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Published on: April 25, 2014
Coronary angiography after thrombolytic therapy for acute myocardial infarction
E J Topol1, D R Holmes, W J Rogers
1University of Michigan School of Medicine, Ann Arbor.
Insights
Emergency coronary angiography aids reperfusion therapy, while urgent angiography is valuable for recurrent ischemia. Routine or selective angiography is acceptable for uncomplicated patients post-thrombolysis, with selective being more practical.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Intravenous thrombolytic therapy is a cornerstone in managing evolving myocardial infarction.
- The role and timing of coronary angiography following thrombolysis require clear definition.
Purpose of the Study:
- To review the current status and indications for emergency, urgent, routine, and selective coronary angiography after intravenous thrombolytic therapy.
- To synthesize evidence from randomized controlled trials regarding post-thrombolysis angiography strategies.
Main Methods:
- Systematic review of English-language articles published between January 1985 and July 1990, identified via MEDLINE.
- Meta-analysis of data from studies incorporating rescue coronary angioplasty.
- Emphasis on findings from multicenter, randomized, controlled trials.
Main Results:
- Emergency angiography is primarily for primary or rescue angioplasty; rescue angioplasty's value is unproven in randomized trials.
- Nonspecific plasminogen activators show significantly better technical success and lower reocclusion rates than specific agents.
- Urgent angiography is valuable for recurrent ischemia, though outcomes remain suboptimal; selective or routine angiography is acceptable for uncomplicated patients, with selective being more practical.
Conclusions:
- Coronary angiography at various stages can optimize follow-up for patients receiving thrombolysis for myocardial infarction.
- Current noninvasive methods for detecting reperfusion, reocclusion, or ischemia are limited.
- Available data can guide the selection of an appropriate post-thrombolysis catheterization strategy.
Purpose:
To review the status of emergency, urgent, routine, and selective angiography after intravenous thrombolytic therapy.
Data Sources:
Relevant English-language articles published from January 1985 to July 1990 were identified through MEDLINE.
Study Selection:
For emergency angiography, four major randomized studies were reviewed and data from nine studies that incorporated rescue coronary angioplasty were pooled for meta-analysis. For urgent angiography, two controlled trials were reviewed. Comparisons of routine and selective angiography were done using data from two dedicated, large-scale, controlled trials and the ancillary findings of four other studies of reperfusion that incorporated angiography.
Data Extraction:
The review emphasizes the findings from multicenter, randomized, controlled trials.
Data Synthesis:
Emergency coronary angiography is done primarily in preparation for primary or rescue angioplasty; the value of rescue angioplasty has yet to be assessed in a randomized trial, but technical success and reocclusion improve significantly after therapy with nonspecific plasminogen activators compared with relatively specific agents (success rate, 86% compared with 75%, respectively; P = 0.03; reocclusion rate, 10.9% compared with 26.8%, respectively; P less than 0.001). Urgent coronary angiography has value for treating recurrent ischemia, but patients who develop this complication after thrombolysis are likely to have a suboptimal outcome despite aggressive care. Studies support the use of either selective or routine angiography in uncomplicated patients after thrombolytic therapy; either approach is acceptable, but the former is more practical and may prove to be cost effective.
Conclusions:
Optimal follow-up for patients with evolving myocardial infarction who receive thrombolysis may incorporate coronary angiography at various stages. Although our ability to noninvasively detect reperfusion, reocclusion, or viable but ischemic myocardium is limited at present, available data may assist in selecting a catheterization strategy.
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