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[PTCA and intracoronary lysis in acute myocardial infarct]
Insights
Successful thrombolysis for acute myocardial infarction often leaves residual stenosis. Immediate percutaneous coronary intervention (PCI) significantly improves prognosis and myocardial perfusion compared to thrombolysis alone.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Thrombolysis is a primary treatment for acute myocardial infarction.
- Residual stenosis after successful thrombolysis is common (76% of patients).
- Management of residual stenosis varies based on disease complexity (single vs. multi-vessel).
Purpose of the Study:
- To evaluate the impact of immediate percutaneous coronary intervention (PCI) following successful thrombolysis on patient prognosis and myocardial perfusion.
- To assess the efficacy of PCI in reducing stenosis and improving clinical outcomes in acute myocardial infarction.
Main Methods:
- A non-randomized study of 411 patients compared outcomes after thrombolysis with bypass surgery, PCI, or medical therapy.
- A randomized study compared thrombolysis alone (95 patients) versus thrombolysis plus immediate PCI (95 patients).
- Immediate PCI was also studied in 27 patients with cardiogenic shock.
Main Results:
- In the non-randomized study, bypass surgery offered the best prognosis, followed by PCI, then medical therapy.
- In the randomized study, immediate PCI significantly reduced stenosis (78% to 33%) and improved clinical course, wall motion, and perfusion compared to thrombolysis alone.
- In cardiogenic shock patients, immediate PCI achieved high recanalisation rates (24/27) and lower clinical mortality.
Conclusions:
- Percutaneous coronary intervention (PCI) is complementary to successful thrombolysis in acute myocardial infarction.
- Immediate PCI improves prognosis and myocardial perfusion after thrombolysis.
- PCI is effective in reducing stenosis and improving outcomes in acute myocardial infarction, including in cardiogenic shock.
Abstract:
In 76% of all patients in whom thrombolysis was successful a residual stenosis exceeding 75% luminal diameter was found. Some patients suffered from single, others from multi-vessel disease. In single vessel diseases immediate intracoronary balloon dilatation of the residual stenosis is feasible. In multi-vessel diseases an aortocoronary bypass operation may follow. In a non-randomized study of 411 patients treated successfully with thrombolysis the best prognosis during the hospital phase and the subsequent 12 months was found in those who had had bypass surgery; patients treated with PTCA had the next best prognosis, and those treated with medical therapy had the worst. In a randomized study 95 patients were treated with thrombolysis alone and another 95 patients with thrombolysis plus immediate PTCA. PTCA diminished the degree of stenosis significantly (78 +/- 16% vs. 33 +/- 21%; p less than 0.001). This value remained constant during the following four weeks (30 +/- 26%). The clinical course, segmental wall motion and myocardial perfusion were more favourable in the PTCA group. No differences were found regarding spontaneous and inducible ventricular electrical vulnerability. Immediate PTCA without prior thrombolysis was performed in 27 patients with overt cardiogenic shock. The clinical mortality was significantly lower than in comparative studies. Recanalisation was successful in 24 of 27 patients. PTCA is complementary to successful thrombolysis in acute myocardial infarction to improve the prognosis and myocardial perfusion.