Search

Background: No randomized comparisons are yet available evaluating the effect of pre-hospital high dose tirofiban on the incidence of early stent thrombosis after primary percutaneous coronary intervention (PCI)., Objectives: The aim of this analysis was to evaluate whether routine pre-hospital administration of high-dose tirofiban in ST-segment elevation myocardial infarction (STEMI) decreases the incidence of early stent thrombosis after primary PCI., Patients/methods: The Ongoing Tirofiban in Myocardial Evaluation (On-TIME) 2 trial was a prospective multicenter study of consecutive STEMI patients referred for primary PCI in which patients were randomized to pre-hospital no high-dose tirofiban/placebo. We examined the incidence of Academic Research Consortium definite and probable early stent thrombosis and determined predictors and outcome of early stent thrombosis., Results: Primary PCI was performed in 1203 out of 1398 patients (86.1%). In 1073 patients (89.2%) a coronary stent was placed. Early stent thrombosis occurred in 39 patients (3.6%). Pre-hospital initiation of high-dose tirofiban significantly reduced early stent thrombosis (2.1% vs. 5.2%, P = 0.006) and was associated with a lower incidence of urgent repeat PCI (1.9% vs. 5.2%, P = 0.005). Early stent thrombosis, as well as pre-hospital initiation of high-dose tirofiban, was independently associated with 30-day mortality., Conclusions: Pre-hospital initiation of high-dose tirofiban reduces the 30-day incidence of stent thrombosis in STEMI patients treated with primary PCI and stenting. Early stent thrombosis and pre-hospital initiation of high-dose tirofiban were independent predictors of 30-day mortality.

Objectives: To study the clinical significance of infarct location during long term follow up in a trial comparing thrombolysis with primary angioplasty., Design: Retrospective longitudinal cohort analysis of prospectively entered data., Setting: Patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI)., Patients: In the Zwolle trial 395 patients with acute STEMI were randomly assigned to intravenous streptokinase or PCI., Main Outcome Measures: Survival according to infarct location and treatment after 8 (2) years of follow up., Results: 105 patients died: 63 patients in the streptokinase group and 42 patients in the primary PCI group (relative risk (RR) 1.6, 95% confidence interval (CI) 1.0 to 2.6; p = 0.03). In patients with non-anterior STEMI there was no difference in mortality between streptokinase and PCI treated patients (RR 1.1, 95% CI 0.6 to 2.1; p = 0.68) but the streptokinase group had significantly more major adverse cardiac events (MACE) than the PCI group (RR 2.1, 95% CI 1.2 to 3.6). The number needed to treat to prevent one MACE was four. In patients with anterior STEMI, mortality was higher in the streptokinase group than in the PCI group (RR 2.7, 95% CI 1.4 to 5.5; p = 0.004). The number needed to treat to prevent one death was five. Kaplan-Meier analysis confirmed the benefits of primary angioplasty in the first year and showed additional benefit of PCI compared with streptokinase between 1-8 years after the acute event., Conclusions: Patients with anterior STEMI have better long term survival when treated with PCI than with streptokinase. In patients alive one year after the acute event, PCI confers a significant additional survival benefit, probably due to better preserved residual left ventricular function.

Background: Although the benefits of primary angioplasty for ST-segment elevation myocardial infarction (STEMI) have been demonstrated, the prognostic role of early recanalization in these patients has yet to be investigated. The aim of the study was to evaluate the impact of preprocedural Thrombolysis in Myocardial Infarction (TIMI) flow on the extent of myocardial reperfusion in patients with anterior STEMI treated with primary angioplasty., Methods: Our population consisted of 754 consecutive patients with anterior STEMI treated by primary angioplasty from April 1997 to October 2001. All angiographic, clinical, and follow-up data were prospectively collected., Results: Preprocedural TIMI flow was related to postprocedural TIMI 3 flow (P < .0001), ST-segment resolution (P = .009), myocardial blush grade (P < .0001), enzymatic infarct size (P < .0001), and predischarge ejection fraction (P < .0001), even in the analysis restricted to patients with postprocedural TIMI 3 flow. These data explain the observed significant impact of preprocedural TIMI flow on 1-year mortality., Conclusions: This study shows that in patients with anterior STEMI, poor preprocedural TIMI flow is associated with impaired perfusion, larger infarct size, and 1-year mortality. This study suggests that all efforts should be made to obtain optimal restoration of antegrade flow as early as possible before angioplasty. Further studies are needed to investigate the impact of early adjunctive pharmacological therapy on preprocedural TIMI flow and mortality in these high-risk patients.

Objectives: The aim of the study was to evaluate the impact of preprocedural Thrombolysis In Myocardial Infarction (TIMI) flow on one-year mortality in patients with ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty., Background: Although there is an excellent outcome conferred by primary angioplasty in patients with STEMI, the prognostic role of early recanalization in these patients has yet to be investigated., Methods: Our population is composed of 1,791 patients with acute myocardial infarction treated by primary angioplasty at our institution from 1994 to 2001. All angiographic, clinical, and follow-up data were prospectively collected. According to the TIMI risk score, patients were stratified in low- and high-risk groups., Results: Preprocedural TIMI flow was related to postprocedural TIMI flow grade 3 (p = 0.002), myocardial blush grade 2 to 3 (p < 0.001), enzymatic infarct size (p < 0.001), predischarge ejection fraction (p < 0.001), and one-year mortality (p < 0.05). Multivariate analysis showed that preprocedural TIMI flow grade 3 was an independent predictor of one-year survival in high-risk patients (p < 0.05)., Conclusions: This study shows that preprocedural TIMI flow grade 3 is an independent predictor of one-year survival in high-risk patients with acute myocardial infarction treated by primary angioplasty. These data suggest that all efforts should be made to obtain early and optimal restoration of antegrade flow, particularly in high-risk patients and when transportation to tertiary centers, with a conceivable further time delay, is required.

Objectives: This study sought to determine the short- and long-term outcome of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) in patients older than 75 years of age., Background: The benefit of reperfusion therapy in elderly patients with AMI is uncertain, although elderly people account for a large proportion of deaths., Methods: We randomly assigned a total of 87 patients with an AMI who were older than 75 years to treatment with angioplasty or intravenous (IV) streptokinase. Clinical outcome was measured by taking the end points of death and the combination of death, reinfarction or stroke during follow-up., Results: The primary end point, a composite of death, reinfarction or stroke, at 30 days had occurred in 4 (9%) patients in the angioplasty group as compared with 12 (29%) in the thrombolysis group (p = 0.01, relative risk [RR]: 4.3, 95% confidence interval [CI]: 1.2 to 20.0). At one year the corresponding figures were 6 (13%) and 18 (44%), respectively (p = 0.001, RR: 5.2, 95% CI: 1.7 to 18.1)., Conclusions: In this series of patients with AMI who were older than 75 years, primary coronary angioplasty had a significant clinical benefit when compared with IV streptokinase therapy.

Objectives: In the Heparin in Early Patency (HEAP) pilot study a beneficial effect of high-dose heparin on early patency in acute myocardial infarction (MI) was observed in a matched-control study., Background: High dose bolus intravenous injection of heparin may achieve lysis of coronary thrombi and could enhance early patency of the infarct related vessel in patients with MI scheduled for primary angioplasty., Methods: Before primary angioplasty, 584 patients with MI entered an open randomized trial of high dose (300 IU/kg) or low dose (0 or 5,000 IU) heparin. Of the 584 patients, 299 were randomized to high dose and 285 patients to low dose heparin., Results: Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 or 3 was observed before primary angioplasty in 65 patients (22%) in the high dose group and 60 patients (21%) in the low dose heparin group (p > 0.1), whereas TIMI flow grade 3 was observed in 38 (13%) and 24 patients (9%), respectively (p = 0.11). There were no differences in the clinical end points between the two groups. There were no hemorrhagic strokes, while 10% of the patients in the high dose group required blood transfusion versus 6% in the low dose/no heparin group (p = 0.07). No subsets of patients showed beneficial effects of high dose heparin, such as patients with longer delay between heparin administration and diagnostic angiogram or patients with short delay between symptom onset and admission., Conclusions: There is no benefit of high dose bolus heparin on early patency compared with no or low dose heparin.

Background: As compared with thrombolytic therapy, primary coronary angioplasty results in a higher rate of patency of the infarct-related coronary artery, lower rates of stroke and reinfarction, and higher in-hospital or 30-day survival rates. However, the comparative long-term efficacy of these two approaches has not been carefully studied., Methods: We randomly assigned a total of 395 patients with acute myocardial infarction to treatment with angioplasty or intravenous streptokinase. Clinical information was collected for a mean (+/-SD) of 5+/-2 years, and medical charges associated with the two treatments were compared., Results: A total of 194 patients were assigned to undergo primary angioplasty, and 201 to receive streptokinase. Mortality was 13 percent in the angioplasty group, as compared with 24 percent in the streptokinase group (relative risk, 0.54; 95 percent confidence interval, 0.36 to 0.87). Nonfatal reinfarction occurred in 6 percent and 22 percent of the two groups, respectively (relative risk, 0.27; 95 percent confidence interval, 0.15 to 0.52). The combined incidence of death and nonfatal reinfarction was also lower among patients assigned to angioplasty than among those assigned to streptokinase, with a relative risk of 0.13 (95 percent confidence interval, 0.05 to 0.37) for early events (within the first 30 days) and a relative risk of 0.62 (95 percent confidence interval, 0.43 to 0.91) for late events (after 30 days). The rates of readmission for heart failure and ischemia were also lower among patients in the angioplasty group than among patients in the streptokinase group. Total medical charges per patient were lower in the angioplasty group (16,090 dollars) than in the streptokinase group (16,813 dollars, P=0.05)., Conclusions: During five years of follow-up, primary coronary angioplasty for acute myocardial infarction was associated with lower rates of early and late death and nonfatal reinfarction, fewer hospital readmissions for ischemia or heart failure, and lower total medical charges than treatment with intravenous streptokinase.

Background: Several studies demonstrate a better outcome after primary angioplasty compared with thrombolysis. The mechanism is assumed to be a higher rate of open infarct-related vessels., Methods and Results: We conducted a randomized trial of primary coronary angioplasty compared with thrombolysis. A total of 401 patients with acute myocardial infarction were randomly assigned to either primary angioplasty or thrombolytic therapy. Radionuclide left ventricular ejection fraction was performed before hospital discharge. Infarct size was estimated by measurement of serial lactate dehydrogenase activity (LDH Q72). Separate analyses were performed in patients with an open infarct-related vessel, either after thrombolysis or angioplasty. Baseline characteristics were comparable between the 2 treatment groups. Of the 197 patients treated with angioplasty, 176 (89%) had an open infarct-related vessel compared with 126 (62%) of the 204 patients treated with thrombolysis (P <.001). In patients with an open infarct-related vessel, those treated with primary angioplasty had a lower enzyme release compared with those treated with thrombolysis: LDH Q72 949 (748) and 1200 (1117), respectively (P <.05). Compared with angioplasty, patients treated with thrombolysis had a lower left ventricular ejection fraction. In the subgroup of patients with an open infarct-related vessel, after thrombolysis or angioplasty, patients treated with thrombolysis still had a lower ejection fraction (47% vs 50%, P <.05). Multivariate analysis, adjusting for differences in several clinical variables, did not change these results. Patients with an open infarct-related vessel and thrombolysis had a higher risk of an ejection fraction <40% compared with patients treated with primary angioplasty (relative risk 1.9, 95% confidence interval 1.0 to 2.7)., Conclusions: Despite successful thrombolysis, with sustained patency of the infarct-related vessel, primary angioplasty remains superior to thrombolytic therapy with regard to left ventricular function and enzymatic infarct size. This may be caused by adverse effects of fibrinolytics on infarcted myocardium.

Objectives: We sought to compare primary coronary angioplasty and thrombolysis as treatment for low risk patients with an acute myocardial infarction., Background: Primary coronary angioplasty is the most effective reperfusion therapy for patients with acute myocardial infarction; however, intravenous thrombolysis is easier to apply, more widely available and possibly more appropriate in low risk patients., Methods: We stratified 240 patients with acute myocardial infarction at admission according to risk. Low risk patients (n = 95) were randomized to primary angioplasty or thrombolytic therapy. The primary end point was death, nonfatal stroke or reinfarction during 6 months of follow-up. Left ventricular ejection fraction and medical charges were secondary end points. High risk patients (n = 145) were treated with primary angioplasty., Results: In low risk patients, the incidence of the primary clinical end point (4% vs. 20%, p < 0.02) was lower in the group with primary coronary angioplasty than in the group with thrombolysis, because of a higher rate of reinfarction in the latter group. Mortality and stroke rates were low in both treatment groups. There were no differences in left ventricular ejection fraction or total medical charges. High risk patients had a 14% incidence rate of the primary clinical end point., Conclusions: Simple clinical data can be used to risk-stratify patients during the initial admission for myocardial infarction. Even in low risk patients, primary coronary angioplasty results in a better clinical outcome at 6 months than does thrombolysis and does not increase total medical charges.

The comparative efficacy of thrombolytic drugs and primary angioplasty for acute myocardial infarction have recently been studied, but long-term follow-up data have not yet been reported. We conducted a randomized trial involving 301 patients with acute myocardial infarction; 152 patients were randomized to primary angioplasty and 149 to intravenous streptokinase. Left ventricular function was assessed with a radionuclide technique both at hospital discharge and at the end of the follow-up period. Follow-up data were collected after a mean (+/-SD) of 31 +/- 9 months. Total medical costs were calculated. At the end of the follow-up period, 5% of the angioplasty patients had died from a cardiac cause compared to 11% of the patients randomized to intravenous streptokinase, P = 0.031. Cardiac death or a non-fatal reinfarction occurred in 7% of angioplasty patients compared to 28% of streptokinase patients, P < 0.001. There was a sustained benefit of angioplasty compared to streptokinase on left ventricular function. The total medical costs in the two groups were similar. Coronary anatomy (patency and single or multivessel disease), infarct location and previous myocardial infarction were important determinants of clinical outcome and costs. After 31 +/- 9 months of follow-up, primary angioplasty compared to intravenous streptokinase results in a lower rate of cardiac death and reinfarction, a better left ventricular ejection fraction, and no increase in total medical costs.

Background: The purpose of this study was to evaluate catheterization laboratory events and angiographic findings in patients randomly assigned to undergo primary coronary angioplasty or to receive intravenous streptokinase for acute myocardial infarction., Methods: We analysed angiographic data in 301 patients with acute myocardial infarction, randomly assigned to undergo primary coronary angioplasty without antecedent thrombolytic therapy or to receive intravenous streptokinase therapy. Follow-up coronary angiography was preferably performed after 3 months. All angiograms were analysed with a quantitative coronary analysis system., Results: Of the 152 patients assigned to angioplasty treatment, 140 underwent this procedure with a success rate of 97%. The residual diameter stenosis of the infarct-related vessel immediately after angioplasty was 27 +/- 15% and there were major events in 14% of the patients in the catheterization laboratory. At follow-up angiography after a mean interval of 92 days in the angioplasty assigned patients, a diameter stenosis of 35 +/- 22% was observed in this group. The restenosis rate was 28% and the reocclusion rate 5%. A Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow immediately after angioplasty was predictive for reocclusion at follow-up (P = 0.001). In the streptokinase assigned patients (149) the infarct-related vessel was patent at follow-up angiography after a mean of 22 days in 66% of the patients with a mean residual diameter stenosis of 77 +/- 20%., Conclusion: Primary coronary angioplasty is a highly effective and safe reperfusion modality for patients with acute myocardial infarction. However, TIMI grade 2 flow through the infarct-related vessel immediately after angioplasty is a predictor of reocclusion.

Background: Early and effective flow through the infarct-related vessel is probably of paramount importance for limitation of infarct size and preservation of left ventricular function in patients with acute myocardial infarction. Primary coronary angioplasty may offer advantages in these respects compared with thrombolytic therapy. The purpose of the present study was to assess the effects on estimated enzymatic infarct size and left ventricular function in patients with acute myocardial infarction randomly assigned to undergo primary angioplasty or to receive intravenous streptokinase., Methods and Results: We evaluated 301 patients with signs of acute myocardial infarction and without contraindications for thrombolysis who presented within 6 hours after onset of symptoms or between 6 and 24 hours if there was evidence of ongoing ischemia. One hundred fifty-two patients were randomly assigned to undergo primary angioplasty, and 149 patients were assigned to receive treatment with streptokinase (1.5 million U i.v.). Infarct size was estimated from enzyme release. Global left ventricular ejection fraction and regional wall motion, if possible in combination with exercise testing, were evaluated by radionuclide ventriculography before discharge. Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 through the infarct-related vessel within 120 minutes after admission was achieved in 92% of all patients assigned to receive primary angioplasty therapy. Myocardial infarct size was 23% smaller in the angioplasty group compared with patients assigned to receive streptokinase (1003 +/- 784 versus 1310 +/- 1198 U/L, P = .012). Global left ventricular ejection fraction (50 +/- 9% versus 45 +/- 11%, P < .001) and regional wall motion in the infarct-related zones (42 +/- 14% versus 34 +/- 13%, P < .001) were better in the angioplasty group, which could mainly be contributed to myocardial salvage in the infarct-related areas. The observed differences were more pronounced in patients with an anterior wall myocardial infarction, although patients with a nonanterior infarct location also showed a beneficial effect of primary coronary angioplasty on left ventricular function compared with streptokinase therapy. Furthermore, the observed differences appeared to be more pronounced in patients presenting relatively early (within 2 hours) after onset of symptoms., Conclusions: In patients with acute myocardial infarction, primary angioplasty results in a smaller infarct size and a better preserved myocardial function compared with patients randomized to receive treatment with intravenous streptokinase. This is probably due to early and optimal blood flow through the infarct-related vessel, as can be accomplished in a very high percentage of patients undergoing primary coronary angioplasty.

Background: Intravenous streptokinase and primary coronary angioplasty are both considered to be effective treatment strategies for patients with acute myocardial infarction. Although primary coronary angioplasty is associated with a high patency rate and a well-preserved left ventricular function, it is not known whether it results in a more favorable clinical outcome in randomized comparisons., Methods: Clinical data were obtained after a mean follow-up of 18 months (range 6-36 months) after random allocation of 301 patients either to intravenous streptokinase (n = 149) or to primary angioplasty (n = 152). The primary endpoint includes death from cardiac causes and non-fatal reinfarction. The secondary endpoint is a weighted unsatisfactory outcome, one that includes death, stroke, heart failure, shock, ejection fraction lower than 30%, reinfarction, reocclusion and bleeding complications. The need for revascularization procedures was recorded., Results: The relative risk of death from cardiac causes and non-fatal reinfarction in the streptokinase group was 6.1 (95% confidence interval 2.9-12.7) compared with the angioplasty group. There was a lower weighted unsatisfactory outcome score of 0.13 +/- 0.29 in patients randomly assigned to angioplasty compared with 0.34 +/- 0.33 in patients randomly assigned to streptokinase (P < 0.001). Coronary angioplasty or coronary artery bypass grafting, or both, were performed more often in the streptokinase group, with a relative risk of 2.1 compared with patients randomly assigned to angioplasty (95% confidence interval 1.5-3.2)., Conclusion: Clinical outcome in patients with acute myocardial infarction after a mean follow-up of 18 months was more favorable in patients randomly assigned to primary angioplasty compared with those receiving intravenous streptokinase.

Background: Treatment of patients with acute myocardial infarction should aim to restore blood flow in the infarct-related artery as soon as possible. Thrombolytic therapy has recently been compared with direct angioplasty; however, these interventions may not be sufficient, and coronary artery bypass grafting (CABG) may be necessary., Methods: In a series of 301 patients with acute myocardial infarction, randomly assigned either to receive intravenous streptokinase (n = 149) or to undergo percutaneous transluminal coronary angioplasty (PTCA; n = 152), 31 patients (aged 61 +/- 10 years; 27 men, four women) underwent CABG within 6 weeks of acute myocardial infarction., Results: Twelve patients (nine in the PTCA group and three in the streptokinase group) underwent surgery within 48 h of the onset of symptoms. Bypass surgery was performed in the streptokinase group on failure of thrombolytic therapy (n = 2), recurrent ischemia (n = 4), or postinfarct angina (n = 9). In the PTCA group, CABG was performed for left main stenosis (n = 6), failed PTCA (n = 3), recurrent ischemia (n = 2), or postinfarct angina (n = 5). An intra-aortic balloon pump (IABP) was required in 15 patients (five streptokinase and 10 PTCA). Major complications after CABG were more common among patients who underwent surgery within 48 h than those after 48 h (eight in 12 patients versus four in 19, respectively). After 17.0 +/- 8.6 months (range 3-33 months), two patients had died; one of end-stage heart failure after 3 months, and one of a stroke after 16 months (both were in the PTCA group and one had undergone surgery within 48 h). One patient suffered a reinfarction after 11 months and one a non-fatal stroke after 1 month (both underwent CABG within 48 h). The left ventricular ejection fraction did not differ between the groups (43 +/- 15% for the 'early' group and 42 +/- 11% for the 'late' group)., Conclusion: CABG can be performed safely and effectively after initial treatment with direct angioplasty or thrombolytic therapy after acute myocardial infarction. If it is performed within 48 h of onset of symptoms, (in-hospital) morbidity is higher, without affecting mortality or left ventricular function.

Objectives: The purpose of the present study was to compare intravenous streptokinase therapy with immediate coronary angioplasty without antecedent thrombolytic therapy with regard to left ventricular function and hospital mortality and reinfarction., Background: Despite the widespread use of intravenous thrombolytic therapy and immediate percutaneous transluminal coronary angioplasty, these two strategies to treat patients with an acute myocardial infarction have only recently been compared in randomized trials. Coronary angioplasty has been shown to result in a higher patency rate of the infarct-related coronary artery, with a less severe residual stenotic lesion, compared with streptokinase therapy, but whether this more favorable coronary anatomy results in clinical benefit remains to be established., Methods: We studied 301 patients with acute myocardial infarction randomly assigned to undergo immediate coronary angioplasty without antecedent thrombolytic therapy or to receive intravenous streptokinase therapy. Before discharge left ventricular ejection fraction was measured by radionuclide scanning., Results: The in-hospital mortality rate in the streptokinase group was 7% (11 of 149 patients) compared with 2% (3 of 152 patients) in the angioplasty group (p = 0.024). In the streptokinase group recurrent myocardial infarction occurred in 15 patients (10%) versus in 2 (1%) in the angioplasty group (p < 0.001). Either death or nonfatal reinfarction occurred in 23 patients (15%) in the streptokinase group and in 5 patients (3%) in the angioplasty group (p = 0.001). Left ventricular ejection fraction was 44 +/- 11% (mean +/- SD) in the streptokinase group versus 50 +/- 11% in the angioplasty group (p < 0.001)., Conclusions: These findings indicate that immediate coronary angioplasty without antecedent thrombolytic therapy results in better left ventricular function and lower risk of death and recurrent myocardial infarction than treatment with intravenous streptokinase.

Background: Despite the widespread use of intravenous thrombolytic therapy and of immediate percutaneous transluminal coronary angioplasty for the treatment of acute myocardial infarction, randomized comparisons of the two approaches to reperfusion are lacking. We report the results of a prospective, randomized trial comparing immediate coronary angioplasty (without previous thrombolytic therapy) with intravenous streptokinase treatment., Methods: A total of 142 patients with acute myocardial infarction were randomly assigned to receive one of the two treatments. The left ventricular ejection fraction was measured by radionuclide scanning before hospital discharge. Quantitative coronary angiography was performed to assess the degree of residual stenosis in the infarct-related arteries., Results: A total of 72 patients were assigned to receive streptokinase and 70 patients to undergo immediate angioplasty. Angioplasty was technically successful in 64 of the 65 patients who underwent the procedure. Infarction recurred in nine patients assigned to receive streptokinase, but in none of those assigned to receive angioplasty (P = 0.003). Fourteen patients in the streptokinase group had unstable angina after their infarction, but only four in the angioplasty group (P = 0.02). The mean (+/- SD) left ventricular ejection fraction as measured before discharge was 45 +/- 12 percent in the streptokinase group and 51 +/- 11 percent in the angioplasty group (P = 0.004). The infarct-related artery was patent in 68 percent of the patients in the streptokinase group and 91 percent of those in the angioplasty group (P = 0.001). Quantitative coronary angiography revealed stenosis of 36 +/- 20 percent of the luminal diameter in the angioplasty group, as compared with 76 +/- 19 percent in the streptokinase group (P < 0.001)., Conclusions: Immediate angioplasty after acute myocardial infarction was associated with a higher rate of patency of the infarct-related artery, a less severe residual stenotic lesion, better left ventricular function, and less recurrent myocardial ischemia and infarction than was intravenous streptokinase.