http://www.ncbi.nlm.nih.gov/pubmed/2394002
Ohman EM, Califf RM, Topol EJ, Candela R, Abbottsmith C, Ellis S, Sigmon KN, Kereiakes D, George B, Stack R.
Source
Department of Medicine, Duke University Medical Center, Durham, NC 27710.Abstract
To
determine the clinical consequences of reocclusion of an
infarct-related artery after reperfusion therapy, we evaluated 810
patients with acute myocardial infarction. Patients were admitted into
four sequential studies with similar entry criteria in which patency of
the infarct-related artery was assessed by coronary arteriography 90
minutes after onset of thrombolytic therapy. Successful reperfusion was
established acutely in 733 patients. Thrombolytic therapy included
tissue-type plasminogen activator (t-PA) in 517, urokinase in 87, and a
combination of t-PA and urokinase in 129 patients. All patients received
aspirin, intravenous heparin and nitroglycerin, and diltiazem during
the recovery phase. A repeat coronary arteriogram was performed in 88%
of patients at a median of 7 days after the onset of symptoms.
Reocclusion of the infarct-related artery occurred in 91 patients
(12.4%), and 58% of these were symptomatic. Angiographic characteristics
at 90 minutes after thrombolytic therapy that were associated with
reocclusion compared with sustained coronary artery patency were right
coronary infarct-related artery (65% versus 44%, respectively) and
Thrombolysis in Myocardial Infarction (TIMI) flow 0 or 1 (21% versus
10%, respectively) before further intervention. Median (interquartile
value) degree of stenosis in the infarct-related artery at 90 minutes
was similar between groups: 99% for reoccluded (value, 90/100%) compared
with 95% for patent (value, 80/99%). Patients with reocclusion had
similar left ventricular ejection fractions compared with patients with
sustained patency at follow-up. However, patients with reocclusion at
follow-up had worse infarct-zone function at -2.7 (value, -3.2/-1.8)
versus -2.4 (SD/chord) (value, -3.1/-1.3) (p = 0.016). The recovery of
both global and infarct-zone function was impaired by reocclusion of the
infarct-related artery compared with maintained patency; median delta
ejection fraction was -2 compared with 1 (p = 0.006) and median delta
infarct-zone wall motion was -0.10 compared with 0.34 SD/chord (p =
0.011), respectively. In addition, patients with reocclusion had more
complicated hospital courses and higher in-hospital mortality rates
(11.0% versus 4.5%, respectively; p = 0.01). We conclude that
reocclusion of the infarct-related artery after successful reperfusion
is associated with substantial morbidity and mortality rates.
Reocclusion is also detrimental to the functional recovery of both
global and infarct-zone regional left ventricular function. Thus, new
strategies in the postinfarction period need to be developed to prevent
reocclusion of the infarct-related artery.
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