[Coronary angioplasty after thrombolytic therapy]

Two strategic choices are available after thrombolytic therapy: an aggressive strategy with the objective of restoring blood flow in the coronary artery responsible for the infarction or a conservative strategy, In the aggressive strategy, there is some debate about the timing of coronary angiography: immediate coronary angiography with a view to angioplasty during the same procedure whenever technically feasible or only when the artery remains occluded after thrombolysis ("salvage" angioplasty); or deferred coronary angiography and angioplasty with the objective of preventing recurrence of ischaemia, performed during the hospital phase before the patient's discharge. Besides this aggressive strategy, some cardiologists prefer to adopt a conservative attitude which consists in only performing coronary angiography and eventual revascularisation when the patients develop ischaemia during follow-up either spontaneously or during stress testing. Several randomised clinical trials performed in recent years, (TAMI, TIMI 2A and 2B, European Study, SWIFT), have all shown that there was no significant difference in survival or global left ventricular function between patients managed "aggressively" and those managed "conservatively". However, these studies are open to criticism, especially in the light of recent data about associated medical therapy which reduces the incidence of complications, especially of reocclusion. This point should be emphasised as secondary studies on subgroups have shown that the benefits of the aggressive strategy were totally lost in patients who developed reocclusion but, conversely, the outcome was much better if the angioplasty was followed by long-term success.(ABSTRACT TRUNCATED AT 250 WORDS)