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To evaluate the predictors and likelihood of success for coronary angioplasty performed in the setting of acute myocardial infarction, 300 consecutive patients with 321 coronary stenoses were studied retrospectively. Success was defined as final diameter stenosis less than 70% and Thrombolysis in Myocardial Infarction (TIMI) flow grade greater than or equal to 2. Nine clinical variables and 15 angiographic variables were assessed. Seventy-nine percent of patients were men; the mean age was 56 +/- 11 years, and 54% of patients also received thrombolytic therapy. The mean left ventricular ejection fraction was 46 +/- 11%, and 18 patients (6%) were in cardiogenic shock. Angioplasty success in the infarct-related artery was achieved in 240 patients (80%). In 177 total occlusions (TIMI flow grade less than or equal to 1), the success rate was 75.7% and success was independently predicted by 1) an ejection fraction greater than 30% (p = 0.001); 2) no arterial bend greater than or equal to 45 degrees at the site of angioplasty (p = 0.008); and 3) no triple vessel disease (p = 0.014). In 144 subtotal occlusions (TIMI flow grade greater than or equal to 2), procedural success was achieved in 84.7% and was predicted by 1) absence of thrombus greater than 5 mm (p = 0.023), and 2) absence of other stenoses greater than or equal to 50% in the same artery (p = 0.043), whereas patency without further emergency intervention was achieved in 71.7% and was predicted only by patient age less than or equal to 60 years and absence of cardiogenic shock.(ABSTRACT TRUNCATED AT 250 WORDS)

To determine the role of tissue-type plasminogen activator (t-PA) and immediate percutaneous transluminal coronary angioplasty (PTCA) in treating patients with evolving transmural myocardial infarction, 50 patients received t-PA (1.25 mg/kg iv over 3 hrs) or placebo according to 3:1 double-blind randomization 3.8 +/- 1.1 hr after onset of symptoms. At emergency coronary arteriography, patency of the infarct-related vessel was demonstrated in 32 of 38 (84%) patients receiving t-PA vs two of 12 (17%) receiving placebo (p less than .001). Of the 32 patients with recanalization after t-PA, 28 had a residual stenosis of at least 50% and underwent randomization a second time to immediate (n = 15) or no PTCA (n = 13). Immediate PTCA of the infarct-related vessel was successful in all 15 patients, with reduction of the residual diameter stenosis from 80.8 +/- 8.2% to 32.5 +/- 15.6% (p less than .001). The incidence of postinfarction angina (greater than or equal to 20 min of chest discomfort and reversible electrocardiographic changes) and reinfarction (documented by recurrent creatine kinase isoenzyme elevation) was reduced in the patients receiving t-PA and PTCA (2/15) compared with that in patients receiving t-PA alone (7/13; p = .006). At 1 week there was no difference in patency of the infarct-related vessel (12/15 t-PA and PTCA vs 9/13 t-PA only) or in global ventricular functional change between the two groups (0.5 +/- 10.4 SD/chord for t-PA and PTCA vs -2.1 +/- 8.2 SD/chord for t-PA only).(ABSTRACT TRUNCATED AT 250 WORDS)

Two hundred forty consecutive patients with acute myocardial infarction treated within 48 hours by successful percutaneous transluminal coronary angioplasty (PTCA) were analyzed to determine the incidence and predictors of recurrent ischemic events during hospitalization. Thirty-nine patients had recurrent ischemia: 20 patients had chest pain or electrocardiographic changes requiring repeat PTCA or bypass surgery, or resulting in a second creatine kinase elevation suggestive of myocardial infarction; 12 had total occlusion of the dilated artery on follow-up angiography; and 7 had exercise-induced ischemia and greater than or equal to 70% diameter stenosis that required PTCA or bypass surgery before hospital discharge. In-hospital mortality was 15% in the recurrent ischemia group, compared to 1% in the group without recurrent myocardial ischemia (p less than 0.001). Angiographic follow-up before hospital discharge was obtained in 198 patients, including 38 of the 39 patients with ischemic events. Thus, the true incidence of recurrent ischemic events was between 39 of 199 and 39 of 240, or 16 and 20%. In multivariate analyses, recurrent ischemia was predicted by translesional gradient greater than 25 mm Hg (p = 0.001), dissection (p = 0.01) and post-PTCA Thrombolysis in Myocardial Infarction 2 flow pattern (p = 0.016). However, even in the absence of these risk factors recurrent ischemic events occurred in 13% of patients. Post-PTCA percent diameter stenosis (whether assessed by objective or visual assessment), degree of the early systemic fibrinolytic state, post-PTCA residual minimal diameter and concomitant use of thrombolytic agents were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

The in-hospital course of 500 consecutive patients treated with coronary angioplasty for acute myocardial infarction was reviewed in relation to their clinical and angiographic presentation and angioplasty outcome to determine which patients benefit most from successful angioplasty in this setting. Patient age was 56 +/- 11 years (mean +/- SD) and 78% were men; 46% had anterior myocardial infarction, 49% received concomitant intravenous thrombolytic therapy, left ventricular ejection fraction was 47 +/- 11% and median time to angioplasty was 4.7 h (range 1 to 24). Angioplasty was successful in 78% of patients and partially successful in 7% of patients; the overall in-hospital mortality rate was 10.2%. Multivariate analysis found six independent correlates (p less than 0.05) of in-hospital mortality: left ventricular ejection fraction less than or equal to 30%, lack of postangioplasty infarct artery patency, age greater than 65 years, recurrent ischemia after successful angioplasty, emergency bypass surgery and arterial pressure on admission to the catheterization laboratory less than 100 mm Hg. After consideration of these predictors of survival in multivariate analyses, angioplasty success still was independently correlated with improved in-hospital survival for patients with cardiogenic shock (p = 0.002) and anterior myocardial infarction (p = 0.007). A trend toward an independent beneficial effect of successful angioplasty on survival was also noted in patients with inferior wall infarction and precordial ST segment depression (p = 0.063) and for all patients who were hypotensive on admission to the catheterization laboratory, regardless of the infarct site (p = 0.057).(ABSTRACT TRUNCATED AT 250 WORDS)

To compare the efficacy of emergency percutaneous transluminal coronary angioplasty and intracoronary streptokinase in preventing exercise-induced periinfarct ischemia, 28 patients presenting within 12 hours of the onset of symptoms of acute myocardial infarction were prospectively randomized. Of these, 14 patients were treated with emergency angioplasty and 14 patients received intracoronary streptokinase. Recatheterization and submaximal exercise thallium-201 single photon emission computed tomography were performed before hospital discharge. Periinfarct ischemia was defined as a reversible thallium defect adjacent to a fixed defect assessed qualitatively. Successful reperfusion was achieved in 86% of patients treated with emergency angioplasty and 86% of patients treated with intracoronary streptokinase (p = NS). Residual stenosis of the infarct-related coronary artery shown at predischarge angiography was 43.8 +/- 31.4% for the angioplasty group and 75.0 +/- 15.6% for the streptokinase group (p less than 0.05). Of the angioplasty group, 9% developed exercise-induced periinfarct ischemia compared with 60% of the streptokinase group (p less than 0.05). Thus, patients with acute myocardial infarction treated with emergency angioplasty had significantly less severe residual coronary stenosis and exercise-induced periinfarct ischemia than did those treated with intracoronary streptokinase. These results suggest further application of coronary angioplasty in the management of acute myocardial infarction.

This study quantitatively evaluated the change in myocardial blood flow resulting from medical revascularization in patients with acute anterior myocardial infarction. Changes in great cardiac vein flow were measured using a thermodilution technique in 13 patients with acute infarction; 3 received intracoronary streptokinase and 10 percutaneous transluminal angioplasty. Average great cardiac vein flow during left anterior descending coronary artery occlusion was 62 +/- 6 ml/min and increased to 70 +/- 7 ml/min (p = 0.039) after arterial recanalization. There was significant individual variability in the great cardiac vein flow increments that was highly predictive of functional recovery as expressed by the change in ejection fraction at 7 to 10 days (r = 0.93, p = 0.0008). Incremental great cardiac vein flow was inversely correlated with the degree of residual stenosis and the duration of ischemia (r = 0.88, p = 0.0007). Patients with residual stenosis less than or equal to 50% had a significantly larger increase in great cardiac vein flow (14 +/- 5 ml/min) than did those with residual stenosis greater than 50% (0 +/- 2 ml/min, p = 0.026). Neither preinterventional left ventricular ejection fraction, hemodynamics nor age predicted incremental great cardiac vein flow. Therefore, quantitative measurements of great cardiac vein flow during medical revascularization in patients with an acute anterior myocardial infarction demonstrate variable reflow that is physiologically significant. A high grade residual stenosis and prolonged period of ischemia limit large increases in flow and prevent functional recovery. This study emphasizes the fact that recanalization in itself cannot be used as an indicator of the success of interventions designed to produce myocardial reperfusion.

To determine the risk of arterial reocclusion or recurrent ischemia after acute intervention in myocardial infarction, we analyzed the results of coronary arteriography performed acutely and at 1 week in 50 consecutive patients who received acute intervention. Successful recanalization of the infarct vessel was achieved in 46 (92%) patients after therapy with intravenous tissue plasminogen activator, percutaneous coronary angioplasty, or both. Follow-up angiography in 44 showed early reocclusion in 10 patients (23%). Intermittent patency during acute arteriography was always associated with reocclusion; suboptimal (Thrombolysis in Myocardial Infarction [TIMI] class 2) flow was associated with a 50% rate of reocclusion. Although residual stenosis of greater than 50% alone was not predictive of rethrombosis, 90% of all reocclusions were associated with either stenosis greater than 50%, TIMI 2 flow, or intermittent patency. Absence of these angiographic risk factors predicted a 95% patency rate at follow-up. In-hospital cardiac complications occurred in 17 of 23 (74%) patients with residual stenosis of greater than 50% (death in four, ischemia in 13), and late revascularization was required in 53% of survivors. Only 15% of the group with less than 50% stenosis had an in-hospital ischemic event (p less than 0.001). Thus, after acute intervention, an infarct vessel with intermittent patency or suboptimal flow is associated with a high rate of reocclusion. Residual stenosis greater than or equal to 50% appears to predict a high incidence of negative in-hospital clinical outcomes and the need for subsequent revascularization.