Circulation, Vol 81, 1457-1476, Copyright © 1990 by American Heart Association
WJ Rogers, DS Baim, JM Gore, BG Brown, R Roberts, DO Williams, JH Chesebro, JD Babb, FH Sheehan and FJ Wackers
To assess the value and timing of percutaneous transluminal coronary
angioplasty (PTCA) after thrombolytic therapy for acute myocardial
infarction (AMI), 586 patients in the Thrombolysis in Myocardial Infarction
Study Phase II-A were randomized among three treatment strategies, one
using immediate coronary arteriography followed by PTCA if appropriate
(immediate invasive strategy group, n = 195), a second that deferred
angiography and PTCA for 18-48 hours (delayed invasive strategy group, n =
194), and a third, more conservative, approach in which PTCA was used only
if ischemia occurred spontaneously or at the time of predischarge exercise
testing (conservative strategy group, n = 197). Predischarge contrast left
ventricular ejection fraction, the primary study end point, was similar
among the patients in all three treatment groups and averaged 49.3%. The
finding of a patent infarct- related artery at the time of predischarge
arteriography was equally common among the patients in the three groups
(mean, 83.7%); however, the mean residual infarct artery stenosis was
greater in the patients in the conservative strategy group (67.2%) as
compared with the patients in the immediate invasive (50.6%) and the
delayed invasive strategy groups (47.8%) (p less than 0.001). Immediate
invasive strategy led to a higher rate of coronary artery bypass graft
surgery (CABG) after PTCA (7.7%) than did delayed invasive and conservative
strategies (2.1% and 2.5%, respectively; p less than 0.01). Furthermore,
among patients not undergoing CABG during the first 21 days, blood
transfusion of more than 1 unit was used in 13.8% of the patients in the
immediate invasive strategy group, 3.1% of the patients in the delayed
invasive strategy group, and 2.0% of the patients in the conservative
strategy group (p less than 0.001). At 1-year follow-up, the three
treatment groups had similar cumulative rates of mortality (8.7%, pooled
over all groups), fatal and nonfatal reinfarction (8.5%), combined death
and reinfarction (14.5%), and CABG (17.2%), although the cumulative
performance rate of PTCA remained higher in the invasive groups (immediate
invasive strategy group, 75.8%; delayed invasive strategy group, 64.3%; and
conservative strategy group, 23.9%; p less than 0.001). Thus, because
conservative strategy achieves equally good short- and long-term outcome
with less morbidity and a lower use of PTCA, it seems to be the preferred
initial management strategy.
ARTICLES
Comparison of immediate invasive, delayed invasive, and conservative strategies after tissue-type plasminogen activator. Results of the Thrombolysis in Myocardial Infarction (TIMI) Phase II-A trial
Thrombolysis in Myocardial Infarction, Coordinating Center, Baltimore, Maryland.
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