Benefit of coronary reperfusion before intervention on outcomes after primary angioplasty for acute myocardial infarction

• Published in: The American journal of cardiology Vol. 85; no. 1; pp. 13 - 18
• Main Authors: Brodie, Bruce R, Stuckey, Thomas D, Hansen, Charles, Muncy, Denise
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 2000; Elsevier; Elsevier Limited
• Subjects: Aged; Angioplasty; Angioplasty, Balloon, Coronary; Aspirin - therapeutic use; Biological and medical sciences; Blood. Blood coagulation. Reticuloendothelial system; Cardiology; Combined Modality Therapy; Coronary Angiography; Female; Fibrinolytic Agents - therapeutic use; Follow-Up Studies; Heart attacks; Heparin - therapeutic use; Humans; Logistic Models; Male; Medical procedures; Medical sciences; Myocardial Infarction - complications; Myocardial Infarction - diagnostic imaging; Myocardial Infarction - mortality; Myocardial Infarction - therapy; Pharmacology. Drug treatments; Proportional Hazards Models; Shock, Cardiogenic - etiology; Stroke Volume; Survival Analysis; Treatment Outcome; Human; Infarct; Surgical revascularization; Cardiovascular disease; Acetylsalicylic acid; Coronary heart disease; Myocardial disease; Chemotherapy; Surgery; Myocardium; Glycosaminoglycan; Combined treatment; Heparin; Preoperative
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/S0002-9149(99)00598-6

Primary percutaneous transluminal coronary angioplasty has become the preferred reperfusion strategy for acute myocardial infarction in most institutions with interventional facilities and experienced operators. The benefit of establishing coronary reperfusion, with or without pharmacologic therapy, before primary angioplasty has not been established. Consecutive patients (n = 1,490) with acute myocardial infarction treated with aspirin and heparin followed by primary percutaneous transluminal coronary angioplasty were followed for 13 years. Follow-up angiography was obtained in 737 patients at 7.7 months. Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow in the infarct artery at initial angiography was present in 18.3% of patients, and TIMI 0 to 1 flow in 81.7% of patients. Baseline variables were similar between the 2 groups, except patients with initial TIMI 2 to 3 flow had significantly less cardiogenic shock (1.7% vs 9.4%, p <0.0001) and a lower incidence of depressed ejection fraction <40% (12.6% vs 19.9%, p = 0.007). Procedural success was better in patients with initial TIMI 2 to 3 flow (97.4% vs 93.8%, p = 0.02), and catheterization laboratory events were less frequent. Patients with initial TIMI 2 to 3 flow had lower peak creatine kinase values (1,328 vs 2,790 IU/L, p <0.0001), higher acute ejection fraction (54.3% vs 51.6%, p = 0.05), higher late ejection fraction (59.2% vs 54.9%, p = 0.004), and lower 30-day mortality (4.8% vs 8.9%, p = 0.02). These data indicate that when reperfusion occurs before primary angioplasty, outcomes are strikingly better with less cardiogenic shock, improved procedural outcomes, smaller infarct size, better preservation of left ventricular function, and reduced mortality. This should encourage new strategies to establish reperfusion before “primary” angioplasty with “catheterization laboratory friendly” platelet inhibitors and/or low-dose thrombolytic drugs.