) were asymptomatic. However, recurrent angina affected 31 patients (32%) and was treated by repeat PTCA (n = 18), coronary bypass surgery (n = 5) or pharmacologic therapy (n = 8). At follow-up, 74% of the patients (73 of 98) were asymptomatic after a successful PTCA and, if necessary, a repeat PTCA, without incidence of recurrent AMI, coronary bypass surgery or death. The high initial success rate, low incidence of subsequent death and late recurrent AMI and sustained symptomatic benefit suggest that PTCA is an effective initial treatment strategy in these selected patients.     

Percutaneous transluminal coronary angioplasty for treatment of acute myocardial infarction: comparison with percutaneous transluminal coronary recanalization

Percutaneous transluminal coronary angioplasty (PTCA) was evaluated as a means of reperfusion of the infarct-related coronary artery, and the results were compared with those of percutaneous transluminal coronary recanalization (PTCR). There were no difference in sex, age, infarct location and time from the onset to start of treatment between 135 patients with evolving acute myocardial infarction treated with PTCA (PTCA group) and 113 patients treated with PTCR alone (PTCR group). Fifty-nine patients in the PTCA group underwent PTCA following PTCR; the remaining 76 patients were without prior PTCR. Successful PTCA, defined as a 20% or more reduction in percent luminal stenosis diameter, was achieved in 123 (90%) of the 135 patients in the PTCA group. The reperfusion rate was 93% in the PTCA group and 77% in the PTCR group (p less than 0.01). Residual stenosis immediately after the treatment was 30 +/- 13% in the PTCA group and 70 +/- 16% in the PTCR group (p less than 0.01). In the PTCA group, three cases developed serious complications which were associated with angioplasty: coronary perforation, side branch occlusion resulting in cardiogenic shock and exacerbation of cardiogenic shock. The latter two patients died, however, there was no difference in hospital mortality rate: 6% in the PTCA group versus 11% in the PTCR group. At follow-up angiography performed four weeks after admission, reocclusion of the successfully recanalized arteries was observed in 3% of the PTCA group and in 14% of the PTCR group (p less than 0.01). Regional wall motion was evaluated by left ventriculography using a wall motion score system which consisted of six grades; from normal counted as 0, to dyskinesis counted as 5. There was no difference in the wall motion score between the successful PTCA group and the successful PTCR group (2.6 +/- 1.4 versus 2.8 +/- 1.4), but the scores of both groups were better than those of the non-recanalized group (3.4 +/- 1.0: p less than 0.01). In conclusion, PTCA and PTCR have the same effect on hospital mortality rate and regional wall motion, but PTCA has a higher reperfusion rate and a lower reocclusion rate than does PTCR. Although PTCA has a potential disadvantage inducing serious complications, it appears to be a useful treatment for acute myocardial infarction.     

急诊经皮腔内冠状动脉成形术治疗急性心肌梗死

目的 :观察急诊经皮腔内冠状动脉成形术 (PTCA)治疗急性心肌梗死 (AMI)的效果。方法 :13例 AMI患者行急诊 PTCA治疗 ,男 10例 ,女 3例 ,年龄 38～ 85 (6 0 .2± 13.6 )岁。其中 6例并发心源性休克 ,3例系溶栓失败后行补救性 PTCA,4例不适作溶栓治疗。梗死相关血管 :前降支 9例 ,右冠状动脉 4例。结果 :PTCA成功率92 .3% ,死亡 1例。术前梗死相关血管狭窄 (98.7± 3.0 ) % ,术后残余狭窄为 (14.6± 16 .2 ) %。 3例术中发生心室颤动 ,1例出现房室传导阻滞 ,1例出现无再流现象 ,经反复冠状动脉内注射硝酸甘油后恢复。术后 1例死亡 ,11例长期生存 ,随访 1～ 18个月无心脏事件发生 ,生活质量明显改善。结论 :AMI时行急诊 PTCA成功率高 ,对溶栓禁忌证、溶栓失败或 AMI并发心源性休克者应积极行急诊 PTCA。     

Percutaneous transluminal coronary angioplasty improves survival in acute myocardial infarction complicated by cardiogenic shock

Modest survival benefits have been reported in patients with acute myocardial infarction complicated by cardiogenic shock who were treated with early surgical revascularization or thrombolytic therapy. To determine whether coronary angioplasty improves survival, 87 patients with cardiogenic shock complicating acute myocardial infarction at the University of Michigan, Ann Arbor, Michigan, from 1975 to 1985 were retrospectively analyzed. Patients in group 1 (n = 59) were treated with conventional therapy; patients in group 2 (n = 24) were treated with conventional therapy and angioplasty. Extent of coronary artery disease, infarct location, and incidence of multivessel disease were similar between groups. Hemodynamic variables including cardiac index, mean arterial pressure, and pulmonary capillary wedge pressure were also similar. The 30-day survival was significantly improved for group 2 patients (50% vs. 17%, p = 0.006). Survival in group 2 patients with successful angioplasty was 77% (10 of 13 patients) versus 18% (two of 11 patients) in patients with unsuccessful angioplasty, (p = 0.006). The findings suggest that angioplasty improves survival in cardiogenic shock compared with conventional therapy with survival contingent upon successful reperfusion of the infarct-related artery.     

Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction

Coronary angioplasty combined with thrombolytic therapy using urokinase (UK-PTCA) was attempted for acute myocardial infarction from September 1983 to December 1985, and without thrombolytic therapy (direct PTCA), thereafter. For UK-PTCA, the lesion was severely stenosed in 13, subtotally occluded in two and totally occluded in 21, and 29 lesions (81%) were successfully dilated. For direct PTCA, the lesion was stenosed in five, subtotally occluded in two and totally occluded in 14, and 19 lesions (90%) were dilated. Only one lesion in UK-PTCA had restenosis during hospitalization, but it was successfully redilated. Follow-up angiography was performed for 26 among 29 UK-PTCA cases and showed patency (diameter stenosis less than 50%) in 13, restenosis (less than 50%) in 12 and occlusion in one. Ten among 12 restenosed lesions were redilated and they were all patent at subsequent angiography. In 15 of 19 dilated lesions with direct PTCA, the lesion was patent in 10, and restenosed in five. Four of them were redilated and remained patent at subsequent angiography. Major complications occurred only in the UK-PTCA group before the judicious use of intra-aortic balloon pumping for hemodynamic instability. These included two deaths due to cardiogenic shock, one coronary dissection, and one sudden reocclusion, possibly due to thrombus formation. PTCA is applicable with or without thrombolytic therapy for acute myocardial infarction with high primary success rate and maintain coronary flow thereafter.