A randomised trial of 367 patients with acute myocardial infarction was performed to determine whether an invasive strategy combining thrombolysis with recombinant tissue-type plasminogen activator (rTPA), heparin, and acetylsalicylic acid, and immediate percutaneous transluminal coronary angioplasty (PTCA) would be superior to a noninvasive strategy with the same medical treatment but without immediate angiography and PTCA. Intravenous infusion of 100 mg rTPA was started within 5 h after onset of symptoms (median 156 min). Angiography was performed 6-165 min later in 180 out of 183 patients allocated to the invasive strategy; 184 patients were allocated to the non-invasive strategy. Immediate PTCA reduced the percentage stenosis of the infarct-related segment, but this was offset by a high rate of transient (16%) and sustained (7%) reocclusion during the procedure and recurrent ischaemia during the first 24 h (17%). The clinical course was more favourable after non-invasive therapy, with a lower incidence of recurrent ischaemia within 24 h (3%), bleeding complications, hypotension, and ventricular fibrillation. Mortality at 14 days was lower in patients allocated to non-invasive treatment (3%) than in the group allocated to invasive treatment (7%). No difference between the treatment groups was observed in infarct size estimated from myocardial release of alpha-hydroxybutyrate dehydrogenase or in left ventricular ejection fraction after 10-22 days. Since immediate PTCA does not provide additional benefit there seems to be no need for immediate angiography and PTCA in patients with acute myocardial infarction treated with rTPA.

SUMMARY Percutaneous transluminal coronary angioplasty (PTCA) was performed in 21 patients with acute myocardial infarction (AMI) treated by intracoronary infusion of streptokinase within 8 hours after the onset of symptoms. Streptolysis therapy began a mean of 3.6 1.2 hours (±+ SD) after the onset of symptoms. The vessel was occluded in 14 patients and highly stenosed in seven. After the infusion of 67,300 + 63,200 IU of streptokinase over 26.1 21.5 minutes, patency of the occluded vessels was reached.PTCA as performed 20-60 minutes after the end of streptokinase treatment in 19 patients and 24 and 31 hours after treatment in two patients. The dilation was successful in 17 patients (81%). The degree of vessel obstruction was reduced from 90.2 + 7.3% to 58.6 19.5% (area method) and from 71.4 + 12.4% to 39.2 + 19.7% (diameter method). The improvement was 31.5 18.4% and 32.2 ± 19.3%, respectively. No reocclusion was induced by PTCA. Twenty patients were discharged. One died during hospitalization; at autopsy, the treated vessel was still patent. During the follow-up period, two reinfarctions and one asymptomatic reocclusion occurred.The clinical findings during the hospital course and the follow-up period were compared with those of a control group of 18 patients with AMI and comparable coronary stenoses who were treated only with streptokinase infusion. Four of these patients had a reinfarction during the hospital course, and three died during the follow-up period.PTCA can be performed safely and successfully immediately after intracoronary infusion of streptokinase in patients with AMI. By reducing the subtotal stenosis, this treatment contributes to the reperfusion of the ischemic myocardium, diminishes the risk of a reocclusion and seems to improve the prognosis.

Non-invasive documentation of restenosis after successful percutaneous transluminal coronary angioplasty (PTCA) remains a problem. Thus, transoesophageal pacing echocardiography (TPE) with simultaneous rapid atrial pacing via the same probe, a recently validated method for detection of coronary artery disease, was used in 60 patients for detection of restenosis after successful PTCA (54 patients with one and six patients with multivessel PTCA). The patients came for routine follow-up angiography 5.4 +/- 3.7 months after PTCA regardless of clinical status. Restenosis (diameter stenosis > or = 50%) was demonstrated in 22 patients. Disease progression in previously normal vessels was noted in three additional patients. Results for detection of restenosis and disease progression were compared to exercise ECG and in 40 patients to Tc-99m methoxy-isobutyl-isonitrile (MIBI)-radionuclide perfusion imaging. Diagnostic standard exercise ECG could be performed in only 38 patients, due to peripheral vascular disease, joint disease or premature exhaustion in the rest of patients. TPE was non-diagnostic in two patients due to ineffective pacing or patient discomfort. Sensitivity of TPE for detection of restenosis and disease progression after PTCA was 84% compared with 50% and 86% for exercise ECG and Tc-99m MIBI-SPECT (P < 0.03 and ns), respectively. Specificity of TPE (85%) was also higher than that of exercise ECG (59%, P < 0.03) and comparable to the specificity of MIBI-SPECT (84%). Overall accuracy of TPE was far superior to exercise ECG and similar to MIBI-SPECT (84% vs 54% and 85%) (P = 0.0007 and ns, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

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