534
JACC Vol. 15, No. 3 March 1, lW:534-43
CLINICAL
STUDIES
Direct Coronary Angioplasty in Acute Myocardial Infarction: Outcome In Patients With Single Vessel Disease GREGG
W. STONE,
MD, BARRY D. RUTHERFORD,
DAVID R. McCONAHAY, LEE V. GIORGI,
MD, FACC, WARREN
MD, FACC, ROBERT
W. LIGON,
MD, FACC,
L. JOHNSON,
JR., MD, FACC,
MA, GEOFFREY
0. HARTZLER,
MD, FACC
Kansas City, Missouri
Percutaneous transluminal coronary angioplasty was performed as primary therapy in 215 consecutive patients (aged 56 + 11 years, 75% male) with acute myoeardial infarction and single vessel coronary artery disease. Wide patency of the infarct-related artery was restored in 212 patients (99%). Complications consisted of one urgent coronary bypass operation (0.5%); there were no procedural deaths. A recurrent ischemic event before discharge occurred in eight patients (4%). The in-hospital mortality rate was 1%; five of six patients presenting with cardiogenic shock were alive at discharge. In 126 patients in whom predischarge angiography was performed, the ejection fraction improved from 55 f 12% to 61 + 12% (p < 0.005) and increased by ~5% units in 66 patients (52%). Regional wall motion improved in 60 patients (48%). By multivariate analysis, a depressed initial ejection fraction, a limited increase in serum creatine kinase, young age and sustained patency of the infarctrelated artery were found to be independent predictors of improvement in left ventricular function.
Recent studies (l-9) have established that early reperfusion in acute myocardial infarction can limit infarct size and decrease mortality. After myocardial infarction, the inhospital survival rate and late prognosis are largely determined by left ventricular function (lo-13), residual myocardial ischemia (14-16) and the number of diseased epicardial coronary arteries (11-14). Angiographic studies (11-14) have revealed a 30% to 58% incidence rate of single vessel coronary artery disease in survivors of myocardial infarction. Although mortality and recurrent infarction rates are
From the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri. Manuscript received June 12, 1989; revised manuscript received October 4, 1989,accepted October 18, 1989. Address for renrintg: Barry D. Rutherford, MD, Cardiovascular Consultants, Inc., Medical Plaza U-20, Kansas City, Missouri 64111. 01990 by the American College of Cardiology
Follow-up data were available in 214 patients (99.5%) at a mean interval of 35 months. The actuarial 3 year cardiac survival rate was 92%. By multivariate analysis, only the baseline ejection fraction correlated with long-term cardiac survival. Nine patients (4%) sustained a late nonfatal myocardial infarction, and 11 patients (5%) underwent subsequent coronary bypass surgery. At late followup study, 149 (77%) of 194 patients alive were free of angina. In summary, in patients with acute myocardial infarction and single vessel disease, coronary angioplasty without prior thrombolytic therapy can be performed with a high success rate and few procedural complications. After direct angioplasty, regional wall motion and global ejection fraction improve in 50% of patients, especially in those with depressed initial left ventricular function. This approach results in an excellent early and late event-free survival. (J Am Co11Cardiol1990;15:534-43)
low after uncomplicated infarction in patients with single vessel disease, inducible ischemia remains in a significant proportion of patients, and over half may develop angina that frequently limits activity and requires hospitalization (15). The optimal therapy for patients with single vessel disease presenting with acute myocardial infarction is unknown. Studies involving reperfusion have not specifically addressed the factors affecting the short- and long-term prognosis, ischemic event rate and determinants of myocardial salvage in patients with single vessel disease after myocardial infarction. At the Mid America Heart Institute, our approach to the management of the patient in the early stages of acute myocardial infarction has been immediate coronary arteriography followed by direct coronary angioplasty without the use of prior thrombolytic therapy. This report describes the 073s1097/90/$3.50
STONE ETAL. CORONARYANGIOPLASTYINACUTEMYOCARDIALlNFARCTION
JACC Vol.15,No.3 March1, 19!90:534-43
short-term outcome and long-term prognosis after application of direct angioplasty in patients with acute myocardial infarction resulting from single vessel disease, and examines the clinical and angiographic factors influencing prognosis and myocardial salvage in this cohort of patients.
Methods Study patients. Between March 12, 1981 and March 30, 1988,500 consecutive patients with acute myocardial infarction were treated with direct coronary angioplasty without prior thrombolytic therapy; 215 patients (43%) had single vessel coronary artery disease and form the basis of this report. Patients were included if they presented with persistent chest discomfort of 90% (11-14). However, 7% to 16% of these patients may develop reinfarction during the same period (13,14). Wilson et al. (15) followed up 97 patients with single vessel disease treated with conventional therapy after uncomplicated myocardlal infarction. Although there were no deaths and only six cases of reinfarction (6%) over a 39 month follow-up period, 56% of patients developed angina and 26% of patients required repeat hospitalization for functional class III or IV angina. Revascularization was required in 10% of patients. Advanced age,
No Predischarge Angiography (n 1 126) _75 56 t Ii 2 2 39 55% + 12% 26 63 292 + 209 100 1.913r 1.702
Predischarge Angiography (n = 89) p Value -- _--. -..- ___I_ 74 Male (%) NS 57 + II NS Age (~0 Prior bypass (%) 2 NS Shock (%) 3 NS Anterior MI (%) 51 NS Initial EF (%) 43% + 12% NS Collateral vessels (%) 13 0.04 Thrombus (%) 62 NS Time to angiopiasty (min) 307 ? 279 NS Angioplasty success (SC) 97 NS Peak CK 1.658* 1,669 EUS -_-CK = serum creatine kinase; EF = ejection fraction: MI = myocardiai infarction: PTCA = percutaneous transiuminal coronary angiopiasty.
Figure 1. Improvement in ejection fraction after direct coronary angioplasty in 126 patients. MI = myocardial infarction. 100 90
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97% of all patients presenting with acute myocardial infarction are taken to the catheterization laboratory without prior administration of thrombolytic therapy, and angioplasty is performed when appropriate. High risk patients, including the elderly and those with prior coronary bypass surgery or cardiogenic shock, are not excluded. Single vessel disease was present in 43% of our patients, consistent with data from other series (11-14). Twenty-five percent of these patients were >65 years old, and 29% had global left ventricular dysfunction (ejection fraction ~50%). Despite the inclusion of high risk patients, the very high patency rate achieved with direct coronary angioplasty (99%), with few complications (0.5% bypass surgery and no procedural mortality), compares favorably with the results seen with other forms of reperfusion therapy (l-5,9,21,24). In-hospital course. After direct angioplasty, only 1% of patients died during the hospitalization. Five (87%) of six patients presenting with cardiogenic shock were alive at discharge. Recurrent ischemic events before discharge were rare (4%) and were usually treated effectively with repeat coronary angioplasty. In-hospital coronary reocclusion was observed in only 11% of patients undergoing predischarge angiography. Prompt restoration of Thrombolysis in Myocardial Infarction (TIMI) grade III flow, aggressive anticoagulation with heparin and aspirin and assurance of hemo-
JACC Vol. IS, No. 3 March 1. 1!990:534-43
dynamic stability may in part have contributed to the low rate of in-hospital mortality and vessel closure. Of note, reocclusion was asymptomatic in the majority of cases, suggesting either significant collateral vessel development, completed infarction or the presence of true “silent” ischemia or reinfarction. An aggressive approach to ensure continued vessel patency was maintained throughout the hospitalization. Thus,
93% of our patients who underwent predischarge angiography were discharged with a patent infarct-related artery. Sustained vessel patency has been shown to be an important determinant of recovery of left ventricular iunction (21,22,25). Additionally, establishment of an open infarctrelated artery may prevent ventricular aneurysm formation (26), raise the threshold for induction of ventricular tachycardia (27) and result in improved long-term survival independent of myocardial salvage (28). Myocardialsalvage. Despite disease limited to one coronary artery, left ventricular ejection fraction and regional wall motion improved significantly in 50% of patients by the time of hospital discharge. In concert with data from other studies (21,22,25), the most powerful predictors of improved left ventricular function were a depressed ejection fraction before angioplasty and sustained patency of the infarctrelated artery. Regional wall motion also improved significantly in patients with a limited increase in creatine kinase, consistent with enhanced myocardial salvage. Alternatively, reversible ischemia in the infarct zone at presentation may explain the marked improvement in regional wall motion in patients with a low initial ejection fraction but subsequent limited increase in creatine kinase. As in recent reports (21,25,29,30), the time to reperfusion was not strongly associated with myocardial salvage, emphasizing the importance of collateral circulation, as well as the dynamic nature of coronary obstruction. Long-termmorbidityand mortality. Previous studies (1l14) have demonstrated a 90% to 99% 3 year survival rate after uncomplicated infarction in patients with single vessel disease. However, these reports generally excluded elderly patients and high risk subsets. Thus, the 94% 3 year survival rate after direct angioplasty and hospital discharge in our patient cohort, which included elderly patients, those in shock and those with in-hospital complications, suggests a favorable effect on long-term mortality. Multivariate analysis identified only depressed initial ejection fraction as predictive of cardiac mortality. As reported by Stack et al. (23), the time to reperfusion was not an independent predictor of long-term mortality. Advanced age was not predictive of cardiac mortality in patients with single vessel disease. Despite this relatively high risk cohort of patients, the 4% incidence rate of late infarction and 5% incidence rate of late coronary bypass surgery also compare favorably with low risk historical control subjects (13-E). In addition, at 3 year follow-up evaluation, 77% of our patients were asymptom-
JACC Vol. 15, No. 3 March I, 1990:534-43
CORONARY
ANGIOPLASTY
IN ACUTE MYOCARDIAL
STONE ET AL. INFARCTION
539
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Improvementin regionalwallmotion(segmentalEF) after direct coronary angioplasty,demonstratingthe influenceof baseline ejectionfraction (EF). PTCA= percutaneoustransluminalcoronary angioplasty. Figure 2.
atic and only 8% had class III or IV angina. Repeat angioplasty was required after discharge in 24% of our patients. The occurrence of a late cardiac event (>I year after discharge), along with the observation that 12% of our patients required repeat coronary angioplasty >8 months after the initial dilation, suggests that progression of atherosclerotic disease may contribute to late morbidity and mortality in patients with single vessel disease after acute
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myocardial infarction. Thus, an aggressive strategy of revascularization may be necessary to ensure angina-free and infarct-free late survival after initial reperfusion. Comparison with thromholytic therapy. Several theoretical and practical considerations limit the ultimate effectiveness of thrombolytic therapy. There appears to be a pharmacologic plateau of coronary thrombolytic efficacy of approximately 70% to 80% (21). There currently is no rapid, accurate means to noninvasively detect reperfusion at the bedside (31). In addition to the 99% reperfusion rate in the present study, the 4% incidence rate of recurrent in-hospital ischemic events and 11% incidence rate of angiographic reocclusion after direct coronary angioplasty compare favor-
STONE ET AL. CORONARY ANGIOPLASTY
540
Anterior
IN ACUTE MYOCARDIAL
JACC Vol. 15, No. 3 March 1, 1990534-43
INFARCTION
Infarct
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ably with the 20% to 30% incidence rate of recurrent ischemic events and reocclusion after thrombolytic therapy (2,8,29,32-34). Myocardial salvage and late survival have not been specifically reported in patients with single vessel disease after thrombolytic therapy. However, direct angioplasty has been associated with greater improvement in ventricular function than after thrombolysis alone (8,9,25); the only two randomized trials (29,35) of thrombolytic therapy versus direct angioplasty found improved global and regional left ventricular function and less exercise-induced ischemia associated with less severe residual coronary stenosis in the patients treated with angioplasty. The 5% to 8% annual
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Figure3. Improvementin regionalwallmotion(segmentalEF) after direct coronary angioplasty, demonstratingthe influence of sustained patency of the infarct-relatedartery.
mortality rate observed after thrombolytic therapy appears to be higher than the 1% to 3% yearly mortality rate after direct angioplasty (8,23,25,36). The 70% to 85% mortality rate in patients with cardiogenic shock treated conventionally or with thrombolytic therapy (1,37-39) may be reduced to 35% to 45% with angioplasty (40,41). In the present series, five (87%) of six patients with single vessel disease and cardiogenic shock were discharged alive.
STONE ET AL. CORONARY ANGIOPLASTY IN ACUTE MYOCARDIAL INFARCTION
JACC Vol. 15, No. 3 March 1, 1990:534-43
loa
Table 6. Long-Term Morbidity and Mortality After Direct Angioplasty in 214 Patients (mean follow-up 35 months) Event
In-Hospital
--------_-_--__
Total
17(8%)
20 (9%)
70 -
COO=
15 (7%) IO (5%)
1I (5%) 29 (14%)
13(6%) 34 (16%)
so-
12 (6%)
52 (24%)
57 (27%)
20 -
New York Heart Association classification (in 194patients alive) 149(77%) Ck+SS i 29 (15%) Class II 8 (4%) Class III 8 (4%) Class IV
With current doses, thrombolytic therapy is associated with an 8% to 12% incidence rate of significant bleeding and a 0.5% risk of intracranial hemorrhage (8,42,43). The risk of major bleeding when coronary angioplasty is performed alone is ~2%; bleeding most commonly occurs at the cath-
eterization site and is usually minor; intracranial hemorrhage is extremely rare (8,42). Finally, with current eligibility criteria, only 14% to 43% of patients presenting with acute myocardial infarction are candidates for thrombolytic therapy (21,42). Limitations. Although this study consists of a consecutive series of patients with acute myocardial infarction and single vessel disease, it is uncontrolled and retrospective in nature and reflects the clinical experience of a single group of experienced interventional cardiologists. Firm conclusions comparing direct angioplasty with other modes of reperfu-
Table 7. Predictors of Morbidity and Mortality in 214 Patients After Direct Angioplasty
Shock Cardiac events* Anterior MI Shock Closed infarct-related artery
L
5 *
M‘lo -
_
Surwva,
. _ - - Cardiac
Survwal ---Event
Free Surwval
Figure 4. Long-term morbidity and mortality in 214 patients after direct coronary angioplasty.
*Cardiac death, myocardial infarction or bypass surgery; 1 patient with in-hospital myocardial infarction and 3 patients with late myocardial infarction also under went bypass surgery; 7 patients had repeat angioplasty both before and after discharge. Abbreviations as in Table 4.
Cardiacmortality Low initial EF
--_
80 -
Out of Hospital 12 (6%) 9 (4%)
Nonfatal MI
Bypasssurgery Cardiacevents* Repeatangioplasty
-----_______________.
so-
3 (1%) 3 (1%) I (1%) 2 (1%) 5 (2%)
Death Cardiacdeath
541
Univariate Analysis (p value)
Multivariate Analysis (p value)
0.007
0.012
0.08
NS
0.09 0.05 0.09
0.018 NS NS
*Cardiac death, myocardial infarction or bypass surgery. Variables not significantly associated with survival included gender, prior bypass surgery, time to angioplasty, stenosis severity, collateral circulation, thrombus and peak creatine kinase. Abbreviations as in Tables 4 and 5.
sion will require controlled randomized studies and should
include a detailed cost-benefit analysis. Despite the goal of predischarge angiography in all patients, paired ventriculography was available in only 59% of patients. Although the baseline clinical and angiographic characteristics were similar in the two groups (Table 4), selection bias may nonetheless have occurred. In addition, multivariate analysis may have identified other covariates of myocardial salvage and survival had greater numbers of patients been available. Practicalconsiderations. Because only 12% of centers in the United States have facilities for coronary angioplasty (44), direct angioplasty is not feasible for the majority of patients with acute myocardial infarction. In addition, this approach requires around the clock availability of an interventional cardiologist and catheterization team skilled in acute infarct angioplasty and committed to rapid mobilization, conditions that are logistically and financially impossible to meet at many institutions. However, in centers so equipped, direct angioplasty in evolving myocardial infarction may be performed expeditiously and result in a low in-hospital mortality rate, dramatic improvement in left ventricular function and extended long-term survival (8,25). In addition, direct coronary angioplasty is the optimal treatment for the 57% to 86% of patients not eligible for thrombolytic therapy (21,42). Conclusions. In patients with single vessel coronary artery disease and evolving acute myocardial infarction, direct coronary angioplasty without prior thrombolytic therapy can be performed with a very high success rate and few procedural complications. Regional wall motion and ejection fraction improve in 50% of patients, especially in those with depressed ventricular function. This approach results in excellent early and late event-free survival and improved symptomatic status and compares favorably with results reported with conventional therapy or thrombolytic reperfusion.
542
STONE ET AL. CORONARY ANGIOPLASTY
IN ACUTE MYOCARDIAL INFARCTION
References 1. Gruppo Italian0 per lo Studio della Streptochinasi Nell’Infarcto Miocardio (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;1:397-402. 2. Kennedy JW, Ritchie JL, Davis KB, Fritz JK. Western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction. N Engl J Med 1983;309:1477-82. 3. Simoons ML, V’D Brand M, DeZwaans C, et al. Improved survival after early thrombolysis in acute myocardial infarction. Lancet 1985;2:578-81. 4. Yusef S, Collins R, Peto R, et al. Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side effects from 33 randomized controlled trials. Eur Heart J 1985;6:556-85. 5. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187cases of suspected acute myocardial infarction. Lancet 1988;2:349-60. 6. Top01 EJ. Coronary angioplasty for acute myocardial infarction. Ann Intern Med 1988;109:970-80. 7. Guerci AD, Gerstenblith G, Brinker JA, et al. A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty. N Engl J Med 1987;317:1613-8. 8. O’Neill WW. Primary percutaneous coronary angioplasty: a protagonist’s view. Am J Cardiol 1988;62:15K-20K. 9. O’Neill WW, Top01EJ, Pitt B. Reperfusion therapy of acute myocardial infarction. Prog Cardiovasc Dis 1988;30:235-66. 10. Stadius ML, Davis K, Maynard C, Ritchie JL, Kennedy JW. Risk stratification for one year survival based on characteristics identified in the early hours of acute myocardial infarction. Circulation 1986;74:70311.
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22. Stack RS, O’Connor CM, Mark DB, et al. Coronary perfusion during acute myocardial infarction with a combined therapy of coronary angioplasty and high-dose intravenous streptokinase. Circulation 1988;77:15161. 23. Stack RS, Califf RM, Hinohara T, et al. Survival and cardiac event rates in the first year after emergency coronary angioplasty for acute myocardial infarction. J Am Coll Cardiol 1988;11:1141-9. 24. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. JAMA 1988;260:2088-93. 25. Rothbaum DA, Linnemeir TJ, Landin RJ, et al. Emergency percutaneous transluminal coronary angioplasty in acute myocardial infarction: a 3 year experience. J Am Coil Cardiol 1987;10:264-72. 26. Hockman JS, Choo H. Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage. Circulation 1987;75:299306. 27. Brugada P, Waldecker B, Kersschot Y, Zehender M, Wellens HJ. Ventricular arrhythmias initiated by programmed stimulation in four groups of patients with healed myocardial infarction. J Am Coll Cardiol 1986:8:1035-40. 28. Kennedy JW, Ritchie JL, Davis KB, Stadius ML, Maynard C, Fritz JK. The western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction: a 12-month follow-up report. N Engl J Med 1985;312:1073-8. 29. O’Neill W, Timmis GC, Bourdillon PD, et al. A prospective randomized clinical trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction: a 12-month follow-up report. N Engl J Med 1986;314:812-8. 30. The I.S.A.M. Study Group. A prospective trial of Intravenous Streptokinase in Acute Myocardial Infarction (I.S.A.M.): mortality, morbidity and infarct size at 21 days. N Engl J Med 1986;314:1465-71. 31. Kircher BJ, Top01EJ. O’Neill WW, Pitt B. Prediction of infarct coronary artery recanalization after intravenous thrombolytic therapy. Am J Cardiol 1987;59:513-9. 32. Stack RS. Phillips HR, Grierson DS, et al. Functional improvement of jeopardized myocardium following intracoronary streptokinase infusion in acute myocardial infarction, J Clin Invest 1983;72:84-95. 33. Harrison DG. Ferguson DW, Collins SM, et al. Rethrombosis after reperfusion with streptokinase: importance of geometry of residual lesions. Circulation 1984:69:991-9.
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37. Killip T, Kimball JT. Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients. Am J Cardiol 1967:20:457-&l. 38. Scheidt S, Wilner G, Meuller H, et al. Intra-aortic balloon counterpulsation in cardiogenic shock: report of a cooperative clinical trial. N Engl J Med 1973;288:979-84. 39 Kennedy JW, Gensini GG, Timmis GC, Maynard C. Acute myocardial infarction treated with intracoronary streptokinase: a report of the Society for Cardiac Angiography. Am J Cardiol 1985;55:871-7. 40 Lee L, Bates ER, Pitt B, Walton JA, Laufer N, O’Neill WW. Percutaneous transluminal coronary angioplasty improves survival in acute myocardial infarction complicated by cardiogenic shock. Circulation 1988:78:1345-51.
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41. Laramee LA, Rutherford BD, LogonRW, McConahay DR. Hartzler GO. Coronary angioplasty for cardiogenic shock following myocardial infarction (abstr). Circulation 1988:78(supplII):634.
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43. The TIM1 Study Group. Comparison of invasive and conservative strat-
JACC Vol. 15, No. 3 March 1, lW:534-43
CLINICAL
STUDIES
Direct Coronary Angioplasty in Acute Myocardial Infarction: Outcome In Patients With Single Vessel Disease GREGG
W. STONE,
MD, BARRY D. RUTHERFORD,
DAVID R. McCONAHAY, LEE V. GIORGI,
MD, FACC, WARREN
MD, FACC, ROBERT
W. LIGON,
MD, FACC,
L. JOHNSON,
JR., MD, FACC,
MA, GEOFFREY
0. HARTZLER,
MD, FACC
Kansas City, Missouri
Percutaneous transluminal coronary angioplasty was performed as primary therapy in 215 consecutive patients (aged 56 + 11 years, 75% male) with acute myoeardial infarction and single vessel coronary artery disease. Wide patency of the infarct-related artery was restored in 212 patients (99%). Complications consisted of one urgent coronary bypass operation (0.5%); there were no procedural deaths. A recurrent ischemic event before discharge occurred in eight patients (4%). The in-hospital mortality rate was 1%; five of six patients presenting with cardiogenic shock were alive at discharge. In 126 patients in whom predischarge angiography was performed, the ejection fraction improved from 55 f 12% to 61 + 12% (p < 0.005) and increased by ~5% units in 66 patients (52%). Regional wall motion improved in 60 patients (48%). By multivariate analysis, a depressed initial ejection fraction, a limited increase in serum creatine kinase, young age and sustained patency of the infarctrelated artery were found to be independent predictors of improvement in left ventricular function.
Recent studies (l-9) have established that early reperfusion in acute myocardial infarction can limit infarct size and decrease mortality. After myocardial infarction, the inhospital survival rate and late prognosis are largely determined by left ventricular function (lo-13), residual myocardial ischemia (14-16) and the number of diseased epicardial coronary arteries (11-14). Angiographic studies (11-14) have revealed a 30% to 58% incidence rate of single vessel coronary artery disease in survivors of myocardial infarction. Although mortality and recurrent infarction rates are
From the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri. Manuscript received June 12, 1989; revised manuscript received October 4, 1989,accepted October 18, 1989. Address for renrintg: Barry D. Rutherford, MD, Cardiovascular Consultants, Inc., Medical Plaza U-20, Kansas City, Missouri 64111. 01990 by the American College of Cardiology
Follow-up data were available in 214 patients (99.5%) at a mean interval of 35 months. The actuarial 3 year cardiac survival rate was 92%. By multivariate analysis, only the baseline ejection fraction correlated with long-term cardiac survival. Nine patients (4%) sustained a late nonfatal myocardial infarction, and 11 patients (5%) underwent subsequent coronary bypass surgery. At late followup study, 149 (77%) of 194 patients alive were free of angina. In summary, in patients with acute myocardial infarction and single vessel disease, coronary angioplasty without prior thrombolytic therapy can be performed with a high success rate and few procedural complications. After direct angioplasty, regional wall motion and global ejection fraction improve in 50% of patients, especially in those with depressed initial left ventricular function. This approach results in an excellent early and late event-free survival. (J Am Co11Cardiol1990;15:534-43)
low after uncomplicated infarction in patients with single vessel disease, inducible ischemia remains in a significant proportion of patients, and over half may develop angina that frequently limits activity and requires hospitalization (15). The optimal therapy for patients with single vessel disease presenting with acute myocardial infarction is unknown. Studies involving reperfusion have not specifically addressed the factors affecting the short- and long-term prognosis, ischemic event rate and determinants of myocardial salvage in patients with single vessel disease after myocardial infarction. At the Mid America Heart Institute, our approach to the management of the patient in the early stages of acute myocardial infarction has been immediate coronary arteriography followed by direct coronary angioplasty without the use of prior thrombolytic therapy. This report describes the 073s1097/90/$3.50
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short-term outcome and long-term prognosis after application of direct angioplasty in patients with acute myocardial infarction resulting from single vessel disease, and examines the clinical and angiographic factors influencing prognosis and myocardial salvage in this cohort of patients.
Methods Study patients. Between March 12, 1981 and March 30, 1988,500 consecutive patients with acute myocardial infarction were treated with direct coronary angioplasty without prior thrombolytic therapy; 215 patients (43%) had single vessel coronary artery disease and form the basis of this report. Patients were included if they presented with persistent chest discomfort of 90% (11-14). However, 7% to 16% of these patients may develop reinfarction during the same period (13,14). Wilson et al. (15) followed up 97 patients with single vessel disease treated with conventional therapy after uncomplicated myocardlal infarction. Although there were no deaths and only six cases of reinfarction (6%) over a 39 month follow-up period, 56% of patients developed angina and 26% of patients required repeat hospitalization for functional class III or IV angina. Revascularization was required in 10% of patients. Advanced age,
No Predischarge Angiography (n 1 126) _75 56 t Ii 2 2 39 55% + 12% 26 63 292 + 209 100 1.913r 1.702
Predischarge Angiography (n = 89) p Value -- _--. -..- ___I_ 74 Male (%) NS 57 + II NS Age (~0 Prior bypass (%) 2 NS Shock (%) 3 NS Anterior MI (%) 51 NS Initial EF (%) 43% + 12% NS Collateral vessels (%) 13 0.04 Thrombus (%) 62 NS Time to angiopiasty (min) 307 ? 279 NS Angioplasty success (SC) 97 NS Peak CK 1.658* 1,669 EUS -_-CK = serum creatine kinase; EF = ejection fraction: MI = myocardiai infarction: PTCA = percutaneous transiuminal coronary angiopiasty.
Figure 1. Improvement in ejection fraction after direct coronary angioplasty in 126 patients. MI = myocardial infarction. 100 90
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97% of all patients presenting with acute myocardial infarction are taken to the catheterization laboratory without prior administration of thrombolytic therapy, and angioplasty is performed when appropriate. High risk patients, including the elderly and those with prior coronary bypass surgery or cardiogenic shock, are not excluded. Single vessel disease was present in 43% of our patients, consistent with data from other series (11-14). Twenty-five percent of these patients were >65 years old, and 29% had global left ventricular dysfunction (ejection fraction ~50%). Despite the inclusion of high risk patients, the very high patency rate achieved with direct coronary angioplasty (99%), with few complications (0.5% bypass surgery and no procedural mortality), compares favorably with the results seen with other forms of reperfusion therapy (l-5,9,21,24). In-hospital course. After direct angioplasty, only 1% of patients died during the hospitalization. Five (87%) of six patients presenting with cardiogenic shock were alive at discharge. Recurrent ischemic events before discharge were rare (4%) and were usually treated effectively with repeat coronary angioplasty. In-hospital coronary reocclusion was observed in only 11% of patients undergoing predischarge angiography. Prompt restoration of Thrombolysis in Myocardial Infarction (TIMI) grade III flow, aggressive anticoagulation with heparin and aspirin and assurance of hemo-
JACC Vol. IS, No. 3 March 1. 1!990:534-43
dynamic stability may in part have contributed to the low rate of in-hospital mortality and vessel closure. Of note, reocclusion was asymptomatic in the majority of cases, suggesting either significant collateral vessel development, completed infarction or the presence of true “silent” ischemia or reinfarction. An aggressive approach to ensure continued vessel patency was maintained throughout the hospitalization. Thus,
93% of our patients who underwent predischarge angiography were discharged with a patent infarct-related artery. Sustained vessel patency has been shown to be an important determinant of recovery of left ventricular iunction (21,22,25). Additionally, establishment of an open infarctrelated artery may prevent ventricular aneurysm formation (26), raise the threshold for induction of ventricular tachycardia (27) and result in improved long-term survival independent of myocardial salvage (28). Myocardialsalvage. Despite disease limited to one coronary artery, left ventricular ejection fraction and regional wall motion improved significantly in 50% of patients by the time of hospital discharge. In concert with data from other studies (21,22,25), the most powerful predictors of improved left ventricular function were a depressed ejection fraction before angioplasty and sustained patency of the infarctrelated artery. Regional wall motion also improved significantly in patients with a limited increase in creatine kinase, consistent with enhanced myocardial salvage. Alternatively, reversible ischemia in the infarct zone at presentation may explain the marked improvement in regional wall motion in patients with a low initial ejection fraction but subsequent limited increase in creatine kinase. As in recent reports (21,25,29,30), the time to reperfusion was not strongly associated with myocardial salvage, emphasizing the importance of collateral circulation, as well as the dynamic nature of coronary obstruction. Long-termmorbidityand mortality. Previous studies (1l14) have demonstrated a 90% to 99% 3 year survival rate after uncomplicated infarction in patients with single vessel disease. However, these reports generally excluded elderly patients and high risk subsets. Thus, the 94% 3 year survival rate after direct angioplasty and hospital discharge in our patient cohort, which included elderly patients, those in shock and those with in-hospital complications, suggests a favorable effect on long-term mortality. Multivariate analysis identified only depressed initial ejection fraction as predictive of cardiac mortality. As reported by Stack et al. (23), the time to reperfusion was not an independent predictor of long-term mortality. Advanced age was not predictive of cardiac mortality in patients with single vessel disease. Despite this relatively high risk cohort of patients, the 4% incidence rate of late infarction and 5% incidence rate of late coronary bypass surgery also compare favorably with low risk historical control subjects (13-E). In addition, at 3 year follow-up evaluation, 77% of our patients were asymptom-
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Improvementin regionalwallmotion(segmentalEF) after direct coronary angioplasty,demonstratingthe influenceof baseline ejectionfraction (EF). PTCA= percutaneoustransluminalcoronary angioplasty. Figure 2.
atic and only 8% had class III or IV angina. Repeat angioplasty was required after discharge in 24% of our patients. The occurrence of a late cardiac event (>I year after discharge), along with the observation that 12% of our patients required repeat coronary angioplasty >8 months after the initial dilation, suggests that progression of atherosclerotic disease may contribute to late morbidity and mortality in patients with single vessel disease after acute
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myocardial infarction. Thus, an aggressive strategy of revascularization may be necessary to ensure angina-free and infarct-free late survival after initial reperfusion. Comparison with thromholytic therapy. Several theoretical and practical considerations limit the ultimate effectiveness of thrombolytic therapy. There appears to be a pharmacologic plateau of coronary thrombolytic efficacy of approximately 70% to 80% (21). There currently is no rapid, accurate means to noninvasively detect reperfusion at the bedside (31). In addition to the 99% reperfusion rate in the present study, the 4% incidence rate of recurrent in-hospital ischemic events and 11% incidence rate of angiographic reocclusion after direct coronary angioplasty compare favor-
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INFARCTION
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ably with the 20% to 30% incidence rate of recurrent ischemic events and reocclusion after thrombolytic therapy (2,8,29,32-34). Myocardial salvage and late survival have not been specifically reported in patients with single vessel disease after thrombolytic therapy. However, direct angioplasty has been associated with greater improvement in ventricular function than after thrombolysis alone (8,9,25); the only two randomized trials (29,35) of thrombolytic therapy versus direct angioplasty found improved global and regional left ventricular function and less exercise-induced ischemia associated with less severe residual coronary stenosis in the patients treated with angioplasty. The 5% to 8% annual
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mortality rate observed after thrombolytic therapy appears to be higher than the 1% to 3% yearly mortality rate after direct angioplasty (8,23,25,36). The 70% to 85% mortality rate in patients with cardiogenic shock treated conventionally or with thrombolytic therapy (1,37-39) may be reduced to 35% to 45% with angioplasty (40,41). In the present series, five (87%) of six patients with single vessel disease and cardiogenic shock were discharged alive.
STONE ET AL. CORONARY ANGIOPLASTY IN ACUTE MYOCARDIAL INFARCTION
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loa
Table 6. Long-Term Morbidity and Mortality After Direct Angioplasty in 214 Patients (mean follow-up 35 months) Event
In-Hospital
--------_-_--__
Total
17(8%)
20 (9%)
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1I (5%) 29 (14%)
13(6%) 34 (16%)
so-
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57 (27%)
20 -
New York Heart Association classification (in 194patients alive) 149(77%) Ck+SS i 29 (15%) Class II 8 (4%) Class III 8 (4%) Class IV
With current doses, thrombolytic therapy is associated with an 8% to 12% incidence rate of significant bleeding and a 0.5% risk of intracranial hemorrhage (8,42,43). The risk of major bleeding when coronary angioplasty is performed alone is ~2%; bleeding most commonly occurs at the cath-
eterization site and is usually minor; intracranial hemorrhage is extremely rare (8,42). Finally, with current eligibility criteria, only 14% to 43% of patients presenting with acute myocardial infarction are candidates for thrombolytic therapy (21,42). Limitations. Although this study consists of a consecutive series of patients with acute myocardial infarction and single vessel disease, it is uncontrolled and retrospective in nature and reflects the clinical experience of a single group of experienced interventional cardiologists. Firm conclusions comparing direct angioplasty with other modes of reperfu-
Table 7. Predictors of Morbidity and Mortality in 214 Patients After Direct Angioplasty
Shock Cardiac events* Anterior MI Shock Closed infarct-related artery
L
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Figure 4. Long-term morbidity and mortality in 214 patients after direct coronary angioplasty.
*Cardiac death, myocardial infarction or bypass surgery; 1 patient with in-hospital myocardial infarction and 3 patients with late myocardial infarction also under went bypass surgery; 7 patients had repeat angioplasty both before and after discharge. Abbreviations as in Table 4.
Cardiacmortality Low initial EF
--_
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Out of Hospital 12 (6%) 9 (4%)
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-----_______________.
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Death Cardiacdeath
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Univariate Analysis (p value)
Multivariate Analysis (p value)
0.007
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*Cardiac death, myocardial infarction or bypass surgery. Variables not significantly associated with survival included gender, prior bypass surgery, time to angioplasty, stenosis severity, collateral circulation, thrombus and peak creatine kinase. Abbreviations as in Tables 4 and 5.
sion will require controlled randomized studies and should
include a detailed cost-benefit analysis. Despite the goal of predischarge angiography in all patients, paired ventriculography was available in only 59% of patients. Although the baseline clinical and angiographic characteristics were similar in the two groups (Table 4), selection bias may nonetheless have occurred. In addition, multivariate analysis may have identified other covariates of myocardial salvage and survival had greater numbers of patients been available. Practicalconsiderations. Because only 12% of centers in the United States have facilities for coronary angioplasty (44), direct angioplasty is not feasible for the majority of patients with acute myocardial infarction. In addition, this approach requires around the clock availability of an interventional cardiologist and catheterization team skilled in acute infarct angioplasty and committed to rapid mobilization, conditions that are logistically and financially impossible to meet at many institutions. However, in centers so equipped, direct angioplasty in evolving myocardial infarction may be performed expeditiously and result in a low in-hospital mortality rate, dramatic improvement in left ventricular function and extended long-term survival (8,25). In addition, direct coronary angioplasty is the optimal treatment for the 57% to 86% of patients not eligible for thrombolytic therapy (21,42). Conclusions. In patients with single vessel coronary artery disease and evolving acute myocardial infarction, direct coronary angioplasty without prior thrombolytic therapy can be performed with a very high success rate and few procedural complications. Regional wall motion and ejection fraction improve in 50% of patients, especially in those with depressed ventricular function. This approach results in excellent early and late event-free survival and improved symptomatic status and compares favorably with results reported with conventional therapy or thrombolytic reperfusion.
542
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