A Randomized Trial of Intravenous Streptokinase Versus Tissue Plasminogen Activator for the Treatment of Acute Myocardial Infarction: Results Using an Aggressive Approach

Seventy-six patients presenting within 6 hours of the onset of an acute myocardial infarction were randomized to either treatment with 1.5 million units of Streptokinase or 100 mg of recombinant tissue plasminogen activator intravenously. Patients not demonstrating clinical reperfusion within 1 hour were taken emergently for “salvage” angioplasty or coronary bypass surgery. Those patients demonstrating clinical reperfusion underwent early (12 to 72 hours) elective angiography and either elective angioplasty or bypass surgery. The mean time from pain onset to treatment was 149 minutes in the Streptokinase group and 134 minutes in the recombinant tissue plasminogen activator group (P = NS). There were no statistical differences between groups with regard to prior myocardial infarction, infarct location, prior coronary bypass surgery and Killip classification. Clinical reperfusion was demonstrated in 56% of the Streptokinase group and 53% of the recombinant tissue plasminogen activator group (P - NS). Angiographic patency was demonstrated in 70% of the Streptokinase group and 66% of the recombinant tissue plasminogen activator group (P = NS). Left ventricular ejection fraction at discharge was no different: 47% in the Streptokinase group and 43% in the recombinant tissue plasminogen activator group (P = NS). Recurrent ischemic events were found more often in the recombinant tissue plasminogen activator group, 18%, versus the Streptokinase group 3% (P = 0.05). Treatment outcomes did not differ between groups. There was one (3%) death in the Streptokinase group versus two (6%) deaths in the recombinant tissue plasminogen activator group (P = NS). There was a trend toward a greater need for emergent coronary bypass surgery after attempted angioplasty in the recombinant tissue plasminogen activator group, four of 18 patients (22%) versus one of 23 patients (4%) in the Streptokinase group (P = 0.14). In summary, in the setting of acute myocardial infarction treated by thrombolysis, those patients treated with recombinant tissue plasminogen activator experienced significantly more recurrent ischemic events and required emergent coronary bypass surgery more frequently for failed angioplasty compared to those treated with Streptokinase. The results suggest there may be agent specific increases in complications dependent upon the thrombolytic agent of choice when salvage or early coronary angioplasty is used.     

Favorable early and long-term prognosis following coronary bypass surgery therapy for myocardial infarction: results of a multicenter trial. TAMI Study Group

Coronary bypass surgery was performed before hospital discharge on 82 (21%) of 386 consecutive patients enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) multicenter trial of intravenous tissue plasminogen activator and coronary angioplasty for acute myocardial infarction. Time from infarct symptom onset to coronary bypass surgery was 7.3 +/- 1.9 hours for 24 patients operated upon on an emergency basis and 9.3 +/- 5.2 days for 58 patients having late in-hospital surgery. There were no operative deaths and five in-hospital deaths in the surgical group, all of which occurred in patients with preoperative cardiogenic shock. Although patients in the surgical group were older (59.7 +/- 10.4 years versus 54.9 +/- 10.2 years; p = 0.03), had more extensive coronary artery disease (42% three-vessel disease versus 11%; p = 0.001), and had a higher incidence of anterior wall myocardial infarction (48% versus 39%; p = 0.02), in-hospital mortality for the surgical group (6%) was similar to that in 301 patients not undergoing surgery (7%) in this trial. For patients discharged from the hospital, mortality at 1 year was 2.5% in the surgical group and 1.8% in patients not having coronary bypass surgery before hospital discharge. At a 1 year follow-up, there were no significant differences in the frequency of cardiac or noncardiac-related hospitalizations or in event-free survival between surgical and nonsurgical groups. The majority of patients in both groups considered themselves to be in excellent or good condition. Coronary bypass surgery can be performed with low morbidity and mortality rates in close temporal association to acute myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

After thrombolytic therapy: angiography, angioplasty, or surgery?

Thrombolytic therapy has been found to improve the prognosis of selected patients with acute myocardial infarction. Many investigators advocate that combined emergency coronary angiography and percutaneous transluminal coronary angioplasty be performed immediately after thrombolytic therapy. Emergency angiography documents the anatomic extent of coronary artery disease, shows whether reperfusion has occurred, and indicates whether emergency angioplasty is necessary. In this setting, emergency catheterization without angioplasty is associated with relatively little additional risk. However, a number of prospective trials have compared emergency angioplasty to more conservative treatment strategies, and emergency angioplasty has been not found to offer any advantage in terms of improved prognosis or preservation of left ventricular function. Therefore, it is probable that most patients with evolving Q-wave myocardial infarction are best treated with conservative strategies after initial thrombolytic therapy, although there may still be a role for emergency angioplasty in a relatively small subset who present with evolving myocardial infarction and severely depressed left ventricular function. Emergency coronary artery bypass surgery also appears to have a limited role in patients treated with thrombolytic therapy. Nevertheless, in occasional patients with a poor prognosis at hospital presentation, in whom thrombolytic therapy and emergency angioplasty have failed or are contraindicated, prompt emergency coronary artery bypass grafting may salvage the ischemic myocardium and improve the prognosis.     

Emergency percutaneous transluminal coronary angioplasty in acute myocardial infarction: a 3 year experience

In 151 patients experiencing acute myocardial infarction, emergency coronary angioplasty was performed as primary therapy. Overall, angioplasty was successful in 132 patients (87%); it was successful in 91 (85%) of 107 patients with a totally occluded infarct-related artery and in 41 (93%) of 44 patients with a subtotally occluded infarct-related artery. After successful angioplasty, mean residual stenosis was 29% (range 0 to 70). Eighteen patients were in cardiogenic shock (12%) including four patients receiving cardiopulmonary resuscitation during the angioplasty procedure. Hospital mortality was 9%, with 7 of 13 deaths occurring in patients presenting with cardiogenic shock or intractable ventricular arrhythmia. Hospital mortality was 5% in patients with successful angioplasty versus 37% in those with unsuccessful angioplasty (p less than 0.001). In the immediate period after angioplasty, left ventricular ejection fraction was significantly lower for patients with lesions of the left anterior descending artery (34 +/- 10%) than for patients with lesions of the left circumflex or right coronary artery (43 +/- 11%). In patients with successful angioplasty, significant improvement in left ventricular ejection fraction averaged 13 +/- 12% (p less than 0.001) for those with lesions of the left anterior descending artery and 10 +/- 12% (p less than 0.001) for those with lesions of the left circumflex or right coronary artery. Repeat coronary angiography was performed in 85 (70%) of 121 patients who had successful angioplasty and survived hospitalization without requiring bypass surgery; restenosis was found in 26 (31%), and angioplasty was repeated in 22 patients, successfully in each.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term outcome of unsuccessful percutaneous transluminal coronary angioplasty

We analyzed the long-term outcome of 198 patients after unsuccessful percutaneous transluminal coronary angioplasty. Forty-nine percent underwent emergency coronary artery bypass grafting surgery, 17% had elective bypass surgery, and 34% were treated medically. The in-hospital mortality rate was 4%, and myocardial infarction occurred in 36% of patients. Follow-up was completed in 100% of patients with a mean follow-up period of 35 +/- 22 months. Actuarial cardiac survival at 4 years was 97% in the emergency bypass surgery group, 100% in the elective bypass surgery group, and 86% in the medically treated group. Actuarial event-free survival (freedom from myocardial infarction, bypass surgery, coronary angioplasty, and cardiac death) at 4-year follow-up was 81% in 198 patients, 90% in the emergency bypass surgery group, 85% in the elective bypass surgery group, and 65% in the medically treated group. Results of multivariate analysis showed that emergency or elective bypass surgery after failed coronary angioplasty, normal or mildly impaired left ventricular function, and male sex were predictors of better outcome at 4 years.     

High risk percutaneous transluminal coronary angioplasty in the treatment of severe coronary artery disease

We report on 27 "high risk" patients out of 171 consecutive patients undergoing percutaneous transluminal coronary angioplasty from June 1984 to August 1985. The ages ranged from 31-80 years (mean 62.7 +/- 10) years. High risk percutaneous transluminal coronary angioplasty was defined as: salvage cases (3 patients) where the patients presented in cardiogenic shock or the vessels were not bypassable; multivessel coronary artery disease (22 patients) where a large area of jeopardized myocardium was dependent on the angioplasty vessel(s); left ventricular dysfunction (7 patients) as defined by two of the three criteria: left ventricular end-diastolic volume index greater than 100 ml/m2; ejection fraction less than 30%; and left ventricular end-diastolic pressure greater than 20 mm Hg. The initial success rate in the high risk patients was 85.2%. Emergency coronary artery bypass surgery in these patients was 7.4%. There was one death in the high risk group, as one of the salvage cases died 24 hours after successful percutaneous transluminal coronary angioplasty due to severe underlying myocardial disease. In conclusion percutaneous transluminal coronary angioplasty can be successfully performed in high risk patients with a low complication rate and should be considered as an alternative to coronary artery bypass graft surgery in selected high risk patients.     

Determinants of the need for early acute intervention in patients treated conservatively after thrombolytic therapy for acute myocardial infarction. TAMI-5 Study Group

This study sought to determine whether clinical variables can be used to identify patients at high risk of recurrent spontaneous myocardial ischemia or hemodynamic compromise during the 1st 4 days after intravenous thrombolysis for acute myocardial infarction. Of 288 patients randomly assigned to a conservative postthrombolysis strategy, 54 (19%) required urgent cardiac catheterization within 24 h; 75 (26%) underwent urgent cardiac catheterization within 4 days of admission. Of the clinical variables examined by multiple logistic regression analysis, only patient age and anterior wall myocardial infarction correlated with the need for urgent cardiac catheterization (p = 0.0016 and p = 0.017, respectively). Compared with recombinant tissue-type plasminogen activator or urokinase monotherapy, combination therapy with these agents was associated with a lower need for acute intervention during the 1st 24 h after admission, but the difference did not reach statistical significance (14% for combination therapy vs. 21% for each agent alone, p = 0.30). Of the 75 patients undergoing urgent coronary angiography, only 39% had an occluded infarct-related artery. Emergency coronary angioplasty was performed in 49% of the patients and coronary artery bypass graft surgery was performed urgently in 3%. Despite these interventions, the need for urgent cardiac catheterization was associated with an in-hospital mortality rate of 7% (vs. 3% in the group not requiring urgent angiography, p = 0.36); mean left ventricular ejection fraction was 50.5 +/- 11% (vs. 54.3 +/- 10.8%, p = 0.12) and regional infarct zone wall motion was -2.68 +/- 1.07 SD/chord (vs. -2.46 +/- 1.19 SD/chord; p = 0.44).(ABSTRACT TRUNCATED AT 250 WORDS)     

Intra-aortic balloon counterpulsation support for elective coronary angioplasty in the setting of poor left ventricular function: a two center experience

A two-center elective coronary angioplasty experience with intra-aortic balloon pump support for patients with severe left ventricular dysfunction is reported. To prevent hemodynamic collapse, an intra-aortic balloon pump was inserted percutaneously before coronary angioplasty in 97 patients with a left ventricular ejection fraction less than 35% (26% of whom had ejection fractions less than 25%). The cohort was predominantly male (71%) with a mean age of 64 +/- 9 years. Angioplasty was successfully performed in 83 (85.6%) patients and 80 (82.5%) of these successful patients were discharged from the hospital. Seven patients had unsuccessful angioplasty without a major cardiac event. Seven patients (7.2%) suffered a major cardiac event; 4 had emergent coronary bypass surgery with q-wave infarction, 2 had uneventful emergency coronary bypass surgery, and one patient died in the operating room after a failed angioplasty. Using logistic regression analysis, the presence of multivessel disease and a history of prior myocardial infarction were associated with more complications during angioplasty (p less than 0.05). Intra-aortic balloon pump placement did not interfere with the angioplasty procedure. Two patients had limb ischemia which resolved when the intra-aortic balloon pump was removed. Of the 80 successful patients discharged, 72 were followed for a mean of 22 months. At the latest follow-up, 52 had not suffered a myocardial infarction and were alive. Of the 20 late deaths, 16 were cardiac and 4 non-cardiac.(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary bypass surgery improves global and regional left ventricular function following thrombolytic therapy for acute myocardial infarction. TAMI Study Group

Coronary bypass surgery was performed prior to hospital discharge in 303 (22%) of 1387 consecutive patients enrolled in the TAMI 1 to 3 and 5 trials of intravenous thrombolytic therapy for acute myocardial infarction. Bypass surgery was of emergency nature (less than 24 hours from treatment with intravenous thrombolytic therapy) in 36 (2.6%) and was deferred (greater than 24 hours) in 267 (19.3%) patients. The indications for bypass surgery included failed angioplasty (12%); left main or equivalent coronary disease (9%); complex or multivessel coronary disease (62%); recurrent postinfarction angina (13%); and refractory pump dysfunction, mitral regurgitation, ventricular septal rupture or abnormal predischarge functional test (1% each). Although patients having bypass surgery were older (59.5 +/- 9.8 versus 56.0 +/- 10.2 years, (p less than 0.0001), had more extensive coronary artery disease (46% with three-vessel disease versus 11%, (p less than 0.0001), had more frequent diabetes mellitus (19% versus 15%, (p = 0.048), had more prior infarctions (p less than 0.0001), had more severe initial depression in global left ventricular ejection fraction (48.0 +/- 11.9% versus 51.8 +/- 11.9%, p = 0.0002), and regional infarct zone (-2.7 +/- 0.94 versus -2.5 +/- 1.1 SD/chord, p = 0.02) and noninfarct zone function (-0.36 +/- 1.8 versus 0.43 +/- 1.6 SD/chord, p less than 0.0001) than patients not having coronary bypass surgery, no difference in the incidence of death in hospital (7% surgical versus 6% nonsurgical) or death at long-term follow-up of hospital survivors (7% surgical versus 6% nonsurgical) was noted between groups. Surgical patients demonstrated a greater degree of recovery in left ventricular ejection fraction (3.4 +/- 9.8% versus 0.16 +/- 8.5%, p = 0.036) and infarct zone regional function (0.71 +/- 1.1 versus 0.34 +/- 0.99 SD/chord, p = 0.001) when immediate (90 minutes following initiation of thrombolytic therapy) and predischarge (7 to 14 days after treatment) contrast left ventriculograms were compared than did patients who received only intravenous thrombolytic therapy with or without coronary angioplasty. These data suggest a beneficial influence of coronary bypass surgery on left ventricular function and possibly on the clinical outcome of patients initially treated with intravenous thrombolytic therapy for acute myocardial infarction.     

Angioplasty in ulcerative coronary artery disease: acute results and early follow-up.

The safety and efficacy of percutaneous transluminal coronary angioplasty (PTCA) for stenoses involving ulcerative lesions were retrospectively studied. Seventy-seven patients (62 men and 15 women, mean age 62 +/- 10 years) representing 3.4% of 2,250 patients treated with PTCA during the period January 1, 1988 and June 30, 1990, had pre-PTCA stenoses defined as ulcerated. Twenty-eight (36%) of the stenoses were localized in the left anterior descending coronary artery, 9 (12%) in the left circumflex and 40 (52%) in the right coronary artery. During angioplasty, percent diameter stenosis was reduced from 73 +/- 14% to 22 +/- 13% and transstenotic gradient decreased from 48 +/- 18 to 12 +/- 6 mm Hg. Clinical success (freedom from angina at discharge without coronary bypass surgery, infarction or death) was achieved in 70 patients (90.9%). There were seven unsuccessful cases: three underwent elective coronary bypass surgery, one was managed medically, and three developed a major flow interrupting dissection during the procedure requiring emergency coronary bypass surgery. There were no deaths. At mean follow-up of 7.6 months, 45 of 61 patients (73.7%) remained asymptomatic. One patient needed an elective coronary bypass surgery and five patients had a successful repeat PTCA. In conclusion, PTCA for an ulcerated stenosis can be performed safely with a high primary success rate and a favorable early clinical course.     

Coronary angioplasty in octogenarians: comparisons to coronary bypass surgery

Coronary angioplasty was performed in 74 patients 80 years of age and older (mean 83 +/- 3). Single vessel coronary disease was present in 34% and multivessel coronary disease in 66%. Angioplasty of a single vessel was performed in 51 patients (69%), while 23 (31%) had angioplasty of multiple vessels. Angioplasty was successful in 59 of 74 patients (80%). Angioplasty was unsuccessful but uncomplicated in 12 (16%) due to (unyielding) calcified lesions or (impassable) old occlusions. Of these 12, 8 were discharged on medical therapy and 4 underwent elective uncomplicated bypass surgery prior to discharge. Three (4%) patients required emergency coronary bypass surgery due to abrupt vessel closure during the angioplasty procedure, with one hospital death (1.4%). Follow-up (mean 24 +/- 22 months) was obtained in all patients. Of the 59 successful angioplasty patients, late mortality was 10% (cardiac 7% and non-cardiac 3%). Survival and survival without myocardial infarction were both 90%; survival without either infarction or bypass surgery was 86%. Actuarial 3-year survival was 91% and 3-year freedom from death, infarction or bypass surgery was 87% by life-table analysis. Repeat angioplasty for restenosis was performed in 7 patients (12%) without complications.     

Percutaneous transluminal coronary angioplasty in patients with prior myocardial infarction: angioplasty at a distance from the prior infarct zone

Patients undergoing coronary angioplasty who have had a prior transmural myocardial infarction in the distribution of a contralateral coronary artery are considered a high-risk group because of potentially severe left ventricular dysfunction if an ischemic complication occurs. The purpose of this study was to evaluate the safety and efficacy of coronary angioplasty in 28 patients with prior myocardial infarction remote from the artery undergoing dilatation. Prior myocardial infarction was defined by the presence of pathologic Q waves on ECG or segmental akinesis on ventriculography. Angioplasty was successful in 30 of 33 lesions (91%) and in 25 of 28 patients (89%). Mean stenosis diameter was reduced from 91% +/- 7% to 28% +/- 16%; mean translesional gradient after angioplasty was 6 +/- 5 mm Hg. No patient developed severe hemodynamic deterioration from transient coronary occlusion during balloon inflation or from an acute ischemic complication. Three patients underwent coronary artery bypass surgery after unsuccessful angioplasty. There were no new Q wave infarctions or deaths. The results of coronary angioplasty in patients with prior infarction were compared with those of 203 patients without prior remote infarction. Primary success and occurrence of major complications were comparable in both groups. At a mean follow-up of 12 +/- 6 months, 18 of the 25 patients (72%) who underwent initially successful dilatation have remained symptom free with angioplasty alone. Therefore, coronary angioplasty is a suitable therapeutic procedure in carefully selected patients with angina pectoris and prior myocardial infarction at a distance from the site of angioplasty.     

Triple vessel coronary angioplasty: acute outcome and long-term results

Triple vessel coronary angioplasty, defined as angioplasty of one or more lesions in each of the three major coronary arteries (left anterior descending, left circumflex, right coronary artery) was performed in 50 (11%) of 469 patients who had angioplasty of multiple vessels. There were 32 men and 18 women with a mean age of 56 years. All 50 patients had severe three vessel coronary disease and represent approximately 5% of patients with three vessel disease who had revascularization in this institution; 8 (16%) had previous coronary bypass surgery, and 23 (46%) had previous myocardial infarction. Unstable angina was present in 33 patients (66%) and 96% had Canadian Heart Association class III or IV angina; mean left ventricular ejection fraction was 57 +/- 11%. Angioplasty was performed in 176 vessels (3.5 vessels per patient, range 3 to 6) and in 250 lesions (5 lesions per patient, range 3 to 9); angiographic success was achieved in 240 lesions (96%) and 166 vessels (94%). Success in all vessels attempted was achieved in 40 (80%) of the 50 patients. Clinical success (angiographic success associated with clinical improvement) was obtained in all 50 patients in whom triple vessel angioplasty was performed; none of them required urgent bypass surgery and 5 patients (10%) had a non-Q wave myocardial infarction. In four other patients triple vessel angioplasty was planned but not performed because of failure to dilate the primary vessel; urgent bypass surgery was required in one of these, who developed a Q wave infarction. Thus, overall clinical success in 54 patients was 93%; the incidence rate of myocardial infarction was 11%, and that of urgent surgery 1.8%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical outcome 5 years after attempted percutaneous transluminal coronary angioplasty in 427 patients

This study was performed to define the 5 year clinical status of 427 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) in 1981. Their mean age was 54 +/- 10 years (+/- 1 SD). Sixty-one percent had unstable angina, 23% had prior myocardial infarction, 86% had one-vessel disease, and 92% had normal left ventricular function. Sixty-seven percent of patients had left anterior descending artery stenosis. Angiographic success was achieved in 84% of patients. Coronary bypass surgery was required in 9.6% of patients, in 5.9% as an emergency procedure. There were no in-hospital deaths. Follow-up at 5 years was 100% complete. There were 15 late deaths (96.3 +/- 1.0% survival), including seven of cardiac cause (98.1 +/- 0.7% cardiac survival). Myocardial infarction occurred in 24 patients (94% freedom from myocardial infarction), coronary bypass surgery was required in 63 (84% freedom from bypass surgery), and 365 patients (85%) were asymptomatic at follow-up. At 5 years, 83 patients (20%) had required an additional PTCA. Unstable angina pectoris and proximal left anterior descending coronary artery stenoses were present in 162 patients. The overall survival and cardiac survival in this subset was 94.4 +/- 1.8% and 98.1 +/- 1.1%, respectively. The excellent survival and low event rates over 5 years in this population support the concept that PTCA is safe and effective for patients with symptomatic angina pectoris, single-vessel disease, and normal left ventricular function.     

Percutaneous angioplasty of unprotected left main coronary disease with implantation of systematic stenting. Immediate and mid-term results

The authors report the immediate and medium term results of percutaneous angioplasty of unprotected left main coronary disease with systematic stenting. Between March 1994 and December 1998, out of 6,006 patients undergoing coronary angioplasty, 92 had significant unprotected left main stem disease. The majority of patients was male (74 men, 80%) with an average age of 74.3 +/- 8.1 years. Between March 1994 and October 1996, only patients with a surgical contraindication were treated by angioplasty (n = 39). After October 1996, the indications were extended to patients who did not have surgical contraindications (n = 53). During the hospital phase, 4 patients (4%) died (ventricular arrhythmia: 1, cardiogenic shock: 2, gastro-intestinal haemorrhage: 1). No non-fatal infarction with or without Q waves were observed, and no emergency coronary bypass surgical procedures were required. The angiographic success rate was 100%. During follow-up (7.3 +/- 5.8 months), 6 other patients died, 13 required a repeat coronary angioplasty, 4 for restenosis of the left main coronary artery, and 2 underwent coronary bypass surgery. The actuarial survival rate was 89 +/- 5% at 1 year and 85 +/- 17% at 3 years. Percutaneous angioplasty for unprotected left main coronary disease with systematic stenting was performed with acceptable hospital and medium term results.     

Coronary angioplasty for acute myocardial infarction

PURPOSE: To critically review the role of coronary angioplasty for acute myocardial infarction. DATA IDENTIFICATION: Studies published from January 1982 to June 1988 were identified through a search of the English-language literature using MEDLINE and thorough extensive hand searching of bibliographies of identified articles. STUDY SELECTION: All consecutive patient series and randomized trials of coronary angioplasty for acute myocardial infarction. DATA EXTRACTION: Demographic characteristics, technical results, clinical outcomes, and left ventricular function results were collated. RESULTS of DATA SYNTHESIS: Three randomized trials have compared immediate and deferred coronary angioplasty after intravenous tissue plasminogen activator. Immediate angioplasty was associated with increased mortality, increased need for emergency bypass surgery, higher transfusion requirement, and no benefit in terms of left ventricular functional recovery. CONCLUSIONS: The role of coronary angioplasty for myocardial infarction has thus far been established as adjunctive, in a delayed time frame after thrombolytic therapy. Coronary angioplasty has not been shown to reduce in-hospital mortality or improve resting left ventricular function. A deferred strategy has improved exercise left ventricular performance, and several follow-up studies suggest a favorable long-term prognosis.     

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery

The results of coronary artery bypass surgery after failed elective coronary angioplasty in patients who have undergone prior coronary surgery are unknown. Coronary angioplasty may be performed to relieve angina after surgery either to the native coronary vessels or to grafts. Failure of attempted coronary angioplasty may mandate repeat coronary surgery, often in the setting of acute ischemia. From 1980 to 1989, 1,263 patients with prior coronary bypass surgery underwent angioplasty; of these patients, 46 (3.6%) underwent reoperation for failed angioplasty during the same hospital stay. Of the 46 patients who underwent reoperation, 33 had and 13 did not have acute ischemia. In the group with ischemia, 3 patients (9.1%) died and 14 (42.4%) died or had a Q wave myocardial infarction in the hospital compared with no deaths (p = NS) and no deaths or Q wave myocardial infarction (p = 0.005) in the group without ischemia. At 3 years, the actuarial survival rate was 88 +/- 6% in the group with ischemia, whereas there were no deaths in the group without ischemia (p = NS), and freedom from death or myocardial infarction was 51 +/- 10% in the group with ischemia, versus no events in the group without ischemia (p = 0.006). In most patients with prior coronary bypass surgery, coronary angioplasty was performed without the need for repeat coronary bypass surgery. Should coronary angioplasty fail, reoperation in patients without acute ischemia can be performed with overall patient survival comparable to that of elective reoperative coronary bypass without coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)     

Determinants of recurrent ischaemia and revascularisation procedures after thrombolysis with recombinant tissue plasminogen activator in primary coronary occlusion

This paper reports the immediate effects of thrombolysis and their subsequent influence on revascularisation procedures and clinical outcome over the subsequent twelve months. Coronary arteriography was performed at 21 days on 131 of 145 patients who received recombinant tissue plasminogen activator (n = 68) or placebo (n = 63) within 2.5 hours of symptom onset after primary coronary occlusion. Patency rates (TIMI grades 2 and 3) of the infarct-related artery were 81% with plasminogen activator and 63% with placebo (P = 0.02). Early (within 21 days) angiography for recurrent ischaemia was necessary in 31 (21%) patients (20 plasminogen activator, 11 placebo NS) and definite reinfarction occurred in 8 (5%) patients (4 plasminogen activator, 4 placebo). During one year follow-up without planned secondary intervention, coronary artery bypass grafting was more frequent in patients who had received thrombolytic therapy (23% plasminogen activator, 4% placebo P = 0.001); coronary angioplasty procedures were similar in both groups (12% plasminogen activator, 11% placebo NS). Mortality at 21 days was 5% (4 plasminogen activator, 4 placebo) and at one year was 7% (5 plasminogen activator, 5 placebo). Logistic regression analysis identified models comprising characteristics predictive of subsequent bypass grafting (plasminogen activator, multivessel disease, occluded infarct-related artery) and coronary angioplasty (non-q wave infarction, severe (91-99%) residual stenosis, left anterior descending infarct-related artery). Initial non-q wave infarction was the only predictor of early recurrent ischemia (odds ratio 4, P = 0.02) irrespective of residual stenosis severity.     

Intravenous Thrombolytic Treatment for Acute Myocardial Infarction

Abstract. Intravenous thrombolytic treatment (streptokinase or anisoylated plasminogen streptokinase activator complex (APSAC) was given to 50 consecutive patients within 3 hours after onset of symptoms of acute myocardial infarction. Left heart catheterisation with coronary angiography and simultaneous double view left ventriculography were performed approximately 4 hours after start of thrombolytic treatment. This examination showed that the acute infarct-related coronary artery was open in 36 patients (72%) and closed in 14 patients (28%). A higher left ventricular ejection fraction was found among patients with open, than among patients with closed infarct-related artery (58.8% vs. 48.4%, p=0.05). The group with open artery also had a lower score of regional left ventricular dysfunction (1.7 vs. 2.4, p<0.05, on a scale from 0–3). Single, double and triple vessel coronary heart disease was found in 22, 14 and 13 patients respectively. Mean age was lower in the group with single vessel disease as compared to double and triple vessel disease (48.4 years vs. 53.4 and 55.4 years, p<0.05 and p<0.005). Independently of whether the infarct-related artery was open or closed, there tended to be an inverse correlation between number of diseased vessels and preservation of left ventricular function (statistical significance only for single vessel versus triple vessel disease with respect to score of regional left ventricular dysfunction, 1.8 vs. 2.4, p<0.05). These findings suggest that early thrombolytic treatment within 3 hours of onset of symptoms may preserve myocardial tissue during the evolution of acute infarction. Furthermore, a presumably better collateralisation from adjacent coronary arteries without stenoses may be important for myocardial preservation. Finally, early angiographic examination can be performed safely and is a good support for determination of further treatment, which in the actual patients was coronary bypass surgery in 8 cases, transluminal angioplasty, PTCA, in 20 cases, and medical treatment alone in 22 cases.     

Multivessel coronary angioplasty from 1980 to 1989: procedural results and long-term outcome

From June 1980 to January 1989, 3,186 patients had coronary angioplasty of two (2,399 patients) or three (787 patients) of the three major epicardial coronary systems. A mean of 3.6 lesions (range 2 to 14) were dilated per patient, with a 96% success rate. Acute complications were seen in 94 patients (2.9%) and included Q wave infarction in 47 (1.4%), urgent coronary artery bypass surgery in 33 (1%) and death in 31 (1%). Multivariate correlates of in-hospital death included impaired left ventricular function, age greater than or equal to 70 years and female gender. Complete long-term follow-up data were available for the first 700 patients and the follow-up period averaged 54 +/- 15 months in duration. Actuarial 1 and 5 year survival rates were 97% and 88%, respectively, and were not different in patients with two or three vessel disease. By Cox regression analysis, age greater than or equal to 70 years, left ventricular ejection fraction less than or equal to 40% and prior coronary artery bypass surgery were associated with an increased mortality rate during the follow-up period. Repeat revascularization procedures were required in 322 patients (46%). Restenosis resulted in either repeat angioplasty or bypass surgery in 227 patients (32%). Repeat coronary angioplasty was performed for isolated restenosis in 126 patients (18%), for restenosis and disease progression at new sites in 85 patients (12%) and for new disease progression alone in 54 patients (8%). Coronary bypass surgery was required in 110 patients (16%) during the follow-up period.(ABSTRACT TRUNCATED AT 250 WORDS)