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Acute coronary occlusion and reperfusion. Reliability of angiographic classification and grading
S G Sorensen1, R A Hackworthy, P G Fitzpatrick
1LDS Hospital, University of Utah Medical Center, Salt Lake City.
Insights
This study compared intracoronary streptokinase and intravenous anisoylated plasminogen streptokinase activator complex (APSAC) for acute myocardial infarction reperfusion. Reperfusion rates varied significantly based on timing and criteria, with streptokinase generally showing higher rates.
Area of Science:
- Cardiology
- Interventional Cardiology
- Thrombolytic Therapy
Background:
- Acute myocardial infarction (AMI) requires prompt restoration of coronary blood flow.
- Fibrinolytic therapy is a key treatment strategy for AMI.
- Coronary angiography is crucial for assessing reperfusion after fibrinolysis.
Purpose of the Study:
- To compare the efficacy of intracoronary streptokinase versus intravenous anisoylated plasminogen streptokinase activator complex (APSAC) in achieving coronary reperfusion in AMI patients.
- To evaluate the impact of different angiographic reperfusion criteria and timing on treatment outcomes.
Main Methods:
- A multicenter, randomized trial involving 93 AMI patients.
- Coronary angiography performed pre- and post-fibrinolytic therapy (streptokinase or APSAC).
- Serial angiograms assessed coronary perfusion using a 4-grade scale at multiple time points.
- Four distinct reperfusion criteria (Groups A-D) were applied to analyze results.
Main Results:
- Inter-reader agreement for angiographic grading was reasonable (K = 0.73).
- Reperfusion rates varied widely based on the definition used: Group A (90 min): Streptokinase 49%, APSAC 44%; Group B (any time): Streptokinase 70%, APSAC 50%; Group C (any time, baseline 0/1): Streptokinase 86%, APSAC 67%; Group D (any time, baseline 0): Streptokinase 79%, APSAC 59%.
- Streptokinase demonstrated higher reperfusion percentages across most criteria compared to APSAC.
Conclusions:
- The choice of reperfusion criteria significantly influences the reported success rates of fibrinolytic therapy in AMI.
- Both streptokinase and APSAC achieved reperfusion, but rates differed based on assessment methods.
- Further research is needed to standardize reperfusion assessment in clinical trials.
Abstract:
93 patients with acute myocardial infarction entered into a multicentre, randomised fibrinolytic therapy study underwent coronary angiography prior to treatment with intracoronary streptokinase or intravenous anisoylated plasminogen streptokinase activator complex (APSAC). Subsequent to administration of fibrinolytic therapy, coronary arteriography of the infarct-related artery was also performed at 15, 30, 45, 60, 75 and 90 minutes. Angiographically defined coronary perfusion was graded as follows: grade 0--no perfusion; grade 1--vessel penetration by contrast without perfusion; grade 2--partial perfusion with delayed flow and/or clearance; grade 3--normal flow and clearance. Two independent readers at separate sites reviewed all serial angiograms with consensus achieved with a third reader. Disagreement potentially affecting therapeutic outcome (grades 1 vs 2, 0 vs 2, 0 vs 3, and 1 vs 3) occurred for only 15 angiographic views. Evaluation of agreement by the K index demonstrated a reasonable level of agreement for all grades (K = 0.73). In order to assess the effect of angiographic classification and timing upon reperfusion percentage rates, 4 reperfusion criteria were applied to these serial angiograms: group A = grade 2 or 3 flow at 90 minutes; group B = grade 2 or 3 flow at any time; group C = grade 1, 2 or 3 flow at any time in patients with control grade 0 or 1 flow; group D = grade 1, 2 or 3 flow at any time in patients with only grade 0 flow at control. Percentage reperfusion varied widely depending upon reperfusion criteria: group A: streptokinase 49%, APSAC 44%; group B: streptokinase 70%, APSAC 50%; group C: streptokinase 86%, APSAC 67%; group D: streptokinase 79%, APSAC 59%.(ABSTRACT TRUNCATED AT 250 WORDS)