Circulation, Vol 90, 753-761, Copyright © 1994 by American Heart Association
MJ de Boer, H Suryapranata, JC Hoorntje, S Reiffers, AL Liem, K Miedema, WT Hermens, MJ van den Brand and F Zijlstra
BACKGROUND: Early and effective flow through the infarct-related vessel is
probably of paramount importance for limitation of infarct size and
preservation of left ventricular function in patients with acute myocardial
infarction. Primary coronary angioplasty may offer advantages in these
respects compared with thrombolytic therapy. The purpose of the present
study was to assess the effects on estimated enzymatic infarct size and
left ventricular function in patients with acute myocardial infarction
randomly assigned to undergo primary angioplasty or to receive intravenous
streptokinase. METHODS AND RESULTS: We evaluated 301 patients with signs of
acute myocardial infarction and without contraindications for thrombolysis
who presented within 6 hours after onset of symptoms or between 6 and 24
hours if there was evidence of ongoing ischemia. One hundred fifty-two
patients were randomly assigned to undergo primary angioplasty, and 149
patients were assigned to receive treatment with streptokinase (1.5 million
U i.v.). Infarct size was estimated from enzyme release. Global left
ventricular ejection fraction and regional wall motion, if possible in
combination with exercise testing, were evaluated by radionuclide
ventriculography before discharge. Thrombolysis in Myocardial Infarction
(TIMI) flow grade 3 through the infarct-related vessel within 120 minutes
after admission was achieved in 92% of all patients assigned to receive
primary angioplasty therapy. Myocardial infarct size was 23% smaller in the
angioplasty group compared with patients assigned to receive streptokinase
(1003 +/- 784 versus 1310 +/- 1198 U/L, P = .012). Global left ventricular
ejection fraction (50 +/- 9% versus 45 +/- 11%, P < .001) and regional
wall motion in the infarct- related zones (42 +/- 14% versus 34 +/- 13%, P
< .001) were better in the angioplasty group, which could mainly be
contributed to myocardial salvage in the infarct-related areas. The
observed differences were more pronounced in patients with an anterior wall
myocardial infarction, although patients with a nonanterior infarct
location also showed a beneficial effect of primary coronary angioplasty on
left ventricular function compared with streptokinase therapy. Furthermore,
the observed differences appeared to be more pronounced in patients
presenting relatively early (within 2 hours) after onset of symptoms.
CONCLUSIONS: In patients with acute myocardial infarction, primary
angioplasty results in a smaller infarct size and a better preserved
myocardial function compared with patients randomized to receive treatment
with intravenous streptokinase. This is probably due to early and optimal
blood flow through the infarct-related vessel, as can be accomplished in a
very high percentage of patients undergoing primary coronary angioplasty.
ARTICLES
Limitation of infarct size and preservation of left ventricular function after primary coronary angioplasty compared with intravenous streptokinase in acute myocardial infarction
Department of Cardiology, Ziekenhuis de Weezenlanden, Zwolle, The Netherlands.
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