INDICATIONS OF CORONARY ANGIOPLASTY AFTER THROMBOLYSIS

Thrombolysis is the most widely used method of coronary reperfusion in the acute phase of myocardial infarction. The indications of angiopla sty after thrombolysis have been subject of considerable controversy o ver the last few years. Three randomised trials (TIMI 2, TAMI, ECSG) h ave shown that it is not desirable to perform systematic immediate ang ioplasty after intravenous thrombolysis with rt-PA. Angioplasty may be carried out as a ''salvage'' procedure in cases of failure of thrombo lysis. The validity of this approach was confirmed recently by the ''R ESCUE'' trial in anterior myocardial infarction. The practical applica tion of its results is confronted by logistical problems inherent to t he practice of angioplasty in the acute phase of myocardial infarction and to the inadequacy of non-invasive methods for the detection of co ronary reperfusion after thrombolysis. Angioplasty may also be necessa ry in cases of left ventricular failure or cardiogenic shock. The effi cacy of a rapid angioplasty in cases of recurrence of ischaemia after thrombolysis has been proved in reducing mortality and preserving left ventricular function. The results of TIMI IIB and SWIFT trials show t hat secondary angioplasty, several days after thrombolysis, is only us ually indicated in patients with residual clinical ischaemia or positi ve stress tests. This attitude should however be modulated in the ligh t of the ''open artery'' theory and the limitations of methods of eval uating myocardial viability. The present strategies will no doubt be m odified with the introduction of new thrombolytic and/or antithromboti c agents and the use of coronary stents.