Nicholas A. Ruocco

Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy (results from the Thrombolysis in Myocardial Infarction [TIMI] II trial)☆

To determine the effect of thrombolytic therapy on the frequency of right ventricular (RV) dysfunction, and whether RV dysfunction is a risk factor for morbidity and mortality after discharge from the hospital, 1,110 patients in the Thrombolysis in Myocardial Infarction (TIMI) II trial with acute inferior wall left ventricular myocardial infarction were studied. RV dysfunction was defined as an RV wall motion abnormality on equilibrium radionuclide ventriculography performed a mean of 9 days after admission to the hospital. Fifty-eight patients (5%) had RV dysfunction. Baseline clinical characteristics among patients with and without RV dysfunction were similar. However, patients with RV dysfunction had a lower mean left ventricular ejection fraction (51.2 +/- 1.2% vs 55.5 +/- 0.3%; p < 0.001) and a greater frequency of in-hospital complications. Angiographic data from patients undergoing protocol catheterization 18 to 48 hours after hospital admission show that the infarct-related artery was more likely to be occluded in those with RV dysfunction (48% [15 of 31] vs 14% [68 of 495]; p < 0.001). There was no difference in the frequency of multivessel disease between the 2 groups. In patients with RV dysfunction in whom radionuclide ventriculography was repeated 6 weeks after hospital discharge, RV wall motion abnormalities persisted in only 18% (8 of 45). Mortality in the year after discharge was 3.5% (2 of 58) among patients with RV dysfunction compared with 1.7% (18 of 1,052; p = NS) among those without RV dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

The degree of revascularization and outcome after multivessel coronary angioplasty

Incomplete revascularization is a common occurrence following angioplasty (PTCA) in patients with multivessel disease. To determine the short-term and long-term consequences of incomplete revascularization and the influence of the functional nature of the incomplete revascularization, 139 consecutive patients with multivessel disease were analyzed: 72 were completely revascularized and 67 had incomplete revascularization. The former patients had a lower incidence of prior myocardial infarction (MI) and prior bypass surgery (CABG). All patients had at least one lesion successfully dilated. In-hospital complications were insignificantly greater in incompletely revascularized patients compared with completely vascularized patients (mortality 3% versus 1%, MI 11% versus 4%, and emergency surgery 5% versus 0%). After 1 year of follow-up, incompletely revascularized patients had similar outcomes (mortality 6% versus 3%, MI 13% versus 7%, CABG 18% versus 15%, and repeat PTCA 19% versus 31%). The degree of incomplete revascularization was categorized as functionally adequate if all stenoses in bypassable vessels supporting viable myocardium were successfully dilated. Significantly fewer adverse events (death, MI, or CABG) occurred in the functionally adequate group than in the functionally inadequate group (27% versus 6%, p less than 0.04). This study demonstrates that incompletely revascularized patients have a favorable 1-year outcome and that patients with incomplete but functionally adequate revascularization have long-term results comparable with those of patients with complete revascularization. This study emphasizes the need to assess the functional significance of a stenosis when considering incomplete revascularization in a patient with multivessel disease.

Results of coronary angioplasty of chronic total occlusions (the National Heart, Lung, and Blood Institute 1985–1986 Percutaneous Transluminal Angioplasty Registry)☆

There has been increasing application of coronary angioplasty to patients with chronic total occlusions. The acute and long-term outcome in 271 patients after coronary angioplasty (142 single and 129 multiple stenoses) of a total occlusion was compared with 1,429 patients undergoing angioplasty of subtotal (less than or equal to 99% stenosis) occlusions (885 single and 544 multilesion) participating in the 1985-1986 National Heart, Lung, and Blood Institute Percutaneous Transluminal Coronary Angioplasty Registry. Baseline characteristics were similar for each lesion group except for a higher incidence of prior myocardial infarction and left ventricular dysfunction (ejection fraction less than 50%) in patients with total occlusion. Major complications (death, myocardial infarction or emergency bypass surgery) were similar (p = not significant) between patients with total and subtotal occlusions for single (6 vs 7%) and multilesion angioplasty (9 vs 6%). At 2 years, after making adjustments for baseline variables, patients with a total occlusion had a significantly increased risk of death compared with those with subtotal occlusion. There were no significant differences in cumulative event rates for myocardial infarction or bypass surgery. Approximately three-fourths of patients in each group were free of angina at 2 years. In conclusion, angioplasty of chronic total occlusions is associated with a similar acute complication rate. Despite similar relief of anginal symptoms, patients in the total occlusion group have a higher 2-year mortality.

Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant tissue-type plasminogen activator: Results from the thrombolysis in myocardial infarction (TIMI) phaes II trial

Objectives. The purpese of this study was to determine the incidence of ventriculer tachycardia and fibrillation without hypotension or heart failure after treatment with recombinant tissue-type plasminogen activator (rt-PA), anatomic correlates of their development, the effect of immediate intravenous metoprolol on their occurrence and the outcome of patients with these arrhythmias. Background. Malignant arrhythmias after thrombolytic therapy have been reported to occur as a result of coronary reperfusion which is associated with reduced mortality in patients receiving thrombolytic therapy. Methods. We analysed data from 2,546 patients in the Thrombolysis in Myocardial Infarction (TIMI) Phase II trial without congestive heart failure or hypotension during the 1st 24 h after study entry. Forty-nine patients (1.9%) developed sustained ventricular tachycardia or ventricular fibrillation within 24 h of study entry (group 1), and 2,497 patients (98.1%) did not (group 2). Results. Baseline characteristics and admission laboraratory values were similar in the two groups. In patients undergoing protocol angiography 18 to 48 h after rt-PA, the infarct-related artery was patent in a greater percent of group 2 patients (87% [1,015 of 1,169]) than group 1 patients (68% [15 of 22], P = 0.01), although angiography was performed less frequently in group 1 than in group 2. More group 1 than group 2 patients died within 21 days (20.4%) (1.6%, p < 0.001). For patients surviving to 21 days, there was no difference in mortality between patients in the two groups in the following year. Conclusions. Ventricular tachycardia and fibrillation are not markers for reperfusion after thrombolytic therapy. These arrhythmias are associated with occlusion, not patency, of the infarct-related artery. Early mortality is increased in patients who develop ventricular tachycardia and fibrillation, even in the absence of congestive heart failure and hypotension.

Outcome after major dissection during coronary angioplasty using the perfusion balloon catheter

Coronary artery dissection is an infrequent but serious complication of coronary angioplasty that can lead to periprocedural vessel occlusion, emergency bypass surgery, myocardial infarction or death. Recently, a perfusion balloon catheter was developed that permits passive perfusion of blood through the central lumen of the catheter. It enables prolonged balloon inflations to be performed and has been used to provide distal blood flow after coronary occlusion. To evaluate the effectiveness of the perfusion balloon catheter in patients with major coronary dissections, 36 consecutive patients treated with the perfusion balloon catheter were compared with 46 consecutive patients treated before its availability. The 2 groups were similar in terms of clinical, angiographic and initial procedural characteristics. Use of the perfusion balloon catheter permitted a significantly longer inflation than standard balloon inflation (average 18 +/- 5 min). Angiographic success was significantly greater with the perfusion balloon catheter (84 vs 62% for conventional therapy), whereas complications were markedly reduced (48 vs 78%). With the perfusion balloon catheter there were fewer deaths (2 vs 6%), myocardial infarctions (14 vs 40%) and emergency bypass operations (11 vs 25%). The findings of this retrospective comparison demonstrate that the perfusion balloon catheter is effective for the management of major dissections after coronary angioplasty. The use of the perfusion balloon catheter should be considered when a major coronary dissection occurs and when emergency bypass surgery is contemplated.

Prediction of risk for hemodynamic compromise during percutaneous transluminal coronary angioplasty

The availability of circulatory support devices has increased the importance of accurately identifying patients at risk for hemodynamic compromise during percutaneous transluminal coronary angioplasty (PTCA). Accordingly, prospective evaluation of 3 criteria to predict hemodynamic compromise (defined as a decrease in systolic blood pressure > or = 20 to < 90 mm Hg during balloon inflation) in 157 patients (group A) undergoing PTCA was performed. Left ventricular ejection fraction < 35% had a sensitivity of 13% and a specificity of 95%. Greater than 50% of the myocardium at risk was associated with a sensitivity of 31% and a specificity of 85%. The angiographers assessment of high risk for hemodynamic compromise had the highest sensitivity of 56% and a specificity of 86%. The clinical and angiographic characteristics of these patients were reviewed to identify risk factors retrospectively. Multivariate analysis of 28 variables identified multivessel disease, diffuse disease, myocardium at risk, and stenosis before PTCA as independent predictors of hemodynamic compromise. With use of this analysis, a 13-point weighted scoring system was created based on the regression of coefficients of the variables. Defining high risk for hemodynamic compromise as a risk score > or = 4, the sensitivity of this criterion in group A patients was 81% and the specificity was 74%. The scoring system was then prospectively applied to 61 consecutive patients (group B) undergoing PTCA. In using a risk score > or = 4 to define high risk, this scoring system had a sensitivity of 92% and a specificity of 92%.(ABSTRACT TRUNCATED AT 250 WORDS)

Invasive versus conservative strategy after thrombolytic therapy for acute myocardial infarction in patients with antecedent angina a report from thrombolysis in myocardial infarction phase II (TIMI II)

OBJECTIVES This study was designed to assess the possibility that a subgroup of patients at high risk for recurrent ischemia and reinfarction after thrombolytic therapy might benefit from early intervention. BACKGROUND The Thrombolysis in Myocardial Infarction Phase II (TIMI II) study recently concluded that an obligatory invasive strategy after thrombolytic therapy offered no advantage over a more conservative strategy. METHODS Data from the 3,534 patients enrolled in the TIMI II trial were analyzed to determine whether a history of antecedent angina before myocardial infarction identifies patients at high risk for subsequent ischemia and whether these patients might benefit from an invasive strategy. RESULTS Within the TIMI II population, antecedent angina identified patients at increased risk for recurrent chest pain in the hospital (32.3% vs. 22.1%, p < 0.001) and recurrent infarction during the 1st year of follow-up (11.2% vs. 7.9%, p = 0.001) compared with that of patients without antecedent angina. Among patients assigned to the invasive strategy, coronary arteriography revealed that those with antecedent angina had a more severe residual stenosis of the infarct-related artery after thrombolytic therapy (77.1 +/- 0.7% vs. 73.0 +/- 0.9%, p < 0.001) and more multivessel disease (37.9% vs. 26.4%, p < 0.001). The clinical outcome of the patients with antecedent angina assigned randomly to either the invasive or the conservative strategy were compared. The invasive strategy patients had a slightly lesser incidence of recurrent chest pain in the hospital (29.9% vs. 34.8%, p = 0.13) and more negative (normal) findings on exercise tolerance tests (24.7 vs. 18.9%, p = 0.003), but there was no difference between the treatment strategies in the end point variable of recurrent myocardial infarction or death. CONCLUSIONS These data demonstrate that antecedent angina identifies patients at increased risk for recurrent ischemic events after thrombolytic therapy. However, similar to the results for the overall population, the invasive strategy does not alter the risk of reinfarction or death compared with the conservative approach.

Factors predicting recurrent restenosis after percutaneous transluminal coronary balloon angioplasty

To identify factors that predict a second restenosis after repeat percutaneous transluminal coronary balloon angioplasty (PTCA), the records of 196 consecutive patients undergoing redilation for treatment of a first restenosis were reviewed. Repeat PTCA was successful in 181 (92%) of these patients. After a successful second PTCA, 47 patients (26%) developed a second restenosis (recurrent restenosis group, group 1) and 134 (single restenosis group, group 2) did not. The 2 patient groups were compared with respect to clinical, angiographic and procedural factors at second PTCA. Univariate correlates of a second restenosis were younger age (54 +/- 10 vs 57 +/- 9 years, p less than 0.05), interval less than 60 days between initial PTCA and recurrence of anginal symptoms (55% of patients in group 1 vs 25% in group 2, p = 0.001), a greater number of inflations (6.3 +/- 4.2 vs 4.4 +/- 2.5, p less than 0.005) and a shorter maximal balloon inflation time (49 +/- 26 vs 69 +/- 36 seconds, p = 0.0006). With multivariate analysis, the 2 factors that emerged as independent predictors of recurrent restenosis were recurrence of symptoms less than 60 days after initial PTCA (p less than 0.004) and a greater number of inflations (p less than 0.04). These data suggest that younger age and rapid recurrence of anginal symptoms after first PTCA predict an increased likelihood that a second restenosis will occur after repeat PTCA and that certain procedural factors, in particular the greater number of balloon inflations and a shorter maximal balloon inflation time, may play an important role in the development of recurrent restenosis.

Outcome in patients with recurrent restenosis after percutaneous transluminal balloon angioplasty.

The records of 1162 consecutive patients undergoing their first percutaneous transluminal coronary angioplasty at a centre between March 1980 and June 1987 were reviewed. Initial angioplasty was successful in 1011 patients (87%). In 202 (20%) symptomatic restenosis developed. Of these, 196 were treated with redilatation; this was successful in 181 (92%). After a second dilatation, restenosis developed in 47 patients (26%). Of these, 41 (87%) were treated with a third angioplasty, with primary success in 38 (93%). A further restenosis developed in 13 of these 38 patients (34%). Eight patients were treated with a fourth angioplasty with restenosis in four (50%). Two of these four patients underwent a fifth angioplasty (with continuing success at long term follow up in both). Overall, 14 of the 47 (30%) patients who developed restenosis twice were eventually treated with coronary bypass surgery. Most patients (33), however, were treated only with repeated angioplasties. Of these 33 patients, 27 were treated with a third angioplasty, four with a fourth procedure, and two with a fifth. Twenty-nine (88%) were symptom free at a mean follow up of 28 (range 8 to 86) months. The combined success rate for a third, fourth, and fifth angioplasty was 94%. These data suggest that most patients with recurrent restenosis after angioplasty may be managed successfully and safely with repeated redilatations.

Comparison of patients with <60% to ≥60% diameter narrowing of the myocardial infarct-related artery after thrombolysis☆

The purpose of this study was to analyze angiographic findings, clinical course, and follow-up data on 1,752 patients who underwent protocol cardiac catheterization 18 to 48 hours after enrollment in the Thrombolysis in Myocardial Infarction (TIMI) II pilot and randomized trial: 244 patients (14.0%) had or = 60% in diameter with TIMI grade 2 or 3 flow, and 259 patients (15%) had TIMI grade 0 or 1 flow (total occlusion). Patients with 55% (p or = 60% and TIMI grade 2 or 3 flow (p = 0.05) and 7.0% for patients with total occlusion (p = 0.004). Patients with stenosis < 60% in the infarct-related artery 18 to 48 hours after thrombolytic therapy have a good prognosis. Infarct artery status predicts predischarge ejection fraction and 1-year mortality.