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Emergency coronary artery reperfusion: a choice therapy for evolving myocardial infarction. Results in 339 patients
Insights
Emergency reperfusion therapy for evolving myocardial infarction (MI) using streptokinase, angioplasty, or bypass grafting shows varying success rates. Bypass grafting is recommended for multi-vessel disease, while lysis and angioplasty are options for single-vessel involvement.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Surgery
Background:
- Acute myocardial infarction (MI) necessitates timely reperfusion to salvage myocardium.
- Various reperfusion strategies have been employed, including thrombolysis, angioplasty, and bypass grafting.
Purpose of the Study:
- To compare the efficacy and outcomes of different emergency reperfusion techniques for evolving myocardial infarction.
- To establish treatment guidelines based on vessel involvement and patient condition.
Main Methods:
- Retrospective analysis of 339 patients undergoing emergency reperfusion between 1975 and 1982.
- Group I: Intracoronary streptokinase (n=112).
- Group II: Intracoronary streptokinase + percutaneous transluminal coronary angioplasty (PTCA) (n=46).
- Group III: Saphenous vein bypass grafting (n=181).
Main Results:
- Successful reperfusion rates varied: 79% for bypass grafting, 33% residual lesions after streptokinase lysis, 16-17% no observable lesion on restudy.
- Mortality was concentrated in patients with cardiogenic shock before reperfusion (Group IV).
- Late follow-up revealed MIs, cerebrovascular accidents, and residual symptoms in a subset of patients.
Conclusions:
- Emergency reperfusion of the infarct-related artery is crucial for evolving MI.
- For single-vessel disease, streptokinase lysis followed by PTCA if needed is recommended.
- Emergency saphenous vein bypass grafting is the preferred treatment for acute MI with significant multi-vessel disease.
Abstract:
Between 1975 and 1982, 339 patients underwent emergency coronary artery reperfusion for treatment of evolving myocardial infarction (MI). Group I (112 patients) had reperfusion with intracoronary streptokinase. Group II (46 patients) had reperfusion with a combination of intracoronary streptokinase and percutaneous transluminal coronary angioplasty (PTCA). Group III (181 patients) had saphenous vein bypass grafting. Twenty Group I patients and one Group II patient had emergency bypass grafting as streptokinase and PTCA were unsuccessful and significant myocardium remained at risk due to residual stenosis in the MI artery. Seventy-nine percent of Group III patients had successful thrombectomy of the infarcted artery, 33% of Group I had significant residual lesions after clot lysis, and 16% of Group I and 17% of Group III patients had no observable lesion on restudy. There were 10 early and two late deaths in the surgical patients. There were two deaths in Group I and no deaths in Group II. All deaths occurred in patients who were in cardiogenic shock before reperfusion (Group IV). Late follow-up (220 patients to 78 months) revealed three late MIs, four cerebral vascular accidents, two late cardiac and three noncardiac late deaths, and 31 patients with residual symptoms. Patients with an emerging MI should be treated via reperfusion of the MI vessel by one of these techniques. With single-vessel involvement, streptokinase lysis of the intercoronary thrombosis should be attempted. If this is successful and there is a significant residual stenotic lesion, the vessel should undergo balloon angioplasty at that time. If PTCA is unsuccessful, then bypass grafting should be done. When significant multiple-vessel disease exists in conjunction with an acute MI, the patient should have emergency saphenous vein bypass grafting as the treatment of choice.