Author + information
- Received August 17, 1994
- Revision received February 24, 1995
- Accepted March 1, 1995
- Published online July 1, 1995.
- Gregg W. Stone, MD, FACCa,1,*,
- Cindy L. Grines, MD, FACCa,*,
- Kevin F. Browne, MD, FACCa,†,
- Jean Marco, MDa,‡,
- Donald Rothbaum, MD, FACCa,§,
- James O'Keefe, MD, FACCa,∣,
- Geoffrey O. Hartzler, MD, FACCa,∣,1,
- Paul Overlie, MD, FACCa,¶,
- Bryan Donohue, MD, FACCa,#,
- Noah Chelliah, MDa,**,
- Gerald C. Timmis, MD, FACCa,*,
- Ronald Vlietstra, MD, FACCa,†,
- Sylvia Puchrowicz-ochocki, MDa,* and
- William W. O'Neill, MD, FACCa,*,1
- ↵*Address for correspondence: Dr. Gregg W. Stone, The Cardiovascular Institute, 2660 Grant Road, Mountain View, California 94040.
Objectives. The purpose of this study was to examine the incidence and implications of recurrent ischemia after different reperfusion strategies in acute myocardial infarction.
Background. The rates and effects of recurrent ischemia after reperfusion with thrombolytic therapy and with primary percutaneous transluminal coronary angioplasty have not been compared.
Methods. At 12 centers 395 patients presenting within 12 h of the onset of acute myocardial infarction were prospectively randomized to receive recombinant tissue-type plasminogen activator (rt-PA) or primary coronary angioplasty. Sixteen clinical variables were examined by using univariate and multiple logistic regression analysis to identify the predictors of recurrent ischemia. The relation of recurrent ischemic events to patient outcome was analyzed.
Results. Recurrent ischemia developed in 76 patients (19.2%) before hospital discharge, resulting in reinfarction in 18 patients (4.6%) and death in 5 (2.6%). Recurrent ischemia occurred in 56 patients (28.0%) after rt-PA but in only 20 patients (10.3%) after coronary angioplasty (p < 0.0001), directly contributing to a higher rate of death or reinfarction (7.5% vs. 3.1%, p = 0.05), catheterization and revascularization procedures and prolonged hospital stay after thrombolysis. By multivariate analysis, treatment with coronary angioplasty rather than rt-PA was the strongest predictor of freedom from recurrent ischemia. Although the incidence of recurrent ischemia after angioplasty and after rt-PA was similar within the 1st 2 days of admission (9.2% vs. 14.5%, p = 0.11), after hospital day 2 recurrent ischemia occurred in only 2 patients who received primary angioplasty compared with 27 patients who received rt-PA (1.1% vs. 13.5%, p < 0.0001).
Conclusions. The development of recurrent ischemia adversely affects patient outcome, increasing morbidity, mortality and resource utilization. The much lower rate of recurrent ischemia after primary coronary angioplasty than after rt-PA results in improved survival without reinfarction and allows a shorter, less complicated hospital stay. Given the extremely low rate of recurrent ischemia after hospital day 2, safe early discharge on day 3 after primary coronary angioplasty should be feasible in selected patients with acute myocardial infarction.
↵1 Drs. Stone, Hartzler and O'Neill have served as consultants to the angioplasty industry.
A complete list of collaborators and participating centers appears in reference 13. This study was funded by the participating institutions and investigators, with no industry support.
- Received August 17, 1994.
- Revision received February 24, 1995.
- Accepted March 1, 1995.
- The American College of Cardiology