EARLY ANGIOGRAPHY CANNOT PREDICT POSTTHROMBOLYTIC CORONARY REOCCLUSION - OBSERVATIONS FROM THE GUSTO ANGIOGRAPHIC STUDY

Objectives. The purpose of this study was to determine whether early q ualitative or quantitative angiographic features can predict reocclusi on after initially successful coronary thrombolysis. Background. Altho ugh both the benefits of early reperfusion and the consequences of sub sequent reocclusion after thrombol ysis for acute myocardial infarctio n have been well described, efforts to describe angiographic markers o f lesions at high risk for reocclusion have produced conflicting resul ts. The Global Utiliza tion of Streptokinase and t-PA for Occluded Cor onary Arteries (GUSTO) angiographic trial provides the opportunity to examine these relations in the largest single, prospective patient coh ort studied to date. Methods. We studied 559 patients undergoing follo w-up angiography at 90 min and 5 to 7 days after thrombolysis in the G USTO trial. Patients received one of four thrombolytic regimens: 1) st reptokinase with intravenous heparin; 2) streptokinase with subcutaneo us heparin; 3) accelerated-dose recombinant tissue-type plasminogen ac tivator (rt-PA) with intravenous heparin; or 4) a combination of strep tokinase and conventionally dosed rt-PA with intravenous heparin. Qual itative variables examined at 90-min angiography included Thrombolysis in Myocardial Infarction (TIMI) how grade, visible thrombus and lesio n morphology. Quantitative variables included percent diameter stenosi s, percent area stenosis, minimal lumen diameter and lesion length. Th e study contained a power >0.85 to detect clinically important differe nces in percent diameter stenosis, percent area stenosis and minimal l umen diameter between the groups with subsequent reocclusion and susta ined patency at the p = 0.05 level. Results. At follow up, 33 patients (5.9%) had reocclusion. The reocclusion rate for patients with early TIMI grade 2 flow was 6.3% versus 5.6% for TIMI grade 3 flow (p = NS). When the group ,vith reocclusion was compared with the group with con tinued patency, there were no differences in presence of early visible thrombus, complex lesion morphology, percent diameter stenosis, perce nt area stenosis, minimal lumen diameter or lesion length. Conclusions . Our findings demonstrate that neither qualitative nor quantitative a ngiographic variables at 90 min after initiation of thrombolytic thera py can be used to predict subsequent coronary reocclusion.