The role of angioplasty after successful thrombolysis for acute myocardial infarction.
Soon after the efficacy of thrombolytic agents in recanalizing totally occluded arteries in the setting of AMI was shown, angiographic studies revealed a residual high-grade stenosis in a majority of these patients. To improve clinical outcome further, the role of coronary angioplasty at varying time intervals after myocardial infarction has been examined. In all studies examining the role of immediate angioplasty, no definite advantage was observed with the invasive strategy. In one study, a higher mortality rate was observed in the invasive group, whereas all studies demonstrated a significant increase in the number of non-fatal ischemic adverse events after PTCA. Although differences in clinical outcomes were noted, no difference in left ventricular function, the primary endpoint of all three studies, was demonstrated. Similar results were obtained in the randomized trials of delayed (< 48 h) or late (> 48 h) angioplasty versus conservative management. The majority of these latter trials suffer from the lack of a true control arm, as many patients in the conservative arms undergo PTCA. Observational series in conservatively treated patients after thrombolysis suggest that the coronary plaque remains unstable for several weeks after myocardial infarction. Pacifying the unstable plaque either by medical therapies or by PTCA with adjunctive therapies may in the future be the way to improve outcome in the post-infarction period. In the acute phase, aortic counterpulsation has been found to reduce ischemic events after PTCA in a randomized trial [36].(ABSTRACT TRUNCATED AT 250 WORDS)
Labinaz
M
M
Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710.
Ellis
S G
SG
Phillips
H R
HR
Ohman
E M
EM
D015906:Angioplasty, Balloon, Coronary; D002986:Clinical Trials as Topic; D006801:Humans; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic; D015912:Thrombolytic Therapy; D013997:Time Factors