Direct angioplasty for acute myocardial infarction. A review of outcomes in clinical subsets.

PURPOSE: To review the usefulness of angioplasty done early in the course of an acute myocardial infarction without preceding thrombolytic therapy. DATA SOURCES: The English-language literature was searched from 1983 through October 1991 using MEDLINE; bibliographies from selected articles were searched by hand. STUDY SELECTION: Series reporting results for direct angioplasty without preceding thrombolytic therapy were reviewed. Twenty-three articles describing a total of 4368 patients were found. DATA EXTRACTION: After duplicate patient series were eliminated, weighted average short- and long-term mortality rates were calculated for the remaining 2073 patients in 10 series and for selected clinical subsets. RESULTS OF DATA SYNTHESIS: Average hospital mortality for patients with acute myocardial infarction having direct angioplasty was 8.3% (95% Cl, 7.1% to 9.5%). Patients in cardiogenic shock had the highest mortality (44.2%; Cl, 35.9% to 52.5%); patients with one-vessel disease had the lowest (1%; Cl, 0% to 2.3%). For patients in cardiogenic shock, data on direct angioplasty appeared superior to data for similar patients receiving thrombolytic therapy. Although few data exist, a survival advantage was also suggested for patients with a history of previous bypass surgery (hospital mortality, 11.1% Cl, 4.4% to 17.8%]). CONCLUSIONS: Direct angioplasty has an overall mortality similar to that of thrombolytic therapy. Patients who may benefit more from mechanical revascularization than from thrombolytic therapy include those at increased risk for thrombolytic therapy (uncontrolled hypertension, recent major surgery, cerebrovascular accident, prolonged cardiopulmonary resuscitation, or bleeding diathesis), and those with cardiogenic shock. The efficacy in several other patient subsets (age greater than 65 years, previous coronary artery bypass grafting, prolonged delay before reperfusion) warrants further study.