title: Inverse relation between diastolic blood pressure and long-term outcomes in patients undergoing pharmacoinvasive therapy for myocardial infarction: the J-shaped relation in the contemporary era of revascularisation.
abstract: OBJECTIVE
  In the thrombolytic era, it was reported that in the presence of significant coronary stenosis, lowering diastolic blood pressure (DBP) below a critical threshold would result in a paradoxical increase in the occurrence of myocardial infarction (MI). We sought to re-evaluate this J-shaped relation in the era of pharmacoinvasive therapy.
  
  
  METHODS
  A total of 182 patients who underwent early (<1 week, mean 2.3 days) coronary angioplasty after thrombolysis were analysed.
  
  
  RESULTS
  Thrombolytic agents (streptokinase in 60%, tissue plasminogen activator in 40%) were administered in an average door-to-needle time of 66 min (<=30 min in 43 [24%] patients). A thrombolysis in myocardial infarction (TIMI) 3 flow was achieved in 56% of patients after thrombolysis, and it was enhanced to 92% after angioplasty. During an average follow-up period of 26 +/-13 months, the adverse event (death, re-MI, target vessel revascularisation or stroke) rate was 21%. Older age, low systolic blood pressure and DBP, fast heart rate, high creatine kinase, hypercholesterolaemia, thrombus-laden lesion, baseline TIMI 0-2 flow were associated with higher occurrence of adverse events. After adjusting for the differing clinical and procedural factors, low DBP (odds ratio 1.10, 95% confidence interval 1.01-1.20, P = 0.041), fast heart rate (odds ratio 1.08, 95% confidence interval 1.02-1.14, P = 0.008) and anterior MI (odds ratio 18.98, 95% confidence interval 2.13-169.19, P = 0.008) were all independent predictors of long-term adverse rate occurrence.
  
  
  CONCLUSIONS
  A low DBP is an independent predictor of long-term adverse event rates in patients undergoing routine early coronary angioplasty after thrombolysis. This suggests that excessive lowering of DBP may not be desirable before complete revascularisation.
authors.affiliation: Cardiac Department, National University Hospital, The Heart Institute, Singapore. leerch@hotmail.com
authors.forename: Chi Hang
authors.initials: CH
authors.lastname: Lee
authors.forename: David
authors.initials: D
authors.lastname: Foo
authors.forename: Hwee Bee
authors.initials: HB
authors.lastname: Wong
authors.forename: Eric C T
authors.initials: EC
authors.lastname: Hong
authors.forename: Swee Chong
authors.initials: SC
authors.lastname: Seow
authors.forename: Kheng Siang
authors.initials: KS
authors.lastname: Ng
authors.forename: Yean Teng
authors.initials: YT
authors.lastname: Lim
authors.forename: Huay Cheem
authors.initials: HC
authors.lastname: Tan
mesh_terms: D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects; D001794:Blood Pressure / Q000187:drug effects*; D017023:Coronary Angiography; D003326:Coronary Circulation / Q000187:drug effects; D003971:Diastole; D005260:Female; D005343:Fibrinolytic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006339:Heart Rate / Q000187:drug effects; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D009204:Myocardial Revascularization / Q000009:adverse effects; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012372:ROC Curve; D012008:Recurrence; D012107:Research Design; D012307:Risk Factors; D012680:Sensitivity and Specificity; D013300:Streptokinase / Q000627:therapeutic use; D020521:Stroke / Q000209:etiology; D015912:Thrombolytic Therapy; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator