Management of myocardial infarction patients with an occluded infarct-related artery: additional commentary

The evidence is becoming stronger (but not conclusive) that restoration of flow in the infarct-related artery at a later date than is generally accepted might decrease mortality. The CORAMI report suggests a good outcome with rescue angioplasty, but, unfortunately, there was no control group. Since urgent rescue PTCA opened the infarct-related artery in the 29% of patients who remained occluded after thrombolysis, those cardiologists advocating emergency PTCA in all infarcting patients argue that 100% of occluded vessels can be opened with PTCA. I don't argue that fact but would point out that 71% of these same patients would have had unnecessary angioplasty since the occluded artery would have opened with thrombolytic therapy. The randomized trial performed by Ellis and colleagues was a difficult one because of physician bias. It took three years to complete at 20 sites, and in the presence of an occluded anterior descending coronary artery some investigators were reluctant to randomize all of their patients to conservative therapy. Obviously, a large trial would be appropriate to confirm Ellis and colleagues' observations but I doubt this will ever be done. Based on what is now known, I think it is worthwhile to consider rescue angioplasty in patients with a known occluded infarct-related artery. Unfortunately, that means performing coronary angiography almost immediately in all patients with infarcting myocardium in order to identify those with persistant occlusion.