Thrombolysis with rt-PA in acute myocardial infarction: no additional benefit of immediate PTCA
A randomised trial of 367 patients with acute myocardial infarction was performed to determine whether an invasive strategy combining thrombolysis with recombinant tissue-type plasminogen activator (rTPA), heparin, and acetylsalicylic acid, and immediate percutaneous transluminal coronary angioplasty (PTCA) would be superior to a noninvasive strategy with the same medical treatment but without immediate angiography and PTCA. Intravenous infusion of 100 mg rTPA was started within 5 h after onset of symptoms (median 156 min). Angiography was performed 6-165 min later in 180 out of 183 patients allocated to the invasive strategy; 184 patients were allocated to the non-invasive strategy. Immediate PTCA reduced the percentage stenosis of the infarct-related segment, but this was offset by a high rate of transient (16%) and sustained (7%) reocclusion during the procedure and recurrent ischaemia during the first 24 h (17%). The clinical course was more favourable after non-invasive therapy, with a lower incidence of recurrent ischaemia within 24 h (3%), bleeding complications, hypotension, and ventricular fibrillation. Mortality at 14 days was lower in patients allocated to non-invasive treatment (3%) than in the group allocated to invasive treatment (7%). No difference between the treatment groups was observed in infarct size estimated from myocardial release of alpha-hydroxybutyrate dehydrogenase or in left ventricular ejection fraction after 10-22 days. Since immediate PTCA does not provide additional benefit there seems to be no need for immediate angiography and PTCA in patients with acute myocardial infarction treated with rTPA.
|Keywords||*Angioplasty, Balloon, 0 (Fibrinolytic Agents), 0 (Recombinant Proteins), 50-78-2 (Aspirin), 9005-49-6 (Heparin), Adult, Aged, Aspirin/administration & dosage/therapeutic use, Clinical Trials, Combined Modality Therapy, Comparative Study, Coronary Angiography, Drug Therapy, Combination, EC 220.127.116.11 (Tissue Plasminogen Activator), Europe, Female, Fibrinolytic Agents/administration & dosage/*therapeutic use, Heparin/administration & dosage/therapeutic use, Human, Infusions, Intravenous, Male, Middle Aged, Myocardial Infarction/mortality/*therapy, Random Allocation, Recombinant Proteins/administration & dosage/therapeutic use, Recurrence, Time Factors, Tissue Plasminogen Activator/administration & dosage/*therapeutic use|
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