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[Direct coronary angioplasty in acute myocardial infarct]
1Departement Medizin, Universitätsklinik, Inselspital, Bern.
Insights
Direct coronary angioplasty is the preferred treatment for acute myocardial infarction, offering better outcomes and reduced mortality compared to thrombolysis. It should be initiated promptly to maximize benefits.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Direct (primary) coronary angioplasty has evolved from rescue therapy to a primary treatment for acute myocardial infarction.
- Randomized studies since 1993 have demonstrated the superiority of angioplasty over thrombolysis for specific patient groups.
Purpose of the Study:
- To evaluate the efficacy and outcomes of direct coronary angioplasty compared to thrombolysis in managing acute myocardial infarction.
- To identify patient subgroups and timeframes where direct angioplasty is the optimal reperfusion strategy.
Main Methods:
- Review of literature and randomized studies comparing direct angioplasty with thrombolysis.
- Analysis of success rates, reocclusion, need for emergency bypass surgery, and hospital mortality.
- Comparison of reperfusion times, neurological complications, and long-term outcomes including ejection fraction and need for reintervention.
Main Results:
- Direct angioplasty has a 90% success rate, with 11% reocclusion and 3% need for emergency bypass surgery; hospital mortality is 7%.
- Angioplasty offers a time advantage in reperfusion (approx. 1 hour faster) and reduces hospital mortality and cerebral bleedings compared to thrombolysis.
- Improved ejection fraction and reduced need for further interventions indicate long-term benefits and economic advantages for direct angioplasty.
Conclusions:
- Direct angioplasty is the treatment of choice for acute myocardial infarction, especially in large, short-duration infarctions, provided treatment organization time is under 30 minutes.
- It establishes patency earlier and leads to better overall hospital and long-term outcomes by addressing the underlying lesion.
- Thrombolysis remains the preferred option if angioplasty organization exceeds 30 minutes; its role in cardiogenic shock is under evaluation.
Abstract:
Direct (primary) coronary angioplasty for acute myocardial infarction has appeared in the literature since 1982, first as a rescue therapy in case of failed intracoronary thrombolysis, then as its complement, and finally as an alternative. In the late eighties, the upsurge of intravenous thrombolysis turned the focus off direct angioplasty until several randomized studies demonstrated the superiority of angioplasty in 1993. For an infarction primarily due to a thrombus, it is the treatment of choice. However, there is no accurate way to predict these lesions. Direct angioplasty yields results comparable with the best published results of thrombolysis. However, the patients included in the thrombolysis studies usually present less severe clinical pictures than those undergoing angioplasty. On the average, direct angioplasty is successful in 90%, reocclusion occurs in 11%, and emergency bypass surgery becomes necessary in 3%. Hospital mortality is 7%. The risk factors known from thrombolysis also apply to direct angioplasty, such as multivessel disease, old age, cardiogenic shock and duration of infarction. Failed angioplasty is also a harbinger of death. In randomized comparisons with thrombolysis, an initial 30-45 minutes delay from decision to treatment because of preparations for cardiac catheterization was noted which converts to a time gain until reperfusion of about 1 hour in favor of angioplasty. Hospital mortality is reduced with angioplasty. Cerebral bleedings were confined to thrombolysis. Ejection fraction at rest or on exercise was better after angioplasty in two studies, and there is a clearcut reduction in the need for further interventions, resulting in an economic benefit in favour of direct angioplasty. A randomized study demonstrated that it was deleterious to routinely complement direct angioplasty with intravenous streptokinase. Direct angioplasty establishes patency earlier than thrombolysis and has a better overall hospital and long term course, probably because it eliminates the lesion in most cases rather than just recanalizing the vessel. It should be used in all patients with acute myocardial infarction provided not more than 30 minutes are lost for its organization. Otherwise, thrombolysis is the preferred treatment. Direct angioplasty is particularly desirable in patients with large infarctions of short duration. Its role for infarctions presenting with cardiogenic shock is currently under evaluation.