Percutaneous transluminal coronary angioplasty with and without thrombolytic therapy for treatment of acute myocardial infarction

American Fc t lded

Nt:

CLINICAL

in

.Thart

7ournaT.

1925

vember

1983

Volume

106,

NI

mt

er 5, Part

I

INVESTIGATIONS

Percutaneous translumi nal coronary an g ioplasty with and without thrombolytic therapy ‘for treatment of acute mycrcardial infarcticbn Successful percutaneous transluminal coronar b angioplasty (PTCA) was perfo ‘mc d during evolving acute myocardial infarction (AM) in 4’ patients. Catheterization was Ipe ,formed with hour of presentation, from 1 to 12 hours (meal 3.3) following symptom onset In 17 of 29 thrombolytic ther; spy was followed patients with a totally occluded coronary arter! , successful PTCA of a residual high-grade atheromatous 8’1mosis. Successful PTCA witho .It 1 lrior thrombolytic therapy was employed in 11 of 1 i subtotal coronary stenoses PI od rcing acute infarction syndromes and in two patients havin 3 critical coronary stenoses nc It iI Imediately responsible for AMI. Three patients experience i early in-hospital reocclusion rvit I reinfarctiol One death occurred in a patient presenting wit 1 cardiogenic shock. All remair in! patients ha prompt pain relief, subsequent stable clinical c aurses, and no clinical or late i In{ iographic evidence of coronary reocclusion. Dramatic inIl brovement of regional and glot .a1 eft ventricul function was evident in 22 of 27 patients undt! going late left ventricular angi :)gl aphy. At follow-up, 94% of patients remained free of ari gina although three required re pe It dilatation recurrent stenoses. We concluded that PTCA II ay be performed with or without hrombolytic therapy in selected patients with AMI and may ‘educe the likelihood of late re IX :lusion follov successful

thrombolytic

therapy.

(AM HEART J +I )6:965,

n 1 by

I. i jr ()f ring

1963.)

Geoffrey 0. Hartzler, M.D., Barry D. Ru-; lerford, M.D., David R. Mc ‘Cc nahay, M.l I., Warren L. Johnson, Jr., M.D., Ben D. Mr Callister, M.D., George M. 1~1ra, Jr., M.l>., Robert C. Conn, M.D., and James E. Crcll :kett, M.D. Kmzsas City, it i

Limitation of myocardial infarct size is a t major goal in the contemporary management of patients with acute myocardial infarction. To achieve this objective, intracoronary perfusion with streptol :inase has been advocated and reported to dissolve thrombi, restore coronary flow in 70 % to 90% ( If acutely obstructed arteries, reverse or stabilize tht patient’s clinical course, limit myocgdial infarct size, and result in improved left ventricular functic n relative to that of nonreperfused control groups.1-g In all reported series, significant coronary stenoses have remained following thrombolytic therap y. Consequently, coronary bypass surgery has bel!n recommended and performed following throm bolysis to prevent unstable angina, coronary reocch Ision, and From Received accepted

the Mid-America for publication Apr. 19, 1983.

Reprint requests: Geoffrey tute, St. Luke’s Hospital,

Heart Feb.

Institute, 15, 1982;

0. Hartzler, 44th & Wornall

St. Luke’s revision

Hospita received

IV arch

M.D., Mid-Americ Rd., Kansas Cit)

22, 1983;

1 Heart Insti, MO 64111.

myocardial rt in ‘arction.6v7*E lo P e report an initi; experience with percutaneous transluminal cor( nary angiopla gNtJ(PTCA) as an a ternative to bypru surgery in thl! I lanagemen; of batients with acul myocardial in 1Fa1 ction, treal ed t 9th with and wit1 out intracorol 1.81 y thrombol ytic .herapy.

.1 s e -

METHODS Patient pop~llalion (Table I). Tl irty-three males ar: cl eight females mt erwent urgti nt cl rdiac catheterizatic n early in the cou rse of a prolong !d an 1 continuous ischem c syndrome cons ist ~:nt with ac lte I lyocardial infarctio t. Their ages rang led from 33 to 7 5 yea es,with a mean age ( Q 58 years. Left heart ca the terization w th m moplane ventriculo; :raphy and core ila’y angiograpl mywe be performed within 1 hour of presenl atilm at a mear of 3. 3 hours (range 1 to 12 hours) after thl ! OI lset of contil IUOUEchest pain associak d with ST segme nt ( levation in Z8 pal lents and ST segmel It depression in tl I.re ?patients. N ew Q waves were present It the time of pr ttsc ntation in 14 pa iente. There were Z1 acute anterior w 111 infarctioik3, 1 : acute inferior wz 11 91’5

November,

966

Table

Hartzler

I. Clinical

et al.

American

characteristics:

PTCA for acute infarc-

tion

Table

II.

33 8 33-75 yrs mean

58 yrs

infarction Prior coronary bypass surgery Duration chest pain l-12 hrs mean 3.3 hrs Infarct location Anterior Inferior Lateral Anterior and inferior ST segment elevation New Q waves LV failure Cardiogenic shock Prior

Journal

Results: PTCA and SK for acute myocardial

infarction Patients

Males Females Ages

1983

Heart

10 4

21 14 4 2 38

14 8 2

Patients Total

occlusions

(29)

Opened with SK, then PTCA PTCA Without SK Unsuccessful SK PTCA of 3rd artery in patients with 2 total occlusions Successful SK, failed PTCA, subsequent CABG Successful SK and PTCA, subsequent CABG of 2nd vessel Subtotal

occlusions

PTCA Initial Initial Initial

16

4 4 2 2

(12)

without SK SK, then PTCA SK, failed PTCA PTCA, then elective

8 2

CABG

infarctions, four acute lateral wall infarctions, and two patients experiencedcombined acute inferior and anterior wall infarctions. Although myocardial enzyme data were not available at the time of catheterization, the MB isoenzymeof creatine kinase (CK-MB) was later reported to be present in admitting blood specimensobtained from 26 of 32 patients. CK-MB wasreported to be absent in the remaining six patients catheterized at a mean of 2.9 hours (1.5 to 6 hours), including four patients having total coronary arterial occlusions. Chest pain persisted despite conventional therapy including oxygen, sublingual nitrates, and narcotics in all instances. Twelve patients were hospitalized prior to the onset of symptoms, 21 patients presented to the Emergency Room, and eight were transferred from other institutions. The clinical history included remote myocardial infarction in three patients and prior coronary artery bypass surgery in four patients. Five additional patients experienced subendocardial infarctions and two experienced transmural myocardial infarctions from 2 days to 5 weeks prior to the onset of clinical reinfarction and inclusion in this study. Eight patients had clinical evidence of left ventricular failure and two patients were in cardiogenic shock. These 41 patients represent consecutive PTCA attempts in patients presenting with acute myocardial infarction, 10% of total patients undergoing elective PTCA in a 22-month period and approximately one third of patients receiving intracoronary streptokinase infusions within the same time period. Patients were selected for PTCA based upon multiple subjective criteria including the proximity of the lesion, presenceand extent of thrombus within the artery asjudged angiographically, character of the residual stenosis(discrete, concentric), and most importantly, experience of the cardiologist performing the procedure.

SK = streptokinase; PTCA = percutaneous transluminal plasty; CABG = coronary artery bypass graft surgery.

coronary

angio-

Procedure. Before transfer to the Catheterization Laboratory, all patients received heparin, 5000to 10,000units intravenously; lidocaine, 75 to 100 mg intravenously; oxygen; sublingual nitroglycerin; and morphine. Blood was obtained for routine laboratory work, myocardial enzyme studies, coagulation studies, and blood grouping. Informed consent for participation in a protocol approved by our institutional Human Investigation Committee was obtained from the patient or a responsiblerelative. Following the administration of an additional 5000 units of heparin, left ventriculography and coronary angiography were performed using the standard percutaneoustransfemoral technique. A monoplaneleft ventricu-

lar angiogram

was obtained

in a 30-degree

right

anterior

oblique (RAO) projection followed by selective angiography of the coronary artery judged not responsiblefor the acute myocardial

infarction.

Following

the injection

of the

responsiblecoronary artery and if coronary occlusionwas present, subselectivecoronary cannulation was performed using

either

a No.

4 French

“probing”

catheter

or a

standard coronary angioplasty balloon catheter (USC1 Corporation; Billerica, Mass.). Streptokinase wasadministered asan initial 10,000unit bolus followed by a 2000 unit/min infusion through the subselectivecatheter, which was positioned as closely as possibleproximal to the site of obstruction. Repeat subselective

contrast

injections

were

performed

every

15

minutes and were recorded on cineangiographic film. Following dissolution of thrombus and restoration of coronary flow, streptokinase was continued for from 15 to 60 minutes, followed by PTCA of the residual obstructive coronary atheromatous lesion. If restoration of flow did not occur within 15 to 30 minutes of streptokinaae infu-

Volume Number

106 5, Part

1

PTCA

in acute myocardial

infarction

967

Fig. 1. SuccessfulPTCA of a totally occluded proximal LAD in a patient with 4-hour-old anteroseptal myocardial infarction. Streptokinase wasnot administered. Panel A showstotal proximal LAD occlusion (arrow). Panel B showspassageof balloon catheter into the occlusion (arrow) with subselectiveinjection of contrast material indicating that the balloon tip waswithin the distal vessellumen. Panel C illustrates balloon inflation. Panel D showsimmediate resultsof wide patency (arrow) but 40% residual narrowing of the previously totally occluded segment.

sion, the zone of total obstruction was gently probed with a balloon angioplasty catheter in an attempt to mechanically enhanceearly reperfusion. If subtotal stenosiswithout overt thrombus was identified in an artery producing apparent acute myocardial infarction, intracoronary nitroglycerin, 250 to 400 pg, wasfirst infused subselectively followed by PTCA without prior streptokinase infusion. A low molecular weight dextran infusion was begun

prior to angioplasty. Although the first 20 patients did not receive calcium channel blockers, subsequent patients were routinely given verapamil, 5 to 10 mg intravenously, within the Catheterization Laboratory. Subsequent to PTCA, all patients were transferred to the Intensive Care Unit where managementincluded heparin, nitroglycerin, and lidocaine by continuous intravenous infusions; aspirin, 5 grains three times daily, and dipyridamole, 75 mg three times daily.

November,

968

Hartzler

et al.

American

Heart

1983 Journal

Fig. 2. Successful PTCA following initial restoration of coronary flow by subselective infusion of streptokinase, 1‘/z hours following onset of anteroseptal infarction. Panel A illustrates total proximal LAD occlusion (arrow). Panel B illustrates restoration of flow but persisting high-grade coronary stenosis (arrow) following 30 minutes of streptokinase. Panel C illustrates balloon inflation with tip of balloon in stenosis.Panel D illustrates immediate post PTCA result (arrow).

RESULTS

patients

without

prior SK infusion

(Fig. 1) and in

II). In 29 patients, a single coronary artery corresponding with the ECG and

four patients whose occluded vessel did not open with initial thrombolytic therapy. There was no

angiographic site of acute myocardial infarction was found to be totally occluded (Figs. 1 to 3). Coronary flow was restored and chest pain relieved with subselective intracoronary infusions of streptokinase (SK) in 17 patients. Infusion times ranged from 15 to 90 minutes, with total streptokinase dosage ranging from 40,000 to 200,000 units. SK was continued for from 15 to 60 minutes following the restoration of coronary flow in an attempt to further increase arterial lumen diameter, but because of persisting high-grade obstructive lesions in each patient following thrombolytic therapy, PTCA was performed (Figs. 2 and 3). Successful PTCA of a totally occluded vessel was accomplished in four

angiographic evidence of distal embolization or arterial dissection following PTCA in any of these eight patients. Subtotal coronary obstruction. Twelve patients had subtotal (greater than 95% obstruction in all angiographic views) coronary stenoses with markedly delayed distal filling. An initial intracoronary nitro-

SK and

PTCA

(Table

glycerin injection failed to improve flow, relieve pain, or alter the degree of stenosis in any patient.

Eight

patients

underwent

initial

successful PTCA

followed by relief of chest pain and improvement of

hyperacute ECG repolarization abnormalities. Two of three patients underwent successful PTCA following an initial SK infusion administered because

Volume Number

106 5, Part 1

Fig. 3. Successful PTCA of proximal wall infarction. Panel A illustrates total of coronary flow (arrow) following 30 continued for a total of 60 minutes prior post PTCA result (arrow). This patient weeks later.

PTCA

in acute myocardial

infarction

969

right coronary artery 4 hours following the onset of acute inferior proximal right coronary occlusion. Panel B illustrates restoration minutes of subselective intracoronary streptokinase, which was to PTCA demonstrated in panel C. Panel D illustrates immediate underwent elective dilatation of a high-grade mid-LAD stenosis 2

of an angiographic appearance suggesting the presence of a nonobstructive intracoronary thrombus. One patient underwent elective three-vessel coronary bypass surgery following initial successful PTCA of a subtotally occluded right coronary artery producing a clinical syndrome consistent with acute inferior wall infarction. Cardiogenic shock. Two patients presented with combined acute inferior and anterior wall infarctions. Both were in shock and required intra-aortic balloon pump insertion prior to coronary angiography, which revealed total occlusion of the left anteri-

or descending and right coronary arteries. SK and probing techniques failed to open either artery in one patient who improved dramatically following successful PTCA of a large but 95% obstructed circumflex marginal branch. A second patient who was catheterized at 10 hours following the onset of infarction had an ejection fraction of 7 % . He died in the Catheterization Laboratory despite successful opening of his left anterior descending coronary artery with SK and successful PTCA of a 95% proximal circumflex artery obstruction. Noninfarct-producing coronary stenoses were

970

Hartzler

et al.

Amarlcan

Table III. Follow-up of 35 patients*: acute myocardial infarction

PTCA

and SK for Patients

In-hospital Uncomplicated clinical course Reocclusion with reinfarction Deaths

32 3 0

Post-discharge 7.3 months (l-21 mos) Functional class I Includes reocclusion with successful SK 1 pt. Includes restenosis with repeat PTCA 3 pts. Functional class II (congestive failure) Deaths *See text. Excludes CABG patients. pt(s) = patients.

one laboratory

death,

2 0 failure,

angiography in five patients (12%). Following DC countershock, each patient remained electrically stable, allowing the initiation of SK infusion and subsequent PTCA without arrhythmia. Significant “reperfusion” arrhythmias uncommonly occurred and were limited to frequent ventricular ectopy. In-hospital clinical observations and late follow-up (Table III). Chest pain was relieved within a few

33

one F’TCA/SK

November, 1983 Heart Journal

four

dilated in the two patients identified above because of a technical inability to dilate the responsible stenoses and the hope that improvement of flow within an additional critically obstructed vessel would improve global left ventricular function and potentially provide collateral circulation to the infarct zone. In five patients two-vessel dilatations were performed, with an additional significantly obstructed coronary segment or artery being dilated electively by PTCA during the initial procedure. immediate effkacy. Following PTCA, the mean residual coronary luminal narrowing at sites of dilatation was 30% (range 10% to 50%), with reduction of pressure gradients from an initial mean value of 60 mm Hg to 20 mm Hg or less in all instances. In seven patients, despite relief of chest pain and both angiographically and hemodynamitally successful PTCA, distal runoff with contrast material appeared slow with delayed opacification of myocardium perfused by the previously occluded vessel. Intracoronary nitroglycerin and SK failed to acutely improve this appearance. Chest pain and ST segment elevation recurred between 15 and 30 minutes following initially successful PTCA of a right coronary stenosis in two patients. Repeat angiography showed total occlusion at the site of PTCA with a new smooth, tubular appearance suggesting coronary spasm. Restoration of flow required intracoronary and intravenous nitroglycerin, intravenous verapamil, and ultimately repeat dilatation of the spastic segments in each case. Significant spasm was not observed in the left coronary circulation before or after PTCA. Ventricular fibrillation occurred during initial coronary

minutes of successful PTCA or restoration of coronary flow through thrombolytic therapy in all cases. Typically, hyperacute ST segment elevation returned promptly to baseline or became depressed with T wave inversion following successful PTCA. Abnormalities of repolarization including profound T wave inversion persisted for days following the procedure, with gradual improvement as is commonly seen in uncomplicated subendocardial myocardial infarction. Q waves were present in 14 patients at the time of catheterization and developed in an additional four patients following the PTCA procedure. Significant Q waves did not develop in any of the remaining 23 patients, although ECG changes consistent with subendocardial injury were present in all. Elective coronary artery bypass surgery of nondilated vessels was performed following successful PTCA in two patients. Two additional patients underwent urgent coronary bypass surgery following unsuccessful PTCA attempts, while a third patient who could not be dilated was treated medically. Excluding these five patients and the single laboratory death, 35 of 41 patients (86%) were treated successfully utilizing PTCA with or without thrombolytic therapy. Coronary reocclusion with reinfarction occurred during the second to third days in three patients within 6 hours of discontinuation of intravenous heparin therapy. Coronary dissection as a complication of the procedure had occurred in two of these patients and a significant but nondilated stenosis adjacent to a previously occluded coronary segment persisted in the third patient. Each underwent repeat left ventricular angiography with coronary angiography documenting total occlusion at sites of previous total occlusion and dilatation. The clinical course remained stable for all other patients without recurrence of angina, extension of myocardial infarction, or clinical evidence of coronary rethrombosis. Elective repeat catheterization was performed in 27 patients at a mean of 10 days (range 2 to 36 days). Twenty-four of 27 dilated coronary arterial segments remained widely patent. Left ventriculography demonstrated improvement of global left ventricular function with a 36% increase in mean

Volume Number

106 5, Part 1

ejection fraction compared with the initial study (Fig. 4). Improvement of regional wall motion occurred in 22 patients, with no improvement or only minor improvement of regional contractility in remaining patients including the three with early coronary reocclusion. Following hospital dismissal, only one patient experienced reinfarction with acute reocclusion of a saphenous vein graft at 2% weeks. He presented to the hospital Emergency Room within 20 minutes of symptom onset and underwent a repeat successful intracoronary SK infusion without PTCA and remains asymptomatic at an additional 6 months’ follow-up. No deaths or recurrent infarctions have occurred during a follow-up period ranging from 1 to 21 months (mean 7.3 months). Three patients underwent repeat PTCA for treatment of progressive angina resulting from restenosis at the site of previous dilatation. A third patient had return of angina 7 months following PTCA but by coronary angiography was shown to have no change in the dilated segment, with progression of occlusive disease in a second vessel. Two patients have mild congestive heart failure controlled with medications. Of the 35 patients successfully treated by PTCA with or without intracoronary SK infusion, 32 (91% ) remain in functional class I. DISCUSSION

Although the role of intracoronary SK infusion is not yet fully defined, it is clearly established that this procedure can result in clot lysis, with restoration of coronary flow in a majority of patients.1-10 Important factors limiting the long-term benefit of thrombolytic therapy include the occurrence of myocardial reinfarction resulting from coronary reocclusion, and the occurrence of unstable angina resulting from a persisting high-grade atheromatous lesion. Because of limited experience with intracoronary thrombolytic therapy, the time course and precise incidence of reocclusion is unknown, although recent reports suggest at least one third of patients will have reobstruction.1° In our experience, symptomatic reocclusion has occurred within the Catheterization Laboratory as early as several minutes following initially successful restoration of flow with thrombolytic therapy alone, and it has also occurred during the continuous intracoronary infusion of SK despite associated full heparin doses. Combined and “definitive” therapy. Coronary bypass surgery following initial clot lysis has been recommended to prevent subsequent unstable ischemic syndromes.6-7~g-*0 Our series illustrates an alternative approach with several potential advantages

PTCA

Ejection Fraction (%I

in acute myocardial

90

.-

80

.I

70

--

6o 5.

*I

40

--

30

--

infarction

971

--w 44

10 t

I Before PTCA l A

After PTCA

patent re-occluded

Fig. 4. Monoplane

ejection fraction data obtained prior to PTCA compared with that obtained at late follow-up ventriculography in 27 patients. Closed circles indicate those patients whose arteries remained patent. Triangles indicate those patients whose arteries acutely reoccluded with reinfarction. The initial mean ejection fraction was 44%) increasing to 60% at late study. over surgery. Although the ideal timing for PTCA remains uncertain, clearly it can be performed successfully and safely immediately following thrombolytic therapy. Prior SK infusion in doses ranging to 200,000 units did not produce or potentiate specific complications related to the procedure. In this series, PTCA effectively opened persisting highgrade atheromatous stenoses, promptly opened four totally occluded coronary arteries without delays imposed by prior SK infusion, restored coronary flow in four patients whose arteries could not be opened by intracoronary SK infusions, and effectively restored coronary flow in patients with subtotal coronary stenoses who did not appear to have intracoronary thrombus present as an additional obstructing factor. Because of this experience, we believe that intracoronary SK infusion cannot be considered the “definitive” therapeutic procedure for acute myocardial infarction, and that successful thrombolysis should be followed by coronary angioplasty, or bypass surgery. Infarction and subtotal occlusion. This series included a higher incidence of subtotal coronary obstruction than that described by DeWood et al.” in their angiographic evaluation of patients during the early hours of acute myocardial infarction. A

November,

972

Hurtzler

et al.

number of potential explanations for this discrepancy exist. Possibly our early and aggressive attempts to identify patients experiencing myocardial infarction led to the inclusion of some who were merely demonstrating markedly prolonged ischemic episodes which would not have evolved to infarction even in the absence of an intervention. However, the long duration of chest pain (greater than 1 hour in all instances) unrelieved by nitroglycerin, and the associated ECG changes clearly suggested the occurrence of evolving myocardial damage, as was confirmed by the presence of CK-MB in all but six patients assessed. Alternatively, superimposed coronary arterial spasm may have been relieved prior to the initial coronary injection through the combined vasodilatory effects of intravenous lidocaine, sublingual nitroglycerin, and angiographic contrast material. However, at the time of the acute intervention, no patient appeared to demonstrate clinically significant spasm prior to PTCA. Intracoronary nitroglycerin was administered to all patients but failed to open any totally occluded vessel, subjectively lessen the degree of subtotal stenosis, improve distal coronary flow through collateral circulation, or relieve chest pain. Apparent coronary spasm did occur following successful PTCA of total right coronary lesions in two patients. Reclosure of the artery with return of chest pain occurred from 10 to 20 minutes following PTCA in each case. The angiographic appearance of a smooth, tubular, and concentric obstruction in the absence of intraluminal filling defect suggested coronary spasm, although intracoronary nitroglycerin failed to acutely restore flow in either case. Repeated dilatation of the affected zone in combination with intravenous verapamil and a continuous infusion of intravenous nitroglycerin were required to restore persistent patency. This sequence of events implies that spasm may have played a role in the genesis of the acute myocardial infarction, although spasm may have been a secondary response to ischemic arterial wall injury or to the balloon dilatation procedure. Ventricular function. Many factors complicate the objective assessment of PTCA with or without SK infusion for the management of patients with acute myocardial infarction. There is no readily available or practical, clinically applicable technique for dynamically predicting and measuring infarct size during its moment-to-moment evolution. Consequently, in an individual case, one cannot be certain about the ultimate state of ventricular function had the patient not undergone an acute intervention. However, the prompt relief of chest pain experi-

American

Heart

1983 Journal

enced by all patients and the dramatic late improvement in left ventricular function demonstrated by repeat left ventricular angiography suggest that myocardial necrosis was limited and function was preserved. These observations are similar to those recently reported for patients undergoing thrombolytic therapy alone. However, the greater improvement of left ventricular function in our series may result from a more adequate restoration of coronary perfusion pressures and flows through PTCA than through thrombolytic therapy. At the present time, this conclusion is not fully warranted and merits further investigation. Future implications. Not every patient will be a technical candidate for PTCA despite initially successful thrombolytic therapy. The stenosis location or associated multiple vessel disease may preclude PTCA in favor of continued medical management or coronary bypass surgery. However, in some instances, multiple vessel or multiple segment dilatation will prove feasible as it did in five patients of this series. PTCA without SK may also benefit patients with acute infarction by improving regional function of noninfarcting zones and by increasing collateral circulation to potentially viable myocardiurn supplied by occluded arteries. In other circumstances it may prove best to selectively perform PTCA of the single vessel responsible for an acute infarction, followed by “elective” multiple vessel bypass surgery. The experience and technical skills of both the cardiologist and laboratory team will continue to be a major factor in determining the interventional approach utilized and its success. Continued clinical experience, corroboration from multiple centers, and possibly randomized trials will be required to establish the role and benefit of PTCA with or without thrombolytic therapy in the management of patients with acute myocardial infarction. The authors thank the technical staff of St. Luke’s Hospital Catheterization Laboratory for their assistance and outstanding support in the management of these critically ill patients. REFERENCES

Rentrop KP, Blanke H, Karsch KR: Acute myocardial infarction: Intracoronary application of nitroglycerin and streptokinase. Clin Cardiol 11:354, 1979. Ganz W, Buchbinder N, Marcus H, Mondkaar A, O’Connor L, Maddahi J, Charuzi Y, Peter T, Berman D, Shah PK, Swan HJC, Kass R: Intracoronary thrombolysis in evolving myocardial infarction in man (abstr). Circulation 62(suppl 111):162, 1980. Rentrop P, Blanke H, Kostering H, Karsch KA: Intracoronary streptokinase infusion in 44 patients with acute ischemic syndromes (abstr). Circulation 62(suppl 111):161, 1980. Gold HK, Leinbach RC: Coronary flow restoration in myocardial infarction by intracoronary streptokinase (abstr). Circulation 62(suppl 111):161, 1980.

Volume Number

106 5, Part 1

PTCA in acute myocardial

5. Ganz W, Buchbinder N, Marcus H, Mondkaar A, Maddahi J, Charuzi Y, O’Connor L, Schell W, Fishbein MC, Kass R, Miyamoto A, Swan HJC: Intracoronary thrombolysis in evolving myocardial infarction. AM HEART J 101:4, 1981. 6. Rentron P. Blanke H. Kaiser H. Kosterina H, Leitz K: Selective intracoronary thrombolysis in acute myocardial infarction and unstable angina pectoris, Circulation 63:307, 1981. 7. Mathey DG, Kuck KH, Tilsner V, Krebber HJ, Bleifeld W: Nonsurgical coronary artery recanalization in acute transmural myocardial infarction. Circulation 63:489, 1981. 8. Reduto LA, Smalling RW, Freund GC, Gould KL: Intracoronary infusion of streptokinase in patients with acute myo-

infarction

cardial infarction: The effects of reperfusion on left ventricular performance. Am J Cardiol 48:403, 1981. 9. Rentrop KP, Blanke H, Karsch KR: Effects of nonsurgical coronary reperfusion on the left ventricle and human subjects compared with conventional treatment. Am J Cardiol 49:1, 1982. 10. Ganz W: Intracoronary thrombolysis in evolving myocardial infarction. Ann Intern Med 95:500, 1981. 11. DeWood MA, Spores J, Notske R, Mouser L, Burroughs R, Golden M, Lang H: Transmural myocardial infarction in man: The prevalence of total coronary occlusion during the early hours. N Engl J Med 303:897, 1980.

Percutaneous transluminal coronary angioplasty in patients with stable and unstable angina pectoris: Analysis of early and late results Percutaneous transluminal coronary angioplasty (PTCA) was performed in 50 patients with stable and in 50 patients with unstable angina pectoris, each patient showing an isolated stenosis of more than 80% of the cross-sectional area of a single coronary artery. The technical success rate was 66% in the stable groups (26 of 37 patients [70%] with left anterior descending artery [LAD], 7 of 12 patients [56%] with right coronary artery [RCA]) and 74% in the unstable group (27 of 34 patients [7g%] with LAD, 10 of 15 patients [67%] with (RCA). The increase in stenotic area in the unstable group exceeding that in the stable group for LAD stenoses (41.5 f 15.1% vs 32.3 f 14.5%, p < 0.03) while in RCA stenoses the results in the stable group were better (45.1 ? 17.6% vs 32.7 + 12.3%, n.s.). One acute vessel occlusion necessitating an emergency bypass operation occurred in each group (2%). The patient in the stable group died (total mortality rate 1%). Sixty-three of the successfully treated patients were routinely restudied 6 months later. According to clinical symptoms, 23% of the stable and 36% of the unstable group were in functional classes Ill and’lV. From the anatomical viewpoint, a restenosis (>85%) was found in 17% of the stable and in 24% of the unstable group. A further spontaneous decrease (>lO%) of the vessel obstruction was found in 47% of the stable group and in 12% of the unstable group. The results show that PTCA can be carried out with equally low risks and comparable good early and late results, both in patients with stable and with unstable angina. (AM HEART J 106:973, 1983.)

Jtirgen Meyer, M.D., Hermann-Josef Schmitz, M.D., Thomas Kiesslich, Raimund Erbel, M.D., Winfried Krebs, Dipl.-Ing., Wolfgang Schulz, M.D., Peter Bardos, M.D., Carmine Minale, M.D., Bruno Josef Messmer, M.D., and Sven Effert, M.D. Aachen, W. Germany Percutaneous transluminal coronary (PTCA) was initially used in patients From the Department of Internal Medical Faculty, Rheinisch-Westftilische Supported Received accepted Reprint University,

by the Deutsche for publication Aug. 5, 1982. requests: Professor Langenbeckstr.

Medicine

I and Cardiovascular Technische Hochschule.

Forschungsgemeinschaft, Dec.

21, 1981;

angioplasty with stable

revision

SFB received

J. Meyer, M.D., IInd Medical 1, D-65 Mainz, W. Germany.

Surgery,

109. July Clinic

19, 1982; of the

angina pectoris in whom isolated stenoses of the major coronary arteries had been demonstrated.’ Localized major subtotal stenoses are also found in about 30% of patients with unstable angina.2s3 Despite medical treatment with nitroglycerin, calcium antagonists, and /3 blockers, emergency coronary artery bypass graft operations have been felt necessary in some patients because of persisting symptoms and in the hope of avoiding an impending 973