Rescue Coronary Angiography after Failed Thrombolysis: A Real-Life Experience

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Abstract

Failed thrombolysis in acute myocardial infarction (AMI) patients is associated with a high risk of morbidity and mortality. Rescue or salvage percutaneous transluminal coronary angioplasty (PTCA) in this group of patients is still controversial. We report our experience with early emergency angiography and rescue PTCA in 27 patients who were hemodynamically unstable or had a large area of myocardium at risk after failed thrombolysis. Rescue PTCA was successful in 95% of attempted PTCA. Three patients were referred to emergency CABG. Early ‘rescue angiography’ with or without rescue PTCA after failed thrombolysis in a selected patient population, is an important tool for early risk stratification and decision-making during the hyperacute phase of AMI, while it may also serve in restoring coronary artery patency of the infarct-related artery with a high success rate.

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The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators.

(1993)

Although it is known that thrombolytic therapy improves survival after acute myocardial infarction, it has been debated whether the speed with which coronary-artery patency is restored after the initiation of therapy further affects outcome. To study this question, we randomly assigned 2431 patients to one of four treatment strategies for reperfusion: streptokinase with subcutaneous heparin; streptokinase with intravenous heparin; accelerated-dose tissue plasminogen activator (t-PA) with intravenous heparin; or a combination of both activators plus intravenous heparin. Patients were also randomly assigned to cardiac angiography at one of four times after the initiation of thrombolytic therapy: 90 minutes, 180 minutes, 24 hours, or 5 to 7 days. The group that underwent angiography at 90 minutes underwent it again after 5 to 7 days. The rate of patency of the infarct-related artery at 90 minutes was highest in the group given accelerated-dose t-PA and heparin (81 percent), as compared with the group given streptokinase and subcutaneous heparin (54 percent, P < 0.001), the group given streptokinase and intravenous heparin (60 percent, P < 0.001), and the group given combination therapy (73 percent, P = 0.032). Flow through the infarct-related artery at 90 minutes was normal in 54 percent of the group given t-PA and heparin but in less than 40 percent in the three other groups (P < 0.001). By 180 minutes, the patency rates were the same in the four treatment groups. Reocclusion was infrequent and was similar in all four groups (range, 4.9 to 6.4 percent). Measures of left ventricular function paralleled the rate of patency at 90 minutes; ventricular function was best in the group given t-PA with heparin and in patients with normal flow through the infarct-related artery irrespective of treatment group. Mortality at 30 days was lowest (4.4 percent) among patients with normal coronary flow at 90 minutes and highest (8.9 percent) among patients with no flow (P = 0.009). This study supports the hypothesis that more rapid and complete restoration of coronary flow through the infarct-related artery results in improved ventricular performance and lower mortality among patients with myocardial infarction. This would appear to be the mechanism by which accelerated t-PA therapy produced the most favorable outcome in the GUSTO trial.

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Immediate vs delayed catheterization and angioplasty following thrombolytic therapy for acute myocardial infarction. TIMI II A results. The TIMI Research Group.

(1988)

The Thrombolysis in Myocardial Infarction II A Study investigated whether immediate cardiac catheterization with percutaneous transluminal coronary angioplasty (PTCA), when appropriate, would confer an advantage over the same procedures performed 18 to 48 hours later. All patients were treated with intravenous recombinant tissue-type plasminogen activator within four hours of the onset of acute myocardial infarction. Percutaneous transluminal coronary angioplasty of the infarct-related artery was attempted in 72% of the 195 patients assigned to immediate PTCA; 84% of the attempts were judged to have shown improvement. Percutaneous transluminal coronary angioplasty was attempted in 55% of the 194 patients assigned to 18- to 48-hour PTCA; 93% of the attempts were judged to have shown improvement. No differences between the two PTCA groups were observed for ejection fraction (primary end point), measured by contrast ventriculography predischarge (50.3% in the immediate and 49.0% in the delayed PTCA groups). Immediate catheterization/angioplasty was associated with increased frequency of bleeding and coronary artery bypass surgery. These findings indicate that immediate performance of coronary arteriography and PTCA compared with delaying these procedures for 18 to 48 hours provides no advantage and may be harmful.

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Journal ID (publisher-id): CRD

Journal ID (nlm-ta): Cardiology

Journal ID (doi): 10.1159/issn.0008-6312

Title: Cardiology

Publisher: S. Karger AG

ISSN (Print): 0008-6312

ISSN (Electronic): 1421-9751

Publication date Subscription-year: 1998

Publication date (Print): July 1998

Publication date (Electronic): 14 August 1998

Volume: 90

Issue: 1

Pages: 48-51

Affiliations

The Heart Institute, Chaim Sheba Medical Center, Tel Hashomer and Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel

Article

Publisher ID: 6816 Other ID: Cardiology 1998;90:48–51

DOI: 10.1159/000006816

PubMed ID: 9693171

SO-VID: 7682df51-61ee-431a-b4b4-3500d3f1c4a0

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Rescue Coronary Angiography after Failed Thrombolysis: A Real-Life Experience

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Karger: Cardiovascular System

Most cited references 2

The effects of tissue plasminogen activator, streptokinase, or both on coronary-artery patency, ventricular function, and survival after acute myocardial infarction. The GUSTO Angiographic Investigators.

Immediate vs delayed catheterization and angioplasty following thrombolytic therapy for acute myocardial infarction. TIMI II A results. The TIMI Research Group.

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