Long-term follow-up of patients treated with intracoronary thrombolysis or percutaneous transluminal coronary angioplasty for acute myocardial infarction]

Long-term follow-up data concerning coronary patients treated for acute myocardial infarction with intracoronary thrombolysis (ICT) or percutaneous transluminal coronary angioplasty (PTCA) are sparse. In this study, the early and long-term outcomes in 95 patients undergoing only ICT (group I) and 190 patients undergoing only PTCA (group II) were retrospectively evaluated. Cardiogenic shock cases in group II were excluded from this study because of the absence of comparable shock cases in group I. The overall in-hospital mortality was 3.5% (10 patients). Treatment by reperfusion therapy during the acute phase was not a significant factor in predicting the in-hospital mortality (5.4% in group I vs 2.6% in group II), but a Forrester subset (p < 0.001) and the extent of coronary artery disease (p < 0.05) were reliable predictors. In a discrimination analysis, a Forrester subset (3, 4) was the most reliable predictor followed by age (> 70 years). Follow-up was completed for 263 of 273 (96%) hospital survivors (88 patients in group I and 185 in group II). Mean follow-up periods of groups I and II (+/- SD) were 57 +/- 35 and 23 +/- 15 months, respectively. Five-year cardiac death-free survival for hospital survivors after ICT was 87% compared with 96% after PTCA (p was not significant). In a univariate analysis, a Forrester subset (p < 0.001) and the extent of residual coronary disease on discharge from the hospital (p < 0.01) were reliable predictors of subsequent cardiovascular deaths. Multivariate analysis also identified these 2 factors as independent predictors. We concluded that the most significant determinant factor of in-hospital and long-term mortality after intervention might be a Forrester subset; namely, left ventricular function at the time of emergency admission, and that long-term survival seemed to relate to the extent of coronary artery disease on discharge from the hospital. This suggested that interventional reperfusion therapy did not necessarily improve left ventricular function at the time of hospital discharge.     

Long-term follow-up after direct percutaneous transluminal coronary angioplasty for acute myocardial infarction

Objectives. The purpose of this study was to analyze long-term follow-up information over several years from consecutive, unselected patients treated with direct percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (MI).Background. Direct PTCA is often used in patients with acute MI. Short-term results are favorable. However, there is less information available on long-term observations over several years in these patients.Methods. A total of 416 consecutive and unselected patients with acute MI underwent direct PTCA. Survival of the acute infarct phase was 94.2%; the remaining 392 patients—the study population—were discharged and followed for 3.3 ± 1.4 years. Mortality as well as cardiac events and reinterventions are reported. Clinical variables assessed at the time of discharge are submitted to statistical analysis to detect potential risk factors.Results. Total cumulative mortality in the first year was 10% for the entire group and 6% for patients not presenting in cardiogenic shock. Mortality after discharge was 4.6% in the first year and dropped to <4% per year thereafter. Reinterventions after discharge were required in 16% in the first year and in <4% per year in years 2 to 4. Poor left ventricular ejection fraction (<35%), three-vessel disease and advanced age (≥75 years) were long-term risk factors for total mortality after direct PTCA.Conclusions. The clinical benefit of direct PTCA for acute MI is maintained during follow-up with respect to mortality. However, reinterventions for restenosis or de novo stenosis are often required (10% to 20%). Although few in number (<10%), patients with severely impaired left ventricular function continue to have a poor prognosis.     

Long-term follow-up of patients with acute myocardial infarction treated with primary angioplasty or thrombolysis. Results of the MITRA trial

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.     

Balloon coronary angioplasty in patients with acute myocardial infarction

After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.     

Essential thrombocythemia and acute myocardial infarction treated with rescue coronary angioplasty

A 48-year-old man with essential thrombocythemia suffered an extensive anterior acute myocardial infarction; this is a rare association. A pharmacological thrombolysis was performed, without success. He subsequently underwent successful rescue coronary angioplasty. To our knowledge, there is no other report in the literature relating the triad of essential thrombocythemia, acute myocardial infarction and rescue coronary angioplasty.     

Long-term prognosis after reperfusion therapy with emergency coronary angioplasty for acute myocardial infarction]

The influence of emergency coronary angioplasty (PTCA) for acute myocardial infarction on long-term survival was investigated. We followed 141 patients treated with emergency PTCA and 202 patients treated with thrombolytic therapy alone for a median of 1,157 days and a median of 2,133 days, respectively. All were initially completely occluded at the infarct-related coronary artery (IRCA). Actuarial survival curves were compared and independent predictors of late cardiac death were determined using Cox's proportional hazard model between overall patients and patients whose IRCA was at the proximal site of the left anterior descending artery (LAD). 1. Actuarial survival curves were similar in 2 groups. 2. Independent predictors of late cardiac death in overall follow-up patients were advanced age over 65 years (p < 0.03), a history of previous myocardial infarction (p < 0.03), severer stage of the Killip class on admission (p < 0.003), and the infarct-related proximal LAD (p < 0.01). 3. Among patients with the proximal LAD, the actuarial survival curve was better in those treated with emergency PTCA than in those treated with thrombolytic therapy alone (p < 0.01). 4. Among patients with the proximal LAD, independent predictors of late cardiac death were advanced age over 65 years (p < 0.03), treatment with thrombolytic therapy alone (p < 0.03), left ventricular ejection fraction < or = 40% (p < 0.06), and occluded IRCA on predischarge angiograms (p < 0.08). Among patients with the occluded proximal LAD, those treated with emergency PTCA showed better long-term survival rate than did patients with thrombolytic therapy alone, and this may be explained by higher successful reperfusion rates in the former than in the latter.     

Long-term benefits of monteplase before coronary angioplasty in acute myocardial infarction

Patients with acute myocardial infarction were randomly assigned to receive direct percutaneous coronary intervention (PCI) or pretreatment with intravenous monteplase followed by PCI. Although the combination of monteplase and PCI did not alter mortality compared with direct PCI, there was a dramatic reduction in the cardiac event rate over a 2-year follow-up compared with direct PCI.     

急性心肌梗塞经桡动脉腔内冠状动脉成形术

目的 近年来随着心导管器械的小型化,经桡动脉冠状动脉造影术及经皮腔内冠状动脉成形术(PTCA)已逐渐成为一种有益的替代途径.本文观察了其在急性心肌梗塞患者中的应用价值.方法和结果 对我院6例急性心肌梗塞患者行直接PT-CA,全部采用经桡动脉途径.其中男性4人,女性2人,平均年龄(62±5.8)岁.对6例梗塞相关血管行直接PTCA均获成功,其中4例各植入支架一枚.所有患者术后即拔导管鞘,局部弹性绷带固定、压迫4～6小时,无出血、假性动脉瘤、动静脉瘘等并发症发生.一例患者桡动脉搏动较术前减弱,无手缺血症状.结论 本研究初步显示,经桡动脉直接PTCA可安全有效应用于急性心肌梗塞患者.采用经桡动脉途径具有快速简便、穿刺中位出血并发症少、患者可尽早离床等优点.     

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 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     

Clinical manifestations and acute myocardial infarction in women treated with primary coronary angioplasty

OBJECTIVES: The differences in presentation, complications, and outcome of acute myocardial infarction treated with primary coronary angioplasty were compared in male and female patients. METHODS: Consecutive patients with acute myocardial infarction who were admitted within 12 hr of onset underwent primary percutaneous coronary intervention, including 120 female (31%) and 264 male (69%) patients. RESULTS: There were significantly more patients with diabetes mellitus (42% vs 31%, p = 0.03), and hyperlipidemia(56% vs 38%, p = 0.001), and fewer patients with current smoking (10% vs 60%, p < 0.0001) in the female group than in the male group (p < 0.01). The female group was significantly older (75 +/- 11 vs 67 +/- 12 years, p < 0.0001). The value of acute phase brain natriuretic peptide was significantly higher (483 +/- 543 vs 306 +/- 404 pg/ml, p = 0.001), and peak creatine kinase value was significantly lower (1,743 +/- 1,732 vs 2,855 +/- 2,997 IU/l, p = 0.0003) in the female group than in the male group. Both Killip's classification on admission (p = 0.04) and Thrombolysis in Myocardial Infarction grade soon after mechanical reperfusion therapy (p = 0.03) were significantly worse in the female group. There were significantly more patients with heart failure in the female group (40% vs 27%, p = 0.04). The cardiac mortality rates during 6 months was significantly higher in the female group (11% vs 5%, p = 0.02). However, multivariate analysis showed that female sex was not an independent predictor of cardiac death. CONCLUSIONS: Female patients with acute myocardial infarction seemed to have a poor prognosis, in spite of lower peak creatine kinase value and higher brain natriuretic peptide value. The reasons for poorer outcomes in women were considered to be patient background, such as higher age and diabetes mellitus, and condition of heart failure on admission.     

急性心肌梗塞合并泵衰竭的介入治疗

目的　评价急诊经皮冠状动脉腔内成形术（ＰＴＣＡ）对治疗急性心肌梗塞（ＡＭＩ）合并泵衰竭的安全性及有效性。方法　回顾性总结５１ 例ＡＭＩ患者（其中１９ 例合并严重泵功能衰竭和／或心源性休克）的急诊ＰＴＣＡ 资料及随访资料。结果　５１ 例患者中,梗塞相关血管再通 ５０ 例（其中１７ 例置入Ｄｅｎｏｖｏ支架）,成功率９８％ ,残余狭窄１０％ 。１９ 例合并严重泵功能衰竭和／或心源性休克的患者,全部ＰＴＣＡ 成功。平均随访（２９±１７）个月,５０ 例患者临床症状基本消失或明显减轻,心功能显著改善。无行急诊冠脉搭桥或死亡。结论　对ＡＭＩ病人,尤其是合并泵衰竭和／或心源性休克者,直接ＰＴＣＡ 可明显降低死亡率,应作为首选的治疗方法     

Clinical significance of acute-phase endothelin-1 in acute myocardial infarction patients treated with direct coronary angioplasty.

BACKGROUND: The aim of the present study was to investigate the relationship between plasma concentrations of endothelin (ET)-1 and clinical outcome (including mortality) and left ventricular (LV) systolic function in acute myocardial infarction (AMI). METHODS AND RESULTS: The study group comprised 110 consecutive first-AMI patients who were successfully reperfused by primary coronary intervention. Plasma ET-1 concentrations were evaluated 24 h from onset and the patients were divided into 2 groups according to the median value, either a high group (H group: > or = 2.90 pg/ml plasma ET-1; n = 55) or low group (L group: < 2.90 pg/ml plasma ET-1; n = 55). Major complications and LV systolic function were monitored in the 2 groups. Both highly sensitive C-reactive protein (hs-CRP) and brain natriuretic peptide (BNP) showed a significant positive correlation with ET-1 (BNP: r = 048, p < 0.0001, hs-CRP: r = 0.43, p < 0.001). Chronic stage left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume index (LVEDVI) were significantly poorer in the H group (LVEF: 51+/-15% vs 60+/-13%, p = 0.003, LVEDVI: 74+/-19 ml/m2 vs 66+/-14 ml/m2, p < 0.05). There were significantly more major complications in the H group than in the L group (cardiogenic shock: 18% vs 5%, p = 0.04; cardiac death: 13% vs 0%, p < 0.01). CONCLUSIONS: In the setting of AMI, plasma ET-1 concentrations may be closely related to LV systolic dysfunction and poor patient outcome, including mortality.     

Prognostic value of angiographic markers of myocardial reperfusion in patients treated with primary coronary angioplasty for anterior wall acute myocardial infarction

BACKGROUND: Modern therapy of acute myocardial infarction (AMI) is aimed at rapid and persisting restoration of blood flow in an infarct-related artery (IRA). However, in some patients myocardial reperfusion is not achieved in spite of effective IRA recanalisation. Myocardial Blush Grade (MBG) is one of the angiographic markers useful for the detection of this phenomenon. AIM: To assess the prognostic value of MBG in patients with anterior AMI treated with primary angioplasty. METHODS: The study group consisted of 104 patients (74 males, 30 females, mean age 62+/-13 years) treated with primary angioplasty due to anterior ST-segment elevation AMI. MBG was assessed after the procedure. The mortality and major cardiovascular event (MACE) rates were analysed one and six months after AMI. RESULTS: Patients with preserved myocardial reperfusion following angioplasty (MBG 2-3, n=64 (61.5%)) had a trend towards lower one-month mortality and significantly reduced six-month mortality compared with 40 (38.5%) patients with an impaired (MBG 0-1) myocardial reperfusion (3% vs 12.5%, NS; and 6.25% vs 20%, p<0.05, respectively). The rate of MACE was significantly lower in patients with rather than without reperfusion both after one and six months of follow-up (9.4% vs 27.5%, p=0.027 and 12.5% vs 42.5%, p<0.001, respectively). Compared with patients with a high MBG score, patients with altered reperfusion more frequently had diabetes (30% vs 12.5%, p=0.04), hypertension (67.5% vs 45%, p=0.043), longer time from the onset of symptoms to balloon inflation (355.9+/-199 min vs 215.5+/-113 min, p<0.001) and lower left ventricular ejection fraction, measured 3 days after AMI (43.3%+/-8 vs 47.4%+/-9, p=0.02). CONCLUSIONS: MBG has a significant prognostic value in patients with anterior AMI treated with primary angioplasty. Diabetes, hypertension and long delay of treatment are associated with the impairment of myocardial reperfusion.     

Efficacy of coronary angioplasty following conventional coronary thrombolysis in patients with acute myocardial infarction

The efficacy of combined thrombolysis and angioplasty for the purpose of coronary reperfusion after acute myocardial infarction has been controversial. The present study was conducted, therefore, to evaluate the effects of angioplasty following administration of conventional thrombolytic agents on the long-term prognosis of acute myocardial infarction patients. A total of 409 patients admitted to the hospital within 12 hours of the onset of infarction between January 1990 and May 2001 were studied retrospectively. These included 151 patients treated with thrombolysis alone (group T), 73 patients treated with angioplasty alone (group A), and 35 patients treated with angioplasty after thrombolysis (group T&A). Group T&A had shorter intervals from onset to initial treatment than group A (3.0 hours vs 6.3 hours, p < 0.01), a higher reperfusion success rate than group T (91.4% vs 74.8%, p < 0.01), and more improved left ventricular wall motion than group A. One-year cardiac mortality rates tended to be higher in group T, which had a higher rate of unsuccessful reperfusion than groups T&A or A (8.1% vs 3.4% vs 3.5%). The frequencies of hemorrhagic complications were similar among the 3 groups. From these findings, we conclude that thrombolytic therapy with subsequent angioplasty is an effective strategy for achieving cardiac reperfusion following acute myocardial infarction.