Alec Vahanian

Thrombolytic therapy for patients with prior percutaneous transluminal coronary angioplasty and subsequent acute myocardial infarction

Our purpose was to evaluate the outcomes of patients with prior coronary angioplasty who underwent thrombolysis for new acute myocardial infarction (AMI) in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries-I trial. Baseline characteristics and clinical outcomes were compared between patients with (n = 1,647) and without (n = 39,150) previous angioplasty. The relations among prior angioplasty, clinical outcomes, and treatment effects were examined with logistic regression modeling. Patients with previous angioplasty tended to be younger and presented sooner after symptom onset, but had more multivessel disease and lower ejection fractions. Unadjusted mortality was significantly lower in the prior-angioplasty group at 24 hours (1.8% vs 2.7%, p = 0.03) and 30 days (5.6% vs 7.0%, p = 0.036). Although most of the survival advantage was due to low-risk characteristics in this group (lower age and heart rate and fewer anterior wall AMIs), prior angioplasty remained a weak but independent predictor of survival. Recurrent ischemia and reinfarction occurred more often in the prior-angioplasty group, as did bypass surgery (12.2% vs 8.5%) and repeat angioplasty (34.5% vs 21.4%). Patients with prior angioplasty and prior AMI had lower 30-day mortality than those with prior infarction alone (6.3% vs 12.6%, p < 0.01). Treatment effects on 30-day mortality were similar among patients with prior angioplasty (odds ratio 1.2 for accelerated tissue-plasminogen activator v. combined streptokinase arms, 95% confidence interval 0.73 to 1.9). Patients with prior angioplasty who present with AMI have fewer in-hospital adverse events and lower 30-day mortality than those without such a history.

Cost-Benefit of TAVR: Should Indications Be Expanded?

The current recommendations state that transcatheter aortic valve replacement (TAVR) is indicated in inoperable patients and should be considered in high-risk patients with severe aortic stenosis. Both sets of recommendations concur to state that TAVR should not be performed in patients at intermediate risk for surgery.

Percutaneous Edge-to-Edge Mitral Valve Repair for Functional Mitral Regurgitation in a High-Surgical-Risk Patient

This case describes the use of the MitraClip to treat severe functional MR in an acutely decompensated high-surgical-risk patient.

725-5 Improved Outcome in Patients with Prior Percutaneous Transluminal Coronary Angioplasty and an Evolving Myocardial Infarction

Despite the increasing prevalence of PTCA, the outcome of patients with prior PTCA who present with an MI and are treated with thrombolytic therapy is unknown. We compared the outcome of the 1647 patients in GUSTO who had undergone a prior PTCA with the 39,150 patients who had not undergone a prior PTCA. Patients with a prior PTCA had a higher incidence of previous MI (67 vs 14%) and CABG (19 vs 4%), lower ejection fraction (50 vs 52%), less anterior MI (34 vs 39%), and lower systolic bp (127.6 vs 129.1). In addition, their mean age was lower (60.4 vs 61.2 yrs), and time to treatment was shorter (2.9 vs 3.1 hrs). Outcomes were: Prior PTCA No Prior PTCA P-value 24 hr mortality (%) 1.8 2.7 0.03 30 day mortality (%) 56 7.0 0.04 CHF (%) 14.3 16.3 0.02 Re-infarction (%) 4.6 4.0 NS Ischemia (%) 24.0 19.8 l0.0001 CABG (%) 12.2 8.5 l0.00001 PTCA (%) 56.2 32.1 l0.00001 Conclusion Patients with prior PTCA had a lower 24-hr and 30-day mortality and less CHF compared with patients without prior PTCA. Although they experienced more recurrent ischemia, no increase in re-infarction was observed. The protective effect of prior PTCA may be due to reactive changes in the treated coronary segment and is associated with a more frequent revascularization.