IMPLICATIONS OF RECURRENT ISCHEMIA AFTER REPERFUSION THERAPY IN ACUTEMYOCARDIAL-INFARCTION - A COMPARISON OF THROMBOLYTIC THERAPY AND PRIMARY ANGIOPLASTY

Objectives. The purpose of this study was to examine the incidence and implications of recurrent ischemia after different reperfusion strate gies in acute myocardial infarction. Background. The rates and effects of recurrent ischemia after reperfusion with thrombolytic therapy and with primary percutaneous transluminal coronary angioplasty have not been compared. Methods. At 12 centers 395 patients presenting within 1 2 h of the onset of acute myocardial infarction were prospectively ran domized to receive recombinant tissue-type plasminogen activator (rt P A) or primary coronary angioplasty. Sixteen clinical variables were ex amined by using univariate and multiple logistic regression analysis t o identify the predictors of recurrent ischemia. The relation of recur rent ischemic events to patient outcome was analyzed. Results. Recurre nt ischemia developed in 76 patients (19.2%) before hospital discharge , resulting in reinfarction in 18 patients (4.6%) and death in 5 (2.6% ). Recurrent ischemia occurred in 56 patients (28.0%) after rt-PA but in only 20 patients (10.3%) after coronary angioplasty (p < 0.0001), d irectly contributing to a higher rate of death or reinfarction (7.5% v s. 3.1%, p = 0.05), catheterization and revascularization procedures a nd prolonged hospital stay after thrombolysis. By multivariate analysi s, treatment with coronary angioplasty rather than rt-PA ms the strong est predictor of freedom from recurrent ischemia. Although the inciden ce of recurrent ischemia after angioplasty and after rt-PA ms similar within the 1st 2 days of admission (9.2% vs. 14.5%, p = 0.11), after h ospital day 2 recurrent ischemia occurred in only 2 patients who recei ved primary angioplasty compared with 27 patients who received rt-PA ( 1.1% vs. 13.5%, p < 0.0001). Conclusions. The development of recurrent ischemia adversely affects patient outcome, increasing morbidity, mor tality and resource utilization. The much lower rate of recurrent isch emia after primary coronary angioplasty than after rt PA results in im proved survival without reinfarction and allows a shorter, less compli cated hospital stay. Given the extremely low rate of recur rent ischem ia after hospital day 2, safe early discharge on day 3 after primary c oronary angioplasty should be feasible in selected patients with acute myocardial infarction.