CAN WE PROVIDE REPERFUSION THERAPY TO ALL UNSELECTED PATIENTS ADMITTED WITH ACUTE MYOCARDIAL-INFARCTION

Objectives. This study sought to assess the maximal rate of acute Thro mbolysis in Myocardial Infarction (TIMI) grade 3 patency that can be a chieved in unselected patients. Background. Early and complete (TIMI g rade 3 flow) reperfusion is an important therapeutic goal during acute myocardial infarction. However, thrombolysis, although widely used, i s often contraindicated or ineffective. The selective use of primary a nd rescue percutaneous transluminal coronary angioplasty (PTCA) may in crease the number of patients receiving reperfusion therapy. Methods. A cohort of 500 consecutive unselected patients with acute myocardial infarction were prospectively treated using a patency-oriented scheme: Thrombolysis-eligible patients received thrombolysis (n = 257) and un derwent 90-min angiography to detect persistent occlusion for treatmen t with rescue PTCA. Emergency PTCA (n = 193) was attempted in patients with contraindications to thrombolysis, cardiogenic shock or uncertai n diagnosis and in a subset of patients admitted under ''ideal conditi ons.'' A small group of patients (n = 38) underwent acute angiography without PTCA. Conventional medical therapy was used in 12 patients wit h contraindications to both thrombolysis and PTCA. Results. Ninety-eig ht percent of patients received reperfusion therapy (thrombolysis, PTC A or acute angiography), and angiographically proven early TIMI grade 3 patency was achieved in 78%. Among patients with TIMI grade 3 patenc y, thrombolysis alone was, the strategy used in 37%, emergency PTCA in 40% and rescue PTCA after failed thrombolysis in 15%; spontaneous pat ency occurred in 8%. Conclusions. Reperfusion therapy fan be provided to nearly every patient (98%) with acute myocardial infarction. Rescue and direct TCA provided effective early reperfusion to patients id wh om thrombolysis failed or was excluded. (C) 1997 by the American Colle ge of Cardiology.