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[Myocardial infarction and revascularization. Current indications]
G Grollier1, P Scanu, B Valette
1service de soins intensifs de cardiologie, CHU Côte de Nacre, Caen, France.
Insights
Early thrombolysis and aspirin significantly reduce myocardial infarction mortality by maintaining coronary artery permeability. Prompt reperfusion is crucial, as demonstrated by studies showing reduced mortality with faster treatment initiation and sustained artery patency.
Area of Science:
- Cardiology
- Thrombosis Research
- Medical Treatment Efficacy
Context:
- Myocardial infarction (MI) pathogenesis involves thrombosis, with thrombolysis emerging as a key treatment.
- Short, middle, and long-term mortality in MI is linked to coronary permeability and reperfusion timing.
- Historical studies like GISSI and GUSTO highlighted the critical importance of rapid reperfusion.
Purpose:
- To evaluate the impact of thrombolytic therapy and adjunctive treatments on coronary permeability and mortality in myocardial infarction.
- To underscore the significance of timely reperfusion and sustained artery patency in reducing MI-related deaths.
- To assess the role of aspirin in preventing reocclusion after thrombolysis.
Summary:
- Thrombolysis, particularly when initiated rapidly, significantly reduces mortality following myocardial infarction.
- The "open artery" theory is supported by data showing lower mortality when coronary circulation is restored quickly.
- Aspirin plays a vital role in preventing reocclusion post-thrombolysis, contributing to improved patient outcomes.
Impact:
- Improved understanding of the physiopathology of myocardial infarction and the efficacy of thrombolytic treatments.
- Established the critical time window for reperfusion therapy in acute MI.
- Demonstrated the synergistic benefit of combining thrombolysis with antiplatelet agents like aspirin for better long-term survival.
Abstract:
The physiopathologic role of thrombosis in the genesis of myocardial infarction, began to be suspected early in the 20th century but its logical treatment, thrombolysis, was first used on a large scale only ten years ago. Today, it is well established that short, middle and long-term mortality is correlated to coronary permeability, the delay in the revascularization treatment start-up, its efficacy, its swiftness of action, and to the maintaining of permeability following reperfusion. The importance of time elapse before reperfusion is obtained was demonstrated as early as 1986 by the GISSI study. According to this study, the administration of streptokinase (compared to a conventional treatment) reduced mortality at 21 days respectively by 47%, 23%, and 17%, depending on whether patients were treated within one hour, three hours, or between 3 and 6 hours following the onset of the painful symptoms. One of the major teachings of the GUSTO study, reported at the end of 1993, was the confirmation of the so-called "open artery" theory: mortality at 30 days was of 4.5% among patients whose coronary circulation was restored at the 90th minute, whatever thrombolytic treatment was used, compared to 8.9% when the coronary artery remained occluded. The value of aspirin in preserving coronary permeability following thrombolysis was demonstrated by the ISIS-2 study: mortality at 5 weeks was reduced by 23% in the group of patients randomised to receive only aspirin, while it was reduced by 25% in the group of patients randomised to be treated with streptokinase, and by 42% in the group randomised to receive both aspirin and streptokinase, compared to the group who received neither aspirin nor streptokinase. However, mortality during the first days following randomisation was identical among the groups, with or without aspirin, which suggested its action was rather one of prevention against reocclusion than one of accelerating dissolution of the thrombus. However, in spite of improved therapeutical protocols, a normal flow, which is the major criteria for a reduced mortality, is only obtained at the 90th minute in 54% of the patients who were administered the up-to-date treatment ie aspirin-accelerated t-PA-heparin in combination.(ABSTRACT TRUNCATED AT 400 WORDS)