Benefit of coronary reperfusion before intervention on outcomes after primary angioplasty for acute myocardial infarction

Primary percutaneous transluminal coronary angioplasty has become the prefe rred reperfusion strategy for acute myocardial infarction in most instituti ons with interventional facilities and experienced operators. The benefit o f establishing coronary reperfusion, with or without pharmacologic therapy, before primary angioplasty has not been established. Consecutive patients (n = 1,490) with acute myocardial infarction treated with aspirin and hepar in followed by primary percutaneous transluminal coronary angioplasty were followed for 13 years. Follow-up angiography was obtained in 737 patients a t 7.7 months. Thrombolysis In Myocardial Infarction (TIMI) 2 to 3 flow in t he infarct artery at initial angiography was present in 18.3% of patients, and TIMI 0 to 1 flow in 81.7% of patients. Baseline variables were similar between the 2 groups, except patients with initial TIMI 2 to 3 flow had sig nificantly less cardiogenic shock (1.7% vs 9.4%, p < 0.0001) and a lower in cidence of depressed election fraction < 40% (12.6% vs 19.9%, p = 0.007). P rocedural success was better in patients with initial TIMI 2 to 3 flow (97. 4% vs 93.8%, p = 0.02), and catheterization laboratory events were less fre quent. Patients with initial TIMI 2 to 3 flow had lower peak creatine kinas e values (1,328 vs 2,790 IU/L, p < 0.0001), higher acute ejection fraction (54.3% vs 51.6%, p = 0.05), higher late election fraction (59.2% vs 54.9%, p = 0.004), and lower 30-day mortality (4.8% vs 8.9%, p = 0.02). These data indicate that when reperfusion occurs before primary angioplasty outcomes are strikingly better with less cardiogenic shock, improved procedural outc omes, smaller infarct size, better preservation of left ventricular functio n, and reduced mortality. This should encourage new strategies to establish reperfusion before "primary" angioplasty with "catheterization laboratory friendly" platelet inhibitors and/or low-dose thrombolytic drugs. (C) 2000 by Excerpta Medico, Inc.