CORONARY-ARTERY BYPASS-GRAFTING EARLY AFTER ACUTE MYOCARDIAL-INFARCTION IN PATIENTS INITIALLY TREATED WITH THROMBOLYTIC THERAPY OR CORONARYANGIOPLASTY

Background: Treatment of patients with acute myocardial infarction sho uld aim to restore blood flow in the infarct-related artery as soon as possible. Thrombolytic therapy has recently been compared with direct angioplasty; however, these interventions may not be sufficient, and coronary artery bypass grafting (CABG) may be necessary. Methods: In a series of 301 patients with acute myocardial infarction, randomly ass igned either to receive intravenous streptokinase (n = 149) or to unde rgo percutaneous transluminal coronary angioplasty (PTCA; n = 152), 31 patients (aged 61 +/- 10 years; 27 men, four women) underwent CABG wi thin 6 weeks of acute myocardial infarction. Results: Twelve patients (nine in the PTCA group and three in the streptokinase group) underwen t surgery within 48 h of the onset of symptoms. Bypass surgery was per formed in the streptokinase group on failure of thrombolytic therapy ( n = 2), recurrent ischemia (n = 4), or postinfarct angina (n = 9). in the PTCA group, CABG was performed for left main stenosis (n = 6), fai led PTCA (n = 3), recurrent ischemia (n = 2), or postinfarct angina (n = 5). An intra-aortic balloon pump (IABP) was required in 15 patients (five streptokinase and 10 PTCA). Major complications after CABG were more common among patients who underwent surgery within 48 h than tho se after 48 h (eight in 12 patients versus four in 19, respectively). After 17.0 +/- 8.6 months (range 3-33 months), two patients had died; one of end-stage heart failure after 3 months, and one of a stroke aft er 16 months (both were in the PTCA group and one had undergone surger y within 48 h). One patient suffered a reinfarction after 11 months an d one a non-fatal stroke after 1 month (both underwent CABG within 48 h). The left ventricular ejection fraction did not differ between the groups (43 +/- 15% for the 'early' group and 42 +/- 11% for the 'late' group). Conclusion: CABG can be performed safely and effectively afte r initial treatment with direct angioplasty or thrombolytic therapy af ter acute myocardial infarction. If it is performed within 48 h of ons et of symptoms, (in-hospital) morbidity is higher, without affecting m ortality or left ventricular function.