Author + information
- Received October 2, 1993
- Revision received June 27, 1994
- Accepted August 25, 1994
- Published online February 1, 1995.
- Gregg W. Stone, MD, FACCa,1,2,
- Cindy L. Grines, MD, FACC∗,
- Kevin F. Browne, MD, FACC†,
- Jean Marco, MD‡,
- Donald Rothbaum, MD, FACC§,
- James O'Keefe, MD, FACC∥,
- Geoffrey O. Hartzler, MD, FACC∥,2,
- Paul Overlie, MD, FACC¶,
- Bryan Donohue, MD, FACC#,
- Noah Chelliah, MD∗∗,
- Gerald C. Timmis, MD, FACC∗,
- Ronald Vlietstra, MD, FACC†,
- Michelle Strzelecki, RN∗,
- Sylvia Puchrowicz-Ochocki, MD∗ and
- William W. O'Neill, MD, FACC∗,2
- ↵1Address for correspondence: Dr. Gregg W. Stone, The Cardiovascular Institute, 2660 Grant Road, Mountain View, California 94040.
Objectives. This study examined the predictors of in-hospital and 6-month outcome after different reperfusion strategies in acute myocardial infarction.
Background. Thrombolytic therapy and primary angioplasty are both widely applied as reperfusion modalities in patients with myocardial infarction. Although it is accepted that restoration of early patency of the infarct-related artery can reduce mortality and salvage myocardium, the optimal reperfusion strategy remains controversial, and the predictors of outcome in the reperfusion era have been incompletely characterized.
Methods. At 12 centers, 395 patients presenting within 12 h of onset of acute transmural myocardial infarction were prospectively randomized to receive tissue-type plasminogen activator (t-PA) or undergo primary angioplasty without antecedent thrombolysis. Sixteen clinical variables were examined with univariate and multiple logistic regression analysis to identify the predictors of clinical outcome.
Results. By univariate analysis, in-hospital mortality was increased in the elderly, women, patients with diabetes and in patients treated with t-PA as opposed to angioplasty. Only advanced age and treatment by t-PA versus angioplasty independently correlated with increased in-hospital mortality (6.5% vs. 2.6%, respectively, p = 0.039 by multiple logistic regression analysis). Similarly, the only variables independently related to in-hospital death or nonfatal reinfarction were advanced age and treatment by t-PA versus angioplasty (12.0% vs. 5.1%, p = 0.02). The reduction in in-hospital death or reinfarction with angioplasty versus t-PA was particularly marked in patients ≥65 years of age (8.6% vs. 20.0%, p = 0.048). Furthermore, primary management with angioplasty versus t-PA was the most powerful multivariate correlate of freedom from recurrent ischemic events (10.3% vs. 28.0%, p = 0.0001). The independent beneficial effect of angioplasty on freedom from death or reinfarction was maintained at 6-month follow-up (8.2% vs. 17.0%, p = 0.02).
Conclusions. In the reperfusion era, the two most powerful determinants of freedom from death, reinfarction and recurrent ischemia after myocardial infarction are young age and treatment by primary angioplasty.
↵2 Drs. Stone, Hartzler and O'Neill have served as consultants in the angioplasty industry.
☆ A complete list of collaborators and participating centers appears in the Appendix.
- Received October 2, 1993.
- Revision received June 27, 1994.
- Accepted August 25, 1994.