Angioplasty In Myocardial Infarction Trial Research Articles

Infarct size and left ventricular remodelling after preventive percutaneous coronary intervention

ObjectiveWe hypothesised that, compared with culprit-only primary percutaneous coronary intervention (PCI), additional preventive PCI in selected patients with ST-elevation myocardial infarction with multivessel disease would not be associated with iatrogenic...

110 Infarct Burden Following Multivessel PCI Vs. Infarct-Only PCI in Patients with Acute Stemi: The Glasgow Prami CMR Sub-Study: Abstract 110 Table 1

Background In the Preventive Angioplasty in Myocardial Infarction trial (PRAMI; ISRCTN73028481), immediate multivessel PCI (MV-PCI) of non-IRA lesions in patients with acute ST elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) improved long term prognosis. We assessed infarct distribution and size in a pre-specified cardiac magnetic resonance (CMR) sub-study. Methods In this single centre prospective sub-study, PRAMI participants were invited to undergo 1.5 Tesla CMR 1 week and 1 year after primary PCI. The CMR scans were analysed using semi-automated software by a clinician blinded to treatment group assignment and clinical outcomes. The presence and extent of infarction were assessed quantitatively with late gadolinium enhancement (LGE) imaging (Gadovist, 0.1 mmol/kg). The infarct was delineated as an area of myocardial enhancement (cm 2 ) using a signal intensity threshold of >5SDs above a remote region, and expressed as a% of total LV mass. The incidence of new LGE in non-infarct related artery territories at baseline and 1 year were assessed. Data were analysed by an independent statistician. Results Of 465 randomised trial participants in 6 UK hospitals, 138 (30%) were enrolled in Glasgow. Of these 80 patients underwent CMR 1 week post primary PCI of whom 41 (51%) were in the multi-vessel PCI group and 39 (49%) were in the IRA-only group. At 1 year, 69 (86%) patients had a follow up CMR scan. Infarct size and distribution are described in Table 1. Conclusion Infarct size and distribution were similar in patients treated by MV-PCI or IRA-only PCI. MV-PCI is not associated with additional MI acutely which supports the safety of this procedure in line with the benefits observed with preventive PCI in PRAMI. Funding Golden Jubilee National Hospital; PRAMI was funded by Barts and the London Charity.

Infarct burden following multivessel PCI vs. infarct-only PCI in patients with acute STEMI: the Glasgow PRAMI CMR sub-study

Background: In the Preventive Angioplasty in Myocardial Infarction trial (PRAMI; ISRCTN73028481), immediate multivessel PCI (MV-PCI) of non-IRA (infarct related artery) lesions in patients with acute ST elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) improved long term prognosis. We assessed infarct distribution and size in a pre-specified cardiac magnetic resonance (CMR) sub-study. Methods: In this single centre prospective sub-study, PRAMI participants were invited to undergo 1.5 Tesla CMR 1 week and 1 year after primary PCI. The CMR scans were analysed using semi-automated software by a clinician blinded to treatment group assignment and clinical outcomes. The presence and extent of infarction were assessed quantitatively with late gadolinium enhancement (LGE) imaging (Gadovist, 0.1 mmol/kg). The infarct was delineated as an area of myocardial enhancement (cm2) using a signal intensity threshold of >5SDs above a remote region, and expressed as a % of total LV mass. The incidence of new LGE in non-infarct related artery territories at baseline and 1 year were assessed. Data were analysed by an independent statistician. Results: Of 465 randomised trial participants in 6 UK hospitals, 138 (30%) were enrolled in Glasgow. Of these 80 patients underwent CMR 1 week post primary PCI of whom 41 (51%) were in the multi-vessel PCI group and 39 (49%) were in the IRA-only group. At 1 year, 69 (86%) patients had a follow up CMR scan. Infarct size and distribution are described in Table 1.

Usefulness of the Presence of Peripheral Vascular Disease in Predicting Mortality in Acute Myocardial Infarction Patients Treated With Primary Angioplasty (from the Primary Angioplasty in Myocardial Infarction Database)

Patients with acute myocardial infarction (AMI) often have multiple co-morbidities that influence outcome. We sought to evaluate the impact of peripheral vascular disease (PVD) on the outcome of patients with AMI treated with primary angioplasty. We evaluated 3,716 patients with AMI who underwent emergency catheterization with planned primary angioplasty in the Primary Angioplasty in Myocardial Infarction trials. Patients with a history of PVD (claudication, stroke, or transient ischemic attack) were compared with patients without PVD. Of the 3,716 patients, 394 (10.6%) had PVD and were older, more often women, and more frequently had a history of diabetes mellitus, hypertension, smoking, congestive heart failure, angina, myocardial infarction, and coronary revascularization. They presented more often with a heart rate >100 beats/min, Killip class >1, lower ejection fraction, and multivessel disease. No difference was found in stent use, final percentage of stenosis, or Thrombolysis In Myocardial Infarction 3 flow. Patients with PVD had a twofold increased in-hospital mortality (5.3% vs 2.6%, p = 0.0021). The difference remained significant at 1 month, 6 months, and 1 year (12.6% vs 6%, p < 0.0001). In multivariate logistic regression analysis, a history of PVD was an independent predictor of in-hospital mortality and death at 1 year (odds ratio 1.64, 95% confidence interval 1.04 to 2.57, p = 0.032). In conclusion, patients with AMI with PVD have increased co-morbidities and higher mortality despite treatment with primary angioplasty. The presence of PVD is an independent predictor of in-hospital mortality and death at 1 year.

Comparison of the Prognostic Effect of Left Versus Right Versus No Bundle Branch Block on Presenting Electrocardiogram in Acute Myocardial Infarction Patients Treated With Primary Angioplasty in the Primary Angioplasty in Myocardial Infarction Trials

The presence of bundle branch block (BBB) has been associated with poor outcomes in patients who have acute myocardial infarction. Whether this is true in the angioplasty era is not known. We sought to evaluate the outcome of patients with acute myocardial infarction and BBB who were treated with primary angioplasty. We evaluated 3,053 patients who underwent emergency catheterization in the PAMI trials. Patients who had left BBB (n = 48, 1.6%) on presenting electrocardiogram were compared with patients who had right BBB (n = 95, 3.1%) or no BBB (n = 2,910, 95.3%). Patients who had BBB were older and more frequently had diabetes mellitus, peripheral vascular disease, and previous coronary artery bypass grafting. They had lower ejection fraction and more multivessel disease. There were no significant differences in door-to-balloon time, final Thrombolysis In Myocardial Infarction flow grade or stent use. In-hospital major adverse cardiac events (death, ischemic target vessel revascularization, and reinfarction) were higher in patients who had BBB due primarily to increased in-hospital death (left BBB 14.6%, right BBB 7.4%, no BBB 2.8%, p < 0.0001). In multivariate logistic regression analysis, left BBB was an independent predictor of in-hospital death (odds ratio 5.53, 95% confidence interval 1.89 to 16.1, p = 0.002). In conclusion, patients who have acute myocardial infarction and BBB have increased co-morbidities and higher mortality rates despite treatment with primary angioplasty. Despite early identification of multivessel disease with triage to angioplasty or coronary artery bypass grafting, if necessary, similar treatment times, and final Thrombolysis In Myocardial Infarction grade 3 flow, the presence of left BBB on admission electrocardiogram in patients who have acute myocardial infarction is an independent predictor of in-hospital mortality. Because 85% of deaths in patients who have left BBB occur within the first week, these patients should be recognized early and receive prompt and aggressive treatment.

Ischemia‐Driven Target Vessel Revascularization After‐Primary Percutaneous Coronary Intervention: Patients At Risk and Their Outcomes

Clinical and angiographic correlates of ischemia-driven target vessel revascularization (ITVR) in patients undergoing primary percutaneous coronary interventions (PCI) are currently less well known. Accordingly, we examined 2,981 patients enrolled in different Primary Angioplasty in Myocardial Infarction trials, who underwent primary PCI to evaluate risk factors and outcomes of individuals requiring subsequent ITVR. At 6 months, ITVR was required in 321 patients (11%). Compared to the cohort without ITVR, patients requiring ITVR were younger (P=0.036), females (P=0.018), and more likely to have systolic blood pressure >100 mmHg on presentation (P=0.022), family history of premature coronary artery disease (P=0.035), and postprocedure dissection (P=0.001). In contrast, Killip Class >I on presentation (P=0.05), left circumflex as infarct-related artery (P=0.022), and the use of ticlopidine (P=0.044) and stents (p=0.057) were less frequent among ITVR patients. Multivariate analysis identified younger age (for each 10-year decrease, odds ratio [OR], 1.18; 95% confidence interval [CI], 1.06-1.32), female gender (OR: 1.41, 95% CI: 1.05-1.89), and final dissection (OR: 1.69, 95% CI: 1.23-2.33) as independent risk factors for ITVR. In-hospital reinfarction (P < 0.001) was increased and at 6 months remained higher in ITVR patients; in-hospital and 6-month mortality did not differ between the two groups. Our study identifies the incidence, risk factors, and outcomes of patients requiring ITVR after primary PCI. Importantly, our data suggest that no increase in mortality occur, if ITVR is promptly performed to treat recurrent ischemia after primary PCI.

Incidence and Prognostic Impact of Gastrointestinal Bleeding After Percutaneous Coronary Intervention for Acute Myocardial Infarction

We examined the incidence, presentation, and outcome of patients who developed gastrointestinal bleeding after percutaneous coronary intervention for acute myocardial infarction in the Primary Angioplasty in Myocardial Infarction trials. Of the 3,130 patients, 71 (2.3%) developed gastrointestinal bleeding, which was more likely to occur in elderly patients. Gastrointestinal bleeding was independently associated with a prolonged hospital stay and greater in-hospital and 6-month mortality.

Frequency of returning to work one and six months following percutaneous coronary intervention for acute myocardial infarction

We conducted an analysis of the frequency and variables associated with early (after 1 month) and late (after 6 months) return to work after percutaneous coronary intervention for acute myocardial infarction in patients who had been randomized in the Stent Primary Angioplasty in Myocardial Infarction trial. Of 450 patients who were employed before the acute myocardial infarction, 230 (51%) returned to work within 1 month with no increases in in-hospital and 1- or 6-month event rates compared with those who did not return to work. Multivariate analysis showed that predictors of early return to work were employment in the United States, no history of smoking, and single-vessel coronary disease. At 6 months, 353 of 435 patients (78%) had returned to work, and multivariate analysis showed that predictors of late return to work were employment in the United States and absence of angina.

815-6 Prognostic effect of left bundle brunch block on presenting electrocardiogram in patients with acute myocardial infarction treated with primary angioplasty in the primary angioplasty in myocardial infarction trials

815-6 Prognostic effect of left bundle brunch block on presenting electrocardiogram in patients with acute myocardial infarction treated with primary angioplasty in the primary angioplasty in myocardial infarction trials

Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention

ObjectivesThe purpose of this study was to determine the clinical and angiographic correlates and outcomes of patients with suboptimal coronary flow after primary percutaneous coronary interventions (PCI). BackgroundThe clinical and angiographic correlates and outcomes of Thrombolysis in Myocardial Infarction (TIMI) ≤2 flow in patients treated with primary PCI are not known. MethodsWe evaluated 3,362 patients with ST elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction trials, who underwent primary PCI. ResultsPost-procedural final TIMI ≤2 flow occurred in 232 (6.9%) patients. Multivariate analysis identified age ≥70 years (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1 to 2.2), diabetes (OR 1.9; 95% CI, 1.3 to 2.7), symptom onset to emergency room presentation (OR 1.1; 95% CI, 1.1 to 1.2); initial TIMI ≤1 flow (OR 3.2; 95% CI, 1.9 to 5.5), and left ventricular ejection fraction <50% (OR 1.7; 95% CI, 1.2 to 2.4) as independent correlates of final TIMI ≤2 flow. In-hospital (composite of reinfarction, ischemic target vessel revascularization, or death, as well as these events individually) and one-year (reinfarction and/or death) events occurred more frequently in patients with TIMI ≤2 flow. The Cox proportional hazards model identified TIMI ≤2 flow to be independently associated with one-year mortality (hazard ratio 3.8, 95% CI, 2.5 to 5.7). ConclusionsFinal TIMI ≤2 flow, although uncommon after primary PCI, was strongly associated with hospital and one-year adverse events. The clustering of final TIMI ≤2 flow in high-risk groups may partially explain the poor prognosis of these patients. Awareness of these risk factors may be useful to clinicians to triage and treat patients undergoing primary PCI.

Long-term outcome in patients with acute myocardial infarction undergoing primary percutaneous intervention: a pooled analysis of the primary angioplasty in myocardial infarction trials

Long-term outcome in patients with acute myocardial infarction undergoing primary percutaneous intervention: a pooled analysis of the primary angioplasty in myocardial infarction trials

Angiographic and clinical characteristics associated with increased in-hospital mortality in elderly patients with acute myocardial infarction undergoing percutaneous intervention (a pooled analysis of the primary angioplasty in myocardial infarction trials)

Advanced age is associated with increased mortality in acute myocardial infarction (AMI) but the mechanism remains unclear. We performed a pooled analysis of 3,032 patients from the Primary Angioplasty in Myocardial Infarction (PAMI)-2, Stent-PAMI, and PAMI-No Surgery On Site trials to determine which clinical, hemodynamic, and angiographic characteristics in the elderly were associated with in-hospital death. There were 452 patients aged ≥75 years and 2,580 patients aged <75 years. Older patients had a lower number of risk factors for coronary artery disease but more comorbidities. Acute catheterization demonstrated more 3-vessel disease, higher left ventricular (LV) end-diastolic pressure, lower LV ejection fraction, and higher initial rates of Thrombolysis In Myocardial Infarction (TIMI) trial 2 or 3 flow. Elderly patients were equally likely to undergo percutaneous intervention but had a lower procedural success rate and lower rates of final TIMI 3 flow, and older patients were more likely to have post-AMI complications. In-hospital mortality was 10.2% and 1.8%, respectively (p = 0.001). Cardiac and noncardiac mortality was higher in elderly patients, and no significant differences in causes of death were identified. Multivariate analysis revealed that the strongest predictors of death were age ≥75 years, lower LV ejection fraction, lower final TIMI flow, higher Killip class, need for an intra-aortic balloon pump (IABP), and post-AMI stroke/transient ischemic attack, or significant arrhythmia. Despite avoiding thrombolysis, elderly patients remain at increased risk of bleeding, stroke, and other post-AMI complications, and death. Cardiac risk factor analysis and acute catheterization offer prognostic information but do not completely explain the mechanism of increased in-hospital mortality in the elderly.

Clinical and angiographic outcomes in patients with previous coronary artery bypass graft surgery treated with primary balloon angioplasty for acute myocardial infarction

OBJECTIVESWe sought to characterize the presenting characteristics of patients with previous coronary artery bypass graft surgery (CABG) and acute myocardial infarction (AMI) and to determine the angiographic success rate and clinical outcomes of a primary percutaneous transluminal coronary angioplasty (PTCA) strategy.BACKGROUNDPatients who have had previous CABG and AMI comprise a high risk group with decreased reperfusion success and increased mortality after thrombolytic therapy. Little is known about the efficacy of primary PTCA in AMI.METHODSEarly cardiac catheterization was performed in 1,100 patients within 12 h of onset of AMI at 34 centers in the prospective, controlled Second Primary Angioplasty in Myocardial Infarction trial (PAMI-2), followed by primary PTCA when appropriate. Data were collected by independent study monitors, end points were adjudicated and films were read at an independent core laboratory.RESULTSOf 1,100 patients with AMI, 58 (5.3%) had undergone previous CABG. The infarct-related vessel in these patients was a bypass graft in 32 patients (55%) and a native coronary artery in 26 patients. Compared with patients without previous CABG, patients with previous CABG were older and more frequently had a previous myocardial infarction and triple-vessel disease. Coronary angioplasty was less likely to be performed when the infarct-related vessel was a bypass graft rather than a native coronary artery (71.9% vs. 89.8%, p = 0.001); Thrombolysis in Myocardial Infarction trial (TIMI) flow grade 3 was less frequently achieved (70.2% vs. 94.3%, p < 0.0001); and in-hospital mortality was increased (9.4% vs. 2.6%, p = 0.02). As a result, mortality at six months was 14.3% versus 4.1% in patients with versus without previous CABG (p = 0.001). By multivariate analysis, independent determinants of late mortality in the entire study group were advanced age, triple-vessel disease, Killip class and post-PTCA TIMI flow grade <3.CONCLUSIONSReperfusion success of a primary PTCA strategy in patients with previous CABG, although favorable with respect to historic control studies, is reduced as compared with that in patients without previous CABG. New approaches are required to treat patients with previous CABG and AMI, especially when the infarct-related vessel is a diseased saphenous vein graft.

Analysis of the Relative Costs and Effectiveness of Primary Angioplasty Versus Tissue-Type Plasminogen Activator: The Primary Angioplasty in Myocardial Infarction (PAMI) Trial

Objectives. We sought to determine the relative cost and effectiveness of two different reperfusion modalities in patients with acute myocardial infarction (AMI).Background. Recent studies have found superior clinical outcomes after reperfusion by primary percutaneous transluminal coronary angioplasty (PTCA) compared with thrombolytic therapy. The high up-front costs of cardiac catheterization may diminish the relative advantages of this invasive strategy.Methods. Detailed in-hospital charge data were available from all 358 patients with AMI randomized to tissue-type plasminogen activator (t-PA) or primary PTCA in the United States from the Primary Angioplasty in Myocardial Infarction trial. Resource consumption during late follow-up was estimated by assessment of major clinical events and functional status.Results. Compared with t-PA, primary PTCA resulted in reduced rates of in-hospital mortality (2.3% vs. 7.2%, p = 0.03), reinfarction (2.8% vs. 7.2%, p = 0.06), recurrent ischemia (11.3% vs. 28.7%, p < 0.0001) and stroke (0% vs. 3.9%, p = 0.02) and a shorter hospital stay (7.6 ± 3.3 days vs. 8.4 ± 4.7 days, p = 0.04). Despite the initial costs of cardiac catheterization in all patients with the invasive strategy, total mean (±SD) hospital charges were $3,436 lower per patient with PTCA than with t-PA ($23,468 ± $13,410 vs. $26,904 ± $18,246, p = 0.04), primarily due to the reduction in adverse in-hospital outcomes. However, professional fees were higher after primary PTCA ($4,185 ± $3,183 vs. $3,322 ± $2,728, p = 0.001), and thus total charges, although favoring PTCA, were not significantly different ($27,653 ± $13,709 vs. $30,227 ± 18,903, p = 0.21). At a mean follow-up time of 2.1 ± 0.7 years, no major differences in postdischarge events or New York Heart Association functional class were present between PTCA- and t-PA–treated patients, suggesting similar late resource consumption. Including in-hospital events, 83% of PTCA-treated patients were alive and free of reinfarction at late follow-up, compared with 74% of t-PA–treated patients (p = 0.06).Conclusions. Compared with t-PA, reperfusion by primary PTCA improves clinical outcomes with similar or reduced costs. These findings have important clinical implications in an increasingly cost-conscious health care environment.(J Am Coll Cardiol 1997;29:901–7)© 1997 by the American College of Cardiology

Influence of acute myocardial infarction location on in-hospital and late outcome after primary percutaneous transluminal coronary angioplasty versus tissue plasminogen activator therapy

In the Primary Angioplasty in Myocardial Infarction trial, 395 patients with acute myocardial infarction (AMI) were prospectively randomized to tissue plasminogen activator (tPA) or primary percutaneous transluminal coronary angioplasty (PICA). In 138 patients with anterior wall AMI, in-hospital mortality was significantly reduced by treatment with PICA compared with tPA (1.4% vs 11.9%, p = 0.01). PICA also resulted in lower rates of death or reinfarction (1.4% vs 18.0%, p = 0.0009), recurrent myocardial ischemia (11.3% vs 28.4%, p = 0.01), and stroke (0.0% vs 6.0%, p = 0.037) in anterior wall AMI. The independent beneficial effect of treatment with primary PICA rather than tPA in anterior wall AMI was confirmed by multivariate analysis and interaction testing. The in-hospital mortality of 257 patients with nonanterior wall AMI was similar after PTCA and tPA (3.2% vs 3.8%, p = 0.82). Compared with tPA, however, primary PTCA resulted in a markedly lower rate of recurrent myocardial ischemia (9.7% vs 27.8%, p = 0.0002), fewer unscheduled catheterization and revascularization procedures, and a shorter hospital stay (7.0 vs 8.6 days, p = 0.01) in nonanterior wall AMI. Thus, compared with tPA, primary PTCA in patients with anterior wall AMI results in significantly improved survival, with lower rates of stroke, reinfarction, and recurrent myocardial ischemia. In nonanterior wall AMI, treatment with PTCA and tPA results in similar early mortality, although PTCA-treated patients have a more stable hospital course characterized by reduced recurrent ischemia, fewer subsequent invasive procedures, and earlier discharge.

Significance of a coronary artery with Thrombolysis in Myocardial infarction grade 2 flow “patency” (outcome in the Thrombolysis and Angioplasty in Myocardial Infarction trials)

To determine whether pharmacologic reperfusion to Thrombolysis in Myocardial Infarction (TIMI) grade 2 flow during acute myocardial infarction confers the same clinical benefit as restoration of TIMI 3 flow, in-hospital clinical and angiographic outcomes in 1,229 patients prospectively enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction trials were analyzed. Patients were treated with intravenous tissue plasminogen activator or urokinase, or both. Angiography of the infarct-related artery 90 minutes after initiation of thrombolytic therapy demonstrated TIMI grades 0, 1, 2, or 3 flow in 20%, 7%, 17%, and 55% of vessels, respectively. Rescue or adjunctive coronary angioplasty was performed in 80%, 27%, and 16% of patients with TIMI 0/1, 2, or 3 flow, respectively. Predischarge angiography was performed in 963 patients. A significant gradient of increasing mortality was seen in patients with lower TIMI flow (4.3%, 6.1%, and 10.1% with TIMI 3, 2, and 0/1 flow, respectively, p = 0.002). The incidence of congestive heart failure and recurrent ischemia was significantly higher in patients with TIMI 2 than with TIMI 3 perfusion (26% vs 19% for heart failure, p = 0.03; 23% vs 17% for recurrent ischemia, p = 0.05). Acute left ventricular ejection fraction and infarct zone regional wall motion were also significantly improved in patients with TIMI 3 than with TIMI 2 flow, with trends toward better improvement in global and regional function in the TIMI 3 group. These findings were not affected by the use of acute coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Thrombolytic therapy in patients requiring cardiopulmonary resuscitation

Cardiopulmonary resuscitation (CPR) is often considered a contraindication to thrombolytic therapy for acute myocardial infarction. Of 708 patients involved in the first 3 Thrombolysis and Angioplasty in Myocardial Infarction trials of lytic therapy for acute infarction, 59 patients required <10 minutes of CPR before receiving lytic therapy (CPR >10 minutes was an exclusion of the trials) or required CPR within 6 hours of treatment. The patients receiving CPR were similar to the remainder of the group with respect to baseline demographics. The indication for CPR was usually ventricular fibrillation (73%) or ventricular tachycardia (24%). The median duration of CPR was 1 minute, with twenty-fifth and seventy-fifth percentiles of 1 and 5 minutes, respectively. The median number of cardioversions/defibrillations performed was 2 (twenty-fifth and seventy-fifth percentiles of 1 and 3 minutes, respectively). Patients receiving CPR were more likely to have anterior infarctions (66 vs 39%), the left anterior descending artery as the infarct-related artery (63 vs 38%) and lower ejection fractions on the initial ventriculogram (46 ± 11 vs 52 ± 12%) than those not receiving CPR. Inhospital mortality was 12 vs 6% with most deaths due to pump failure (57%) or arrhythmia (29%) in the CPR group and pump failure (38%) or reinfarction (25%) in the non-CPR group. At 7 day follow-up the CPR group had a significant increase in ejection fraction (+5 ± 9%) compared with no change in non-CPR group. There were no bleeding complications directly attributed to CPR. In particular, the decrease in hematocrit (median 11) and need for transfusion (37 vs 32%) were the same in both groups. In addition, the CPR group did not spend more days in the cardiac care unit or in hospital than the non-CPR group. In conclusion, patients who have received CPR for <10 minutes had no additional complications attributable to thrombolytic therapy (95% confidence interval 0 to 5%). Therefore, CPR, especially of short duration, should not be considered a contraindication to lytic treatment. In addition, our results suggest that patients requiring CPR during acute infarction constitute a high-risk subgroup which may particularly benefit from receiving thrombolytic therapy.

Pericardial effusion after intravenous recombinant tissue-type plasminogen activator for acute myocardial infarction

The effect of thrombolytic therapy on the frequency, time course and sequelae of pericardial effusion after myocardial infarction are unknown. A prospective, serial, 2-dimensional echocardiographic study of patients with myocardial infarction who received recombinant tissue-type plasminogen activator (rt-PA) was undertaken to address this issue. The study population comprised 52 of the 112 patients enrolled in the first Thrombolysis and Angioplasty in Myocardial Infarction trial at Duke University Medical Center. Enrollment in the serial echocardiography protocol was determined by equipment and support staff availability. Complete echocardiographic studies were performed within 90 minutes after initiation of thrombolytic therapy (day 0), and on days 1, 3 and 6. Patients undergoing serial echocardiography did not differ in demographic or clinical characteristics from those who did not. Pericardial effusion was present in 3 of 38 patients (8%) at day 0, in 2 of 44 (5%) at day 1, in 8 of 43 (19%) at day 3, and in 10 of 42 (24%) at day 6. By day 6,3 of 10 pericardial effusions were moderate in size, 1 of 10 was large and the remainder were small. No patients developed echocardiographic or hemodynamic signs of cardiac tamponade. The prevalence and time course of pericardial effusion among patients with acute myocardial infarction who received rt-PA in this study are similar to observations reported in earlier studies in which patients did not receive thrombolytic therapy. Adverse sequelae of pericardial effusion after thrombolytic therapy are rare.

One-year outcome after therapy with tissue plasminogen activator: Report from the Thrombolysis and Angioplasty in Myocardial Infarction trial

To evaluate the long-term effects of reperfusion with tissue plasminogen activator (t-PA) and an aggressive strategy of revascularization with angioplasty and coronary artery bypass grafting, we obtained 1-year follow-up results from 386 consecutive patients enrolled in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI I) trial. All patients were treated with 100 to 150 mg of t-PA intravenously over 6 to 8 hours, and coronary angiography was performed within 90 minutes of initiation of therapy. In 197 patients with suitable anatomic characteristics, angioplasty was either performed immediately or was deferred for 7 to 10 days on a randomized basis. The remainder of the patients were treated as considered clinically appropriate. The in-hospital mortality rate was 7%, and only 1.9% of patients died in the first year after discharge from the hospital; three patients died of cardiac events and four died of noncardiac causes. Ninety-four percent of patients discharged alive from the hospital remained alive and had no myocardial infarctions during the first 12 posthospital months. Revascularization procedures after discharge from the hospital included angioplasty in 8% of patients and coronary artery bypass grafting in 5%. The high survival rates were evident in high-risk groups defined by age, ejection fraction, and extent of coronary artery disease. At 1-year follow-up 64% of patients less than 65 years of age were employed and only 10% reported that they were disabled; 94% of patients were in Canadian Heart Association class I or II. These low rates of follow-up events suggest a change in the "natural history" of the first year after acute myocardial infarction.