Reappraising the role of immediate intervention following thrombolytic recanalization in acute myocardial infarction

• Published in: The American journal of cardiology Vol. 86; no. 4; pp. 400 - 405
• Main Authors: Grech, Ever D, Sutton, Andrew G.C, Campbell, Philip G, Ashton, Victoria J, Price, Dallas J.A, Hall, James A, de Belder, Mark A
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 15-08-2000; Elsevier; Elsevier Limited
• Subjects: Adult; Age; Aged; Aged, 80 and over; Angina; Angina pectoris; Angina, Unstable - etiology; Angiography; Angioplasty; Angioplasty, Balloon, Coronary; Biological and medical sciences; Blood clots; Blood. Blood coagulation. Reticuloendothelial system; Combined Modality Therapy; Coronary Angiography; Coronary Disease - classification; Coronary Disease - pathology; Coronary vessels; Early intervention; Female; Fibrinolytic Agents - therapeutic use; Gender; Heart attacks; Humans; Intervention; Lesions; Male; Medical imaging; Medical sciences; Middle Aged; Mortality; Myocardial infarction; Myocardial Infarction - drug therapy; Myocardial Infarction - therapy; Pain; Patients; Pharmacology. Drug treatments; Prospective Studies; Recurrence; Risk Factors; ROC Curve; Software; Stenosis; Stents; Streptokinase - therapeutic use; Therapy; Thrombolysis; Thrombosis; Treatment Outcome; Veins & arteries; Human; Prognosis; Infarct; Acute; Coronary artery; Instrumentation therapy; Cardiovascular disease; Instrumental dilatation; Coronary heart disease; Myocardial disease; Chemotherapy; Streptokinase; Treatment; Myocardium; Fibrinolytic
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/S0002-9149(00)00954-1

Early studies indicated that after successful thrombolytic recanalization, adjunctive percutaneous transluminal coronary angioplasty (PTCA) was not appropriate, even when a significant residual stenosis was present. The aim of this study was to assess in-hospital clinical outcomes of patients with acute myocardial infarction (AMI) who underwent successful recanalization after thrombolytic therapy. The relation between repeat AMI/unstable angina and the severity of the stenosis, as well as other angiographic and clinical features was also examined. One hundred patients with AMI of <10 hours underwent coronary angiography 2 hours after receiving thrombolytic therapy. Salvage PTCA ± stenting was performed if recanalization was unsuccessful (Thrombolysis In Myocardial Infarction [TIMI] trial grade 0 to 2), and no PTCA was undertaken if there was brisk anterograde flow (TIMI 3). Angiographic analysis was performed to assess the severity of the residual lesion, as well as the presence or absence of thrombus. Forty patients had unsuccessful recanalization, and of these, 36 underwent attempted PTCA. Of the 60 patients with TIMI 3 flow, 15 required repeat angiography and PTCA after repeat AMI (n = 13) or unstable angina (n = 2) within 5 days. Receiver-operating characteristic analysis indicated an optimum percent diameter stenosis predictor of 85% for repeat AMI/unstable angina. There was no additional relation to age, gender, time to thrombolysis, the infarct-related artery, or the presence of culprit lesion thrombus. After recanalization, a high-grade stenosis >85% is common (n = 25, 42.4%). This is associated with a 54% repeat AMI/unstable angina risk—a ninefold increase in the incidence of such events than in patients with lesions <85%. Thus, patients with narrowings >85% may benefit from early intervention rather than a conservative approach. Narrowings <85% have a 94% probability of no repeat AMI/unstable angina and do not require early intervention.