The emerging role of stenting for acute myocardial infarction.

Although the benefits of primary angioplasty for acute myocardial infarction have been demonstrated, several areas for improvement remain. The initial results of randomized trials have shown that primary stenting for acute myocardial infarction is feasible and effective with a low complication rate. Primary stenting results in a reduction in recurrent infarction and in the need for subsequent re-intervention, when compared to balloon angioplasty. Whether long-term clinical and angiographic outcome is also favourable has yet to be confirmed in large-scale multicentre trials, before primary stenting can be adopted as routine approach for acute myocardial infarction.     

Projected Cost-Effectiveness of Primary Angioplasty for Acute Myocardial Infarction

Objectives. This study sought to evaluate the cost-effectiveness of primary angioplasty for acute myocardial infarction under varying assumptions about effectiveness, existing facilities and staffing and volume of services.

Background. Primary angioplasty for acute myocardial infarction has reduced mortality in some studies, but its actual effectiveness may vary, and most U.S. hospitals do not have cardiac catheterization laboratories. Projections of cost-effectiveness in various settings are needed for decisions about adoption.

Methods. We created a decision analytic model to compare three policies: primary angioplasty, intravenous thrombolysis and no intervention. Probabilities of health outcomes were taken from randomized trials (base case efficacy assumptions) and community-based studies (effectiveness assumptions). The base case analysis assumed that a hospital with an existing laboratory with night/weekend staffing coverage admitted 200 patients with a myocardial infarction annually. In alternative scenarios, a new laboratory was built, and its capacity for elective procedures was either 1) needed or 2) redundant with existing laboratories.

Results. Under base case efficacy assumptions, primary angioplasty resulted in cost savings compared with thrombolysis and had a cost of $12,000/quality-adjusted life-year (QALY) saved compared with no intervention. In sensitivity analyses, when there was an existing cardiac catheterization laboratory at a hospital with ≥200 patients with a myocardial infarction annually, primary angioplasty had a cost of <$30,000/QALY saved under a wide range of assumptions. However, the cost/QALY saved increased sharply under effectiveness assumptions when the hospital had <150 patients with a myocardial infarction annually or when a redundant laboratory was built.

Conclusions. At hospitals with an existing cardiac catheterization laboratory, primary angioplasty for acute myocardial infarction would be cost-effective relative to other medical interventions under a wide range of assumptions. The procedure’s relative cost-ineffectiveness at low volumes or redundant laboratories supports regionalization of cardiac services in urban areas. However, approaches to overcoming competitive barriers and close monitoring of outcomes and costs will be needed.     

Mortality, reinfarction, left ventricular ejection fraction and costs following reperfusion therapies for acute mvocardial infarction

The comparative efficacy of thrombolytic drugs and primary angioplastyfor acute myocardial infarction have recently been studied,but long-term follow-up data have not yet been reported. Weconducted a randomized trial involving 301 patients with acutemyocardial infarction; 152 patients were randomized to primaryangioplasty and 149 to intravenous streptokinase. Left ventricularfunction was assessed with a radionuclide technique both athospital discharge and at the end of the follow-up period. Follow-updata were collected after a mean (± SD) of 31 ±9 months. Total medical costs were calculated. At the end ofthe follow-up period, 5% of the angioplasty patients had diedfrom a cardiac cause compared to 11% of the patients randomizedto intravenous streptokinase, P=0·031. Cardiac deathor a non-fatal reinfarction occurred in 7% of angioplasty patientscompared to 28% of streptokinase patients, P0·001. Therewas a sustained benefit of angioplasty compared to streptokinaseon left ventricular function. The total medical costs in thetwo groups were similar. Coronary anatomy (patency and singleor multivessel disease), infarct location and previous myocardialinfarction were important determinants of clinical outcome andcosts. After 31±9 months of follow-up, primary angioplasty comparedto intravenous streptokinase results in a lower rate of cardiacdeath and reinfarction, a better left ventricular ejection fraction,and no increase in total medical costs. (Eur Heart J 1996; 17: 382–387)     

Influence of treatment delay on infarct size and clinical outcome in patients with acute myocardial infarction treated with primary angioplasty

Objectives. The purpose of this analysis was to determine the influence of an additional treatment delay inherent in transfer to an angioplasty center for primary angioplasty of patients with acute myocardial infarction who are first admitted to hospitals without angioplasty facilities.Background. Several randomized trials have demonstrated the benefits of primary angioplasty in acute myocardial infarction. In recent years, increasing numbers of patients with myocardial infarction, initially admitted to hospitals without angioplasty facilities are transported to our hospital for primary angioplasty. However, the additional delay due to the transport may have a deleterious effect on infarct size and clinical outcome.Methods. In a three-year period (December 1993 to November 1996), 207 consecutive patients who were transferred for primary angioplasty were analyzed in a matched comparison with nontransferred patients. Matching criteria were age, sex, infarct location, presentation delay and Killip class.Results. Patients who were transferred had an additional median delay of 43 min. This resulted in a more extensive enzymatic infarct size and a lower ejection fraction measured at 6 months. The rate of angioplasty success defined as TIMI grade 3 flow, and the 6-month mortality rate (7%) were comparable in both groups.Conclusions. The additional delay had a deleterious effect on myocardial salvage, reflected by a larger infarct size and a lower left ventricular function. However, the patency rate and 6-month clinical outcome were not affected by this delay.     

Primary angioplasty reduces risk of myocardial rupture compared to thrombolysis for acute myocardial infarction

Although the mechanical complications of acute ventricular septal defect and acute mitral regurgitation are uncommon after acute myocardial infarction, these complications are associated with an extremely high morbidity and mortality. We hypothesized that the administration of thrombolytic drugs may result in hemorrhagic infarction as well as the potential for incomplete revascularization and thus may lead to an increased incidence of mechanical complications compared to primary angioplasty. Accordingly, we reviewed the data of the most contemporary thrombolytic and primary angioplasty trials and compared the incidence of mechanical complications among 36,303 patients treated with thrombolytics reported in the GUSTO trial to the incidence of mechanical complications among 1,295 patients treated with primary angioplasty obtained from the PAMI-1 and PAMI-2 trials. We found that angioplasty resulted in an overall 86% relative risk reduction in mechanical complications (2.20% vs. 0.31%, P < 0.001). In comparison to thrombolytic therapy, angioplasty resulted in an 82% decrease in acute mitral regurgitation (1.73% vs. 0.31%, P < 0.001) and a 100% decrease in acute ventricular septal defect (0.47% vs. 0.00%, P < 0.03). In conclusion, in patients with acute myocardial infarction, reperfusion with primary angioplasty is associated with less myocardial rupture and mechanical complications than thrombolytics. This finding may, in part, explain the improved prognosis observed in myocardial infarction patients treated with primary angioplasty. Cathet. Cardiovasc. Diagn. 42:151–157, 1997. © 1997 Wiley-Liss, Inc.     

Are there differences in late outcome after PTCA for angina pectoris after non-Q wave vs Q wave myocardial infarction?

AIMS: Revascularization is thought to improve prognosis better ifischaemia persists after so-called non-Q wave myocardial infarction,than after Q-wave myocardial infarction, because it is assumedthat prognosis is better where there is less left ventricularfunction loss. This study evaluates the differences in clinicaloutcome between patients with Q wave and those with non-Q wavemyocardial infarction who underwent percutaneous transluminalcoronary angioplasty because of recurrent ischaemia. METHODS: We retrospectively analysed two consecutive groups of patientswho underwent percutaneous transluminal coronary angioplastyfor ischaemia after either a non-Q wave (n=175) or a Q wave(n=175) myocardial infarction, and who were followed for 4 years. RESULTS: Initial angioplasty success rates were similar in both groups.At follow-up there were no significant differences between thetwo patient groups in rates of death (9% vs 11%, P=ns), myocardialinfarction (3% vs 7%, P=ns) and target vessel revascularizationby repeat percutaneous angioplasty (11% vs 15%, P=ns) or coronarybypass surgery (both 7%). CONCLUSION: We conclude that elective coronary angioplasty in patients withangina pectoris after non-Q wave myocardial infarction doesnot lead to a better prognosis than after Q wave myocardialinfarction. Thus, management strategies after myocardial infarctionshould not be based on the absence or presence of Q waves onthe electrocardiogram.     

Outcome of patients with acute myocardial infarction who are ineligible for primary angioplasty trials.

We determined acute outcome in 148 consecutive patients with ST segment elevation myocardial infarction undergoing angioplasty including 72 patients (48.7%) considered ineligible for primary angioplasty trials. Overall, in-hospital mortality for acute infarct angioplasty was 12%, with fivefold higher mortality in the trial-ineligible group (21% vs. 4%, P = 0.003). Thus, primary angioplasty trials continue to exclude nearly 50% of acute infarction patients and reported mortality rates of primary angioplasty trials are likely to be significantly lower than the unselected in-hospital mortality rates. Cathet. Cardiovasc. Intervent. 49:237-243, 2000.     

Long-term follow-up after primary angioplasty: is stenting beneficial?

BACKGROUND: Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI). OBJECTIVES: The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction. METHODS: We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR). RESULTS: The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different. CONCLUSION: In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.     

Facilitated percutaneous coronary intervention.

The goal of the initial treatment for ST-segment elevation myocardial infarction is rapid and effective reperfusion. Randomized trials have demonstrated that primary angioplasty is preferred over thrombolysis if done in a timely manner and by an experienced team. However, due to many factors, performance of primary angioplasty within the goal of 90 min is often not possible. A combined strategy of immediate thrombolysis in the emergency room or in the ambulance followed by angioplasty theoretically could provide early reperfusion with subsequent angioplasty to insure complete reperfusion. Over 17 clinical trials have been reported. Compared with thrombolysis, facilitated angioplasty in the most recent trials has been shown to have a more favorable long-term outcome. Trials comparing facilitated angioplasty with full- or half-dose thrombolysis versus primary angioplasty have been far less favorable with the largest trial to date, the ASSENT (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention)-4 trial, demonstrating a worse outcome in the primary end point of death, congestive heart failure, or shock at 90 days. Pending the results of the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial, current data suggest that facilitated angioplasty does not offer any advantage over primary angioplasty and may be harmful.     

Facilitated percutaneous coronary intervention

The goal of the initial treatment for ST-segment elevation myocardial infarction is rapid and effective reperfusion. Randomized trials have demonstrated that primary angioplasty is preferred over thrombolysis if done in a timely manner and by an experienced team. However, due to many factors, performance of primary angioplasty within the goal of 90 min is often not possible. A combined strategy of immediate thrombolysis in the emergency room or in the ambulance followed by angioplasty theoretically could provide early reperfusion with subsequent angioplasty to insure complete reperfusion. Over 17 clinical trials have been reported. Compared with thrombolysis, facilitated angioplasty in the most recent trials has been shown to have a more favorable long-term outcome. Trials comparing facilitated angioplasty with full- or half-dose thrombolysis versus primary angioplasty have been far less favorable with the largest trial to date, the ASSENT (Assessment of the Safety and Efficacy of a New Treatment Strategy with Percutaneous Coronary Intervention)-4 trial, demonstrating a worse outcome in the primary end point of death, congestive heart failure, or shock at 90 days. Pending the results of the FINESSE (Facilitated Intervention with Enhanced Reperfusion Speed to Stop Events) trial, current data suggest that facilitated angioplasty does not offer any advantage over primary angioplasty and may be harmful.     

Long-term cardiac function and outcome in patients receiving primary angioplasty for AMI at a community hospital without on-site surgical back-up

BACKGROUND: Short- and long-term comparative follow-up studies of patients receiving primary angioplasty or thrombolytic therapy for acute myocardial infarction show higher 30-day survival, and sustained benefits in mortality, reinfarction and ejection fraction in patients treated with primary angioplasty. Long-term benefits of primary angioplasty on cardiac function performed in community hospitals without surgical back-up have not been fully assessed. METHODS: Sixty-one patients who underwent primary angioplasty were compared with patients receiving thrombolytic therapy who were matched for age, gender and location of acute myocardial infarction. Clinical information, reviewed through August 2000, was provided by retrospective analysis of healthcare databases and office and hospital charts. Mortality data were confirmed by the social security death index. RESULTS: Of the original 61 primary angioplasty patients, two died during initial hospitalization. Of the 59 surviving patients, fifty-four (92%) had complete follow-up averaging 57 months. Of the original 61 thrombolytic therapy patients, three died during initial hospitalization. Of the 58 surviving patients, fifty-two (90%) had complete follow-up averaging 46 months. At follow-up, averaging 57 months, ejection fraction was significantly higher in the primary angioplasty group, as compared with the thrombolytic therapy group (51.4% versus 45.8%, respectively; p = 0.038). There was no statistical difference between the two groups regarding reinfarction, revascularization at > or = 6 months after the initial presentation or cardiac death. CONCLUSIONS: Primary angioplasty performed in a community hospital without surgical back-up results in improved cardiac function when compared to thrombolytic therapy. These results are similar to those reported from large tertiary centers with on-site surgical back-up, and provide an explanation for the improved long-term outcome that is observed in patients with acute myocardial infarction treated with primary angioplasty.     

Comparison of the prognostic effect of left versus right versus no bundle branch block on presenting electrocardiogram in acute myocardial infarction patients treated with primary angioplasty in the primary angioplasty in myocardial infarction trials

The presence of bundle branch block (BBB) has been associated with poor outcomes in patients who have acute myocardial infarction. Whether this is true in the angioplasty era is not known. We sought to evaluate the outcome of patients with acute myocardial infarction and BBB who were treated with primary angioplasty. We evaluated 3,053 patients who underwent emergency catheterization in the PAMI trials. Patients who had left BBB (n = 48, 1.6%) on presenting electrocardiogram were compared with patients who had right BBB (n = 95, 3.1%) or no BBB (n = 2,910, 95.3%). Patients who had BBB were older and more frequently had diabetes mellitus, peripheral vascular disease, and previous coronary artery bypass grafting. They had lower ejection fraction and more multivessel disease. There were no significant differences in door-to-balloon time, final Thrombolysis In Myocardial Infarction flow grade or stent use. In-hospital major adverse cardiac events (death, ischemic target vessel revascularization, and reinfarction) were higher in patients who had BBB due primarily to increased in-hospital death (left BBB 14.6%, right BBB 7.4%, no BBB 2.8%, p < 0.0001). In multivariate logistic regression analysis, left BBB was an independent predictor of in-hospital death (odds ratio 5.53, 95% confidence interval 1.89 to 16.1, p = 0.002). In conclusion, patients who have acute myocardial infarction and BBB have increased co-morbidities and higher mortality rates despite treatment with primary angioplasty. Despite early identification of multivessel disease with triage to angioplasty or coronary artery bypass grafting, if necessary, similar treatment times, and final Thrombolysis In Myocardial Infarction grade 3 flow, the presence of left BBB on admission electrocardiogram in patients who have acute myocardial infarction is an independent predictor of in-hospital mortality. Because 85% of deaths in patients who have left BBB occur within the first week, these patients should be recognized early and receive prompt and aggressive treatment.     

Primary PTCA in a Rural Hospital

The results of primary percutaneous transluminal coronary angioplasty (PTCA) to treat patients with acute myocardial infarction in a rural hospital were reviewed. Thirty-five patients presenting with acute myocardial infarction, including 40% considered high risk, were treated using the strategy of primary angioplasty. Following cardiac catheterization, two patients were found to have anatomy deemed unsuitable for primary angioplasty and subsequently underwent urgent coronary artery bypass graft (CABG) surgery. Thirty-three patients underwent primary angioplasty with a procedural success rate of 94%. Procedural success was defined as reduction of the infarct arteries stenosis to less then 50% and the establishment of TIMI-III flow. Six percent of these patients required urgent CABG surgery because of unsuccessful angioplasty. In-hospital cardiac mortality was 3%. Six month follow-up was achieved for all patients. There were no cardiac deaths following hospital discharge. Recurrent ischemia occurred in 17% of the patients. Favorable in-hospital and late results were achieved. This review indicates that the strategy of primary angioplasty to treat myocardial infarction may be successfully applied in a rural setting.     

Left main coronary artery occlusion with myocardial infarction in a cocaine user. Successful angioplasty with a drug-eluting stent

A patient presented with acute ST segment elevation myocardial infarction following cocaine abuse. He was transferred for primary angioplasty. The emergent coronary angiography revealed acute left main coronary artery occlusion. Recanalization with balloon angioplasty was performed, followed by thrombectomy and stenting of the left main coronary artery with a paclitaxel-eluting stent. The patient recovered with a left ventricular ejection fraction of 35% at discharge. The pathophysiology of cocaine-induced myocardial infarction includes vasospasm, thrombosis and increased myocardial oxygen demand. Primary percutaneous coronary intervention allows local delivery of vasodilators and mechanical reperfusion in a timely manner. The authors argue that it is the best option for cocaine-induced ST segment elevation myocardial infarction. Recent data from randomized trials comparing bare metal and drug-eluting stents for primary percutaneous coronary intervention are discussed, as is the lack of evidence supporting the use of thrombectomy devices in acute myocardial infarction. The authors believe that primary percutaneous coronary intervention should be considered early for a patient presenting with cocaine-induced ST segment elevation myocardial infarction.     

Retrospective comparative study of primary intracoronary stenting versus balloon angioplasty for acute myocardial infarction

Balloon angioplasty has been shown to be an effective therapy for the treatment of acute myocardial infarction but is associated with a high restenosis rate, substantial early recoil, persistent thrombus and need for intracoronary thrombolysis, and a high rate of reclosure. Because many of the limitations of balloon angioplasty in the noninfarction setting are addressed by intracoronary stenting, we examined the results of primary stenting of 18 consecutive patients treated for acute myocardial infarction, and compared the results to those achieved with primary balloon angioplasty in 18 prior cases. Despite the presence of thrombus prior to angioplasty in 13 of the stented patients, no intracoronary thrombolytic therapy was required. Mean percent stenosis using quantitative coronary angiography was 17.7 ± 10.2% after primary stenting compared with 43.7 ± 20.3% after primary balloon angioplasty (P < .001). One stent patient who had all anticoagulant and antiplatelet therapy withdrawn early suffered subacute thrombosis. Patients were followed up to 3 yr. Complications were similar in the two groups. We conclude that primary stenting for acute myocardial infarction results in superior angiographic appearance as well as resolution of thrombus without the need for routine thrombolysis, and is associated with a low complication rate and excellent short-term clinical patency. Cathet. Cardiovasc. Diagn. 40:235–239, 1997. © 1997 Wiley-Liss, Inc.     

Primary angioplasty for acute myocardial infarction complicated by cardiogenic shock on admission.

AIM: To evaluate primary angioplasty results for the treatment of acute myocardial infarction complicated by cardiogenic shock on admission. POPULATION AND METHODS: Retrospective analysis of 11 consecutive patients with acute myocardial infarction complicated by cardiogenic shock (defined as systolic blood pressure below 80 mmHg and signs of hypoperfusion, despite volume expanders and/or vasopressors infusion) treated with primary angioplasty. Clinical characteristics, angiographic data, hospital outcome and follow-up were analysed. RESULTS: There were ten males (90.9%) with a mean age of 66 years. Eight patients had anterior wall myocardial infarction and three patients had inferior wall myocardial infarction, two of which with extension to the right ventricle. The mean time between symptom onset and angioplasty was 3.5 hours. Three patients had left main coronary artery occlusion; three patients had single vessel disease and five patients had multivessel disease. The angiographic success rate (open infarct-related artery and TIMI III flow) was 90.9% (ten patients). Stent implantation was performed in five patients. Abciximab was given in five patients. In-hospital mortality rate was 36.4% (four patients). The surviving patients had a mean ejection fraction of 43.1% on discharge. In a mean follow-up of 16.2 months, one patient had coronary artery bypass graft and one had stroke. CONCLUSION: Based on published data, our experience with this short series of cases shows that primary angiography should be regarded as a positive option for the treatment of acute myocardial infarction complicated by cardiogenic shock.     

Update on mechanical revascularization in acute myocardial infarction: which role and when?

Mechanical revascularization in the acute myocardial infarction by primary angioplasty has several advantages over thrombolytic therapy. The short-term patency rates of the infarct-related artery range from 95 to 99% and a normal flow is achieved in more than 90% of the cases. This prompt and effective reperfusion is probably responsible for the improved prognosis with primary angioplasty. The better outcome after primary angioplasty is observed both in low- and in high-risk patients, in all ages and in patients presenting late (>6 h) after the chest pain. Pooled analysis of randomized studies, show that primary angioplasty as compared to thrombolysis, has a lower incidence of death, stroke and reinfarction. Additional advantages of primary PTCA include the possibility of reperfusion in patients in whom lysis is contraindicated or less effective (e.g. patients in cardiogenic shock, or with prior coronary artery bypass surgery) and the ability to provide prognostic information helpful in the patient triage. Thus, primary PTCA results in better outcome than thrombolysis when performed in centers with success rates comparable to those achieved in the randomized trials. Further studies are still needed to assess its long-term efficacy. Several randomized trials are underway to assess the role of stents and the use of more potent antiplatelet drugs, as the GPIIb/IIIa receptor blockers, in adjunct to balloon angioplasty in the treatment of acute myocardial infarction.     

Safety of single versus multi-vessel angioplasty for patients with acute myocardial infarction and multi-vessel coronary artery disease: report from the New York State Angioplasty Registry

BACKGROUND: The conventional strategy for primary angioplasty during acute myocardial infarction is angioplasty of the infarct-related vessel, even in patients with multi-vessel disease. Patients, however, often have significant lesions in multiple coronary arteries and a strategy for multi-vessel angioplasty during acute myocardial infarction has not been explored. The purpose of this study was to examine whether multi-vessel angioplasty is as safe as infarct-related vessel angioplasty in patients with multi-vessel coronary artery disease during acute myocardial infarction. METHODS: Using the 2000-2001 New York State Angioplasty Registry database, we compared the in-hospital clinical outcomes of patients with multi-vessel disease (>70% stenosis in at least two major coronary arteries), who underwent either multi-vessel angioplasty (n=632) or infarct-related vessel angioplasty (n=1350) within 24 h of acute myocardial infarction. Patients with previous myocardial infarction, angioplasty, bypass surgery, or cardiogenic shock were excluded. RESULTS: Patients in the multi-vessel angioplasty group were less likely to be female, to have peripheral vascular disease or diabetes. They had more complex lesions and were more likely to receive stents. In-hospital mortality was three-fold lower (0.8 versus 2.3%, P=0.018) in the multi-vessel angioplasty group. No differences were observed in other ischemic complications, renal failure, or length of stay. After multivariate analysis, multi-vessel angioplasty remained a significant predictor of lower in-hospital death (odds ratio=0.27, 95% confidence interval=0.08-0.90, P=0.03). CONCLUSIONS: Despite the added complexity of multi-vessel angioplasty, patients in this group had significantly lower in-hospital mortality. Therefore, a strategy of multi-vessel angioplasty during acute myocardial infarction may be safe compared with infarct-related angioplasty in selected patients.     

Type of treatment and short-term outcome in elderly patients with acute myocardial infarction admitted to hospitals with a primary coronary angioplasty facility. The TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry

INTRODUCTION AND OBJECTIVES: The nature and outcome of treatment for acute myocardial infarction in elderly patients admitted to Spanish hospitals with primary angioplasty facilities are not well documented. PATIENTS AND METHOD: Prospective analysis of registry data on patients > or =75 years old with ST-segment-elevation acute myocardial infarction admitted between April and July 2002 to Spanish hospitals with an active primary angioplasty program. RESULTS: We followed up 410 consecutive patients for 1 month. Their mean age was 80 (4.3) years and 46% were female. The median delay between symptom onset and arrival at hospital was 190 minutes. Around 42% of patients received no reperfusion therapy, 35% were treated by thrombolysis, and 22% by primary angioplasty. Patients who underwent reperfusion therapy were younger, were more frequently male, had a shorter delay from symptom onset to hospital arrival, and had a better initial hemodynamic status (Killip Class). However, they were more likely to have extensive anterior infarctions. Overall, 30-day mortality was 24.9%. Independent predictors of death were age, systolic blood pressure, and Killip class >1, but not use of thrombolysis or primary angioplasty. CONCLUSIONS: Over 42% of elderly patients with myocardial infarction admitted to Spanish hospitals with angioplasty facilities did not receive reperfusion therapy. Thrombolysis was the most frequently used reperfusion therapy. However, neither thrombolysis nor primary angioplasty improved 30-day mortality.     

Repeat percutaneous coronary angioplasty; clinical and angiographic follow-up in patients with stable or unstable angina pectoris

This study analyses the immediate outcome and the risk of recurrentrestenosis in patients who, at the time of repeat coronary angioplastyfor a first restenosis, had unstable (n = 50), 19%) or stable(n = 218, 81%) angina. Successful angioplasty was accomplishedin 250 (93%) patients, 222 (89%) of whom hadfollow-up angiography.Mean time from initial to repeat angioplasty was shorter (P= 0.0002) and angiographic evidence of thrombus was commoner(P = 0.0001) in the unstable group. Major complications (coronaryartery bypass grafting or myocardial infarction) were morefrequent(P <0.01) in the unstable group (6% vs 0.5%); no procedure-relateddeaths occurred. The angiographic rate of restenosis was significantlyhigher in the unstable group (61% vs 43%, P <0.05). Despitethis high rate of recurrent restenosis, most of the patientsin both groups were either asymptomatic or had atypical chestpain at follow-up. Repeat coronary angioplasty, in patients with unstable angina,has a high primary success rate but a higher risk of acute complicationsthan in patients with stable angina. The angiographic rate ofrestenosis was significantly higher in unstable than in stablepatients, however, the clinical status of most patients wasimproved at follow-up.