Is the duration of dual antiplatelet therapy (DAPT) excessive in post-angioplasty in chronic coronary syndrome? Data from the France-PCI registry (2014-2019).

Background: while the duration of dual antiplatelet therapy (DAPT) following coronary angioplasty for chronic coronary syndrome (CCS) recommended by the European Society of Cardiology has decreased over the last decade, little is known about the adherence to those guidelines in clinical practice in France. Aim: To analyze the real duration of DAPT post coronary angioplasty in CCS, as well as the factors affecting this duration. Methods: Between 2014 and 2019, 8.836 percutaneous coronary interventions for CCS from the France-PCI registry were evaluated, with 1 year follow up, after exclusion of patients receiving oral anticoagulants, procedures performed within one year of an acute coronary syndrome, and repeat angioplasty. Results: Post-percutaneous coronary intervention (PCI) DAPT duration was > 12 months for 53.1% of patients treated for CCS; 30.5% had a DAPT between 7 and 12 months, and 16.4% a DAPT ≤ 6 months. Patients with L-DAPT (>12 months) were at higher ischemic risk [25.0% of DAPT score ≥2 vs. 18.8% DAPT score ≥2 in S&I-DAPT group (≤12 months)]. The most commonly used P2Y12 inhibitor was clopidogrel (82.2%). The prescription of ticagrelor increased over the period. Conclusions: post-PCI DAPT duration in CCS was higher than international recommendations in the France PCI registry between 2014 and 2019. More than half of the angioplasty performed for CCS are followed by a DAPT > 12 months. Ischemic risk assessment influences the duration of DAPT. This risk is probably overestimated nowadays, leading to a prolongation of DAPT beyond the recommended durations, thus increasing the bleeding risk.

[stent thrombosis : A won battle ? (data from the France PCI registry)]. / Thrombose de stent : une bataille gagnée ? (Données du registre France PCI).

GOAL: The aim of the study is to assess the incidence, risk factors and prognosis of definite stent thrombosis (ST) at 1 year in the France PCI multicenter prospective registry. PATIENTS AND METHODS: Only patients who underwent coronary angioplasty with at least one stent implantation between 1st January 2014 and 31 December 2019 were included. The population was separated into 2 groups: the "ST" group with stent thrombosis and the "control" group without stent thrombosis. RESULTS: 35,435 patients were included. 256 patients (0.72%) presented a ST at 1 year. The rate of ST decreased significantly in acute coronary syndrome (1.5% in 2014 vs. 0.73% in 2019; p = 0.05) but not in chronic coronary syndrome (0.46% in 2014 vs 0.40%; p = 0.98). The risk factors are young age (65.8 years vs 68.2; p = 0.002), clinical context (35.27% vs 16.68%; p = 0.0001), diabetes (35.2 % vs 26.4%; p = 0.002), renal failure (11.7% vs 8%; p = 0.009) and history of coronary angioplasty (28.63% vs 21.86%; p = 0.009) and peripheral arterial disease (14.5% vs 10.1%; p = 0.021), LV dysfunction (37% vs 27.5%; p = 0.003), mean length (39.6 mm vs 31, 7mm; p <0.0001) and the mean number of stents per procedure (1.9 vs 1.6; p <0.0001), a TIMI flow ≤1 pre procedure (21.5% vs 12.4%; p <0.0001) and an intrastent restenosis (11% vs 6%; p <0.0001). The 1-year mortality of the ST group was significantly higher than that of the control group (19.14% vs 5.82%; p <0.0001). CONCLUSION: Since 2014, the incidence of ST at 1 year has been decreasing but remains stuck at a floor level of 0.54% in 2019. The battle for ST seems to have been partly won and its risk factors well identified, but its mortality is still high.

[Radial artery occlusion ofter coronarography: is it really a problem?] / L'occlusion de l'artère radiale après cathétérisme cardiaque : est-ce réellement un problème ?

The use of transradial access for cardiac procedures has increased worldwide over the past two decades. Despite the many advantages this technique offers, there remains some concern that radial artery occlusion, a potential complication of radial cannulation, might lead to significant ischemic sequelae in the hand. This paper reviews the major causes, its possible consequences and the strategies for its prevention and treatment. It appears however from multiple studies that there is little or no correlation between radial occlusion and symptomatic hand ischemia.

[Surgical treatment of infective endocarditis: Surgical indications, complications, intrahospital and long-term mortality]. / Endocardites infectieuses opérées : indications chirurgicales, complications, mortalité intrahospitalière et à long terme.

BACKGROUND: In addition to medical treatment, half of the patients with infective endocarditis (IE) receive surgical treatment. Despite clear recommendations on the indications and the operating delays, the decision remains difficult and must take into consideration several factors. METHODS: A retrospective study was performed at Foch Hospital. All patients operated for IE between 2005 and 2018 were included. Patient characteristics, indications and operating delays, as well as intrahospital mortality, were noted. Patient follow-up was provided by phone calls. RESULTS: Fifty-two patients were operated on for IE between 2005 and 2018. The most frequent surgical indications were the presence of a massive symptomatic regurgitation, an uncontrolled infection and large vegetations with embolism. The average operative delay was 13.2 days with 56.5% of patients operated within the first 10 days. The most common postoperative complications were acute kidney injury (AKI) in 57.7% of cases, with 9.6% of dialysis, shock in 50% of cases, rhythm disorders in 40.4% of cases, infectious complications in 19.2% of cases, conductive disorders in 25% of cases, of which 17.3% require a definitive pacemaker implementation. The intrahospital mortality was 7.7% and the average length of hospital stay was 35 days. Survival at one year and 5 years was 95% and 85%, respectively. CONCLUSION: The indications and the operating delays were conformed to international recommendations. Intrahospital and long-term mortality rate was low.

[Infective prosthetic endocarditis following percutaneous edge-to-edge mitral valve repair - A Case-report of a successfully medically-treated Staphylococcus epidermidis endocarditis and a literature review]. / Endocardite infectieuse sur prothèse après implantation de Mitra-Clip ­ Cas d'un succès du traitement médical sur une endocardite à Staphylococcus epidermidis et revue de littérature.

During the last decade there has been a craze for the percutaneous edge-to-edge mitral valve repair technique with the Mitra-Clip device. This is an alternative treatment to mitral valve surgery for severe mitral regurgitation. In France, this device is aimed at poor candidates for mitral valve surgery. It involves intra-cardiac prosthetic material, which exposes them to the risk of bacterial endocarditis. The consequences of this infective disease can be dramatic, especially for these old patients who suffer from multiple comorbidities. It appears to be a rare but relatively unknown and potentially underestimated complication. The relative data remain scarce and consist of rare case-reports. We report an original case of a Methicilline-sensitive Staphylococcus epidermidis mitral endocarditis following the implantation of clips two months earlier. The patient was then successfully treated with antibiotics. Since the first Mitra-Clip implantation in 2003, only 19 cases of endocarditis have previously been reported. This article proposes a review of theses case-reports and a collection of their relevant clinical, echocardiographic and microbiological characteristics, the delivered therapies and their outcomes. These data contribute to a humble discussion around the main stakes of the disease, which are the prevention, the diagnosis, the involved bacteria's type, the prognosis and the treatments with a focus on the question of the recourse to surgical management.

Scientific publication productivity of Libyan medical schools: a bibliometric study of papers listed in PubMed, 1988-2007.

BACKGROUND: Scientific publication is a vital mission of medical schools and it is important to periodically document how well schools fulfil this mission. AIMS: This study aimed to analyse the publication record of Libyan medical schools in international journals indexed in PubMed between 1988 and 2007. METHODS: Medline was searched using PubMed for publications affiliated to Libya during 1988-2007. RESULTS: Out of 417 papers related to Libya, 348 (84%) are affiliated to the medical schools and related hospitals. More than 60% of the 348 papers are affiliated to Al-Arab Medical University, Benghazi, while Al-Fateh Medical University, Tripoli, contributed 103 papers (30%). The rest of the papers (n=25, 7%) were published by medical schools in other parts of the country. The publication rate declined by 3% annually between 1988 and 2007. The decline was mainly due to a decrease in the publication rate by Al-Arab Medical University, Benghazi. Overall, nine departments produced 10 or more papers each. Out of about 1675 staff members, there are only 148 first authors and 207 last authors. The estimated annual publication rate is 0.7 papers per 100 academic staff members. CONCLUSION: This study reveals that published scholarship of the Libyan medical schools is extremely low, that the publication rate has declined, and that most academic staff have no publications listed in PubMed. This issue needs urgent attention.

[Vasospastic angina: An under-diagnosed pathology]. / L'angor spastique : une pathologie sous-diagnostiquée.

The clinical and physiopathological clinical entity known as spastic angina or variant angina has been long documented. It remains, however, an under-estimated condition, which is insufficiently diagnosed and explored. This pathology is associated with severe complications such as heart rhythm disorders, which may potentially result in ventricular fibrillation and cause sudden death. In Japan, this condition occurs more frequently and is better documented. Stimulation tests are also carried out more often and have a higher positivity rate than in France where vasospastic angina is less frequently reported and where provocation tests are associated with negative results and are, consequently, performed less often. In order to improve the detection of this pathology, its potential presence should be explored in patients with rest angina who experience chest pain in the second half of the night and also in instances of acute coronary syndrome with sudden death and no angiographically visible coronary artery disease. The diagnosis should be confirmed by means of ergonovine provocation tests. In order to enhance the sensitivity of these tests without increasing the risk of complications, injection of ergonovine should be preferably carried out via the intracoronary route. By increasing the frequency and sensitivity of these tests, this pathology, which responds well to medical treatment in many cases, could be amenable to therapeutic management as any other form of coronary artery disease.

[TAVI in women, very encouraging results]. / TAVI chez les femmes, des résultats très encourageants.

The population of elderly patients comprises a high percentage of women. This population is more vulnerable due to the presence of numerous comorbidities and is, therefore, particularly exposed to the risk of aortic valve degeneration, resulting in aortic valve stenosis whose symptoms are predictors of poor short-term outcomes. In the presence of symptomatic aortic stenosis, the recommended therapeutic option in this vulnerable population is the implementation of transcatheter aortic valve implantation, preferably via the femoral route. The outcomes of this procedure are better in women than in men despite a more frequent occurrence of vascular, bleeding and cerebral complications. Several hypotheses have been reported in the literature regarding the reasons for such differences. Among other reasons, it is likely that in female patients, the myocardium adjusts better to the occurrence of aortic stenosis and that recovery after valve treatment is also more optimal. Another explanation is the higher frequency of coronary artery disease in this older population. This has a considerable impact on the outcome even when coronary lesions are treated prior to valve implantation. There is still room for improvement and progress can be achieved by further reducing the size of the equipment used in order to decrease the diameter of the vascular access, and by continuing to simplify TAVI procedures. Less invasive techniques should result in decreased complication rates. In addition, dedicated studies should allow us to further improve our practice in this growing population of vulnerable patients.

Position paper of French Interventional Group (GACI) for TAVI in France in 2018.

Aortic stenosis is a frequent disease in the elderly. Its prevalence is 0.4% with a sharp increase after the age of 65, and its outcome is very poor when the patient becomes symptomatic. The interventional procedure known as TAVI (trans-catheter aortic valve implantation), which was developed in France and carried out for the first time in Rouen by Prof. Alain Cribier and his team in 2002, has proven to be a valid alternative to surgical aortic valve replacement. At first, this technique was shown to be efficient in patients with contra-indications to surgical treatment or deemed to be at high surgical risk. Given the very promising outcomes achieved as a result of close heart team collaboration, appropriate patient selection, simplified procedures and reduced complication rates, transfemoral (TF) TAVI is now preferred in symptomatic intermediate risk patients>75 years old according to the latest ESC guidelines. In 2017, in France, TAVI is currently performed in 50 centers with on-site cardiac surgery. The 2016 TAVI outcomes recorded in the French national TAVI registry (France TAVI) are very encouraging and show that for 7133 patients treated (age 83.4±7 years, logistic Euroscore 14%), 87% of whom via the TF approach, cross-over to surgery was very low (0.5%) with a 3.0% in-hospital mortality rate. The substantial increase in TAVI indications and the improvement of its outcomes may in the near future call for a reconsideration of the number of high volume centers authorized to carry out this technique.

[Treatment of intrastent restenosis by drug eluting stents: experience from one cardiology centre]. / Traitement des resténoses intrastent par un stent actif: experience monocentrique.

Many interventional treatments have been proposed for intrastent stenosis, in particular by drug-eluting stents, with encouraging results. The aim of this study was to assess the clinical outcome of patients with restenosis of an ordinary uncovered stent treated by a drug eluting stent in a prospective series. The register included 43 patients (50 intrastent restenoses) treated by a drug eluting stent (Cypher or Taxus). The restenosis lesion was focal in 32% of cases with an average length of 14.8 +/- 8 mm and diameter inferior to 2.5 mm in 48% of cases. A Cypher stent was implanted in 44% of cases and a Taxus stent in 56% of cases. After an average follow-up of 6.7 +/- 1.3 months, the major adverse cardiac event rate was 9.3%. It included one transmural infarct in a patient, due to stent thrombosis, and symptomatic restenoses in 3 patients (clinical restenosis rate: 7%). An angiographic control was performed in 15 patients (35%) identifying focal restenosis at the exit of the stent in the 3 symptomatic patients. As in previously reported studies, these results show that with well conducted platelet antiaggregant therapy, the treatment of intrastent restenosis with a drug eluting stent is effective with a low rate of adverse cardiovascular events which compares favourably with previously proposed techniques of management.

[Saphenous graft angioplasty]. / Angioplastie des pontages veineux.

In our daily practice the rate of saphenous graft angioplasty is less than 5%. This kind of angioplasty is more complex with a higher rate of complications in known fragile patients. Some technical trips and tricks are necessary to easily perform these angioplasties. Main difficulties are the extension of saphenous graft lesions, the risk of distal embolism, coronary slow or no flow and the high rate of restenosis. Pharmacological treatment is disappointing with no efficacy of the Gp IIb-IIa blockers. Otherwhise the use of protection devices is clearly effective and must be used when it is technically possible. With the use of bare metal stents in saphenous graft angioplasty the rate of restenosis is very high. There are some encouraging results with drug eluting stents. But we are still now not allowed to use them in this indication in our daily practice.

[Coronary artery disease and coronary angioplasty in chronic hemodialysis patients]. / Coronaropathie et angioplastie coronaire dans l'insuffisance rénale dialysée.

Chronic renal insufficiency leads to many cardiovascular complications and provide worst prognosis, especially when patients need hemodialysis. The atherosclerosis of chronic hemodialysis patients is qualified as "accelerated" by some authors, because of a very fast and large progression. To improve prognosis, it seems to be very important to detect and treat the frequent and serious underlying cardiovascular disease. Because of the high rate of diabetes mellitus, silent ischemia is a very frequent clinical situation. In the other hand, coronary artery disease in chronic hemodialysis patients is frequently complex, with a large coronary extension and high rate of coronary calcifications. Consequently, this disease needs a specific therapeutic approach. Even though, percutaneous coronary interventions (PCI) are more complex in this population, it provides good results, and improves patient's prognosis. However, the rate of complications of the vascular approach and the rate of restenosis is high. New devices, such as Drug Eluting Stents (DES) can critically decrease restenosis rate, and closure devices for trans-femoral approach, provides very encouraging results in this high risk population. Despite, good results of PCI with DES use, the mortality is still high in this population. To improve our efficiency, we have to progress in our therapeutic strategies and optimize medical approach to treat the important biological perturbations.

[Coronary ectasias and thrombosis]. / Ectasies coronaires et thrombus.

Ectasias and coronary aneurysms are uncommon coronary artery diseases, can coexist and are poorly known. Their principal etiology in adults is coronary atherosclerosis. It has been suggested that these abnormalities would have poor prognosis and that slow flow could lead to in situ thrombosis and distal embolisation. However, ectasias and aneurysms are most often associated with coronary stenosis. We report a series of 47 cases of ectasias and coronary aneurysms with evaluation of the clinical and angiographic characteristics, the therapeutic choices and we review the literature concerning these lesions. In situ thrombosis does not seem to be the usual pathophysiological mechanism. We retain that this is a particular form of coronary atherosclerosis in this population and present technical problems in case of revascularization with an predominant indication of medical treatment (57.4 % of the cases), but rarely the introduction of anticoagulants (4.25 % of the cases), except in acute coronary syndromes where revascularization is most common (70.6 % of cases) as is usually expected in the general population. The complex angiographic presentation of these lesions is probably an explanation for the low numbers of revascularizations performed.

[Ischemic stroke related to spontaneous]. / Accident vasculaire cérébral ischémique en rapport avec hématome coronaire spontané.

Cardiovascular disease in women is a particularly complex pathology especially in the youngest population. The clinical presentation of acute coronary syndromes is sometimes misleading and does not necessarily point to the potential presence of cardiac disease given the frequent absence of cardiovascular risks. Such complexity results in delayed diagnosis, which worsens the outcome of myocardial infarction and generates complications related to the absence of coronary revascularization. We report the case of a patient who suffered an (undiagnosed) apical myocardial infarction that went undetected and was complicated by a voluminous intraventricular thrombus with embolus migration in the cerebral circulation resulting in an ischemic accident. The combination of these two pathologies make their therapeutic management particularly difficult. As widely reported in the literature, the outcome of myocardial infarction in women is poorer than in their male counterparts for a number of reasons. We can assume that in the youngest patients, another physiopathological mechanism is often involved, namely, the occurrence of hematoma and spontaneous coronary dissection. Diagnosis is often difficult even with coronary angiography diagnosis. As shown in the case reported here, initial examination results, if not thoroughly analyzed, may be erroneously interpreted as normal. It is also likely that the presence of hematoma or coronary wall dissection without any plaque rupture may negatively influence the outcome owing to the implementation of inappropriate treatments. In conclusion, in patients presenting with an ischemic cerebral accident, meticulous cardiac examination must be performed even in young women with no cardiovascular risk factors given that the occurrence of hematoma or coronary dissection may contribute to the formation of mural thrombi in the setting of myocardial infarction. Cardiac MRI seems to be particularly effective in the diagnosis of myocardial infarction complicated by the presence of intracavitary thrombi.

[Difficulty in diagnosis of a cardiogenic shock with thrombotic and sub-occluded LAD. A train can hide another one!] / Difficulté diagnostic d'un choc cardiogénique sur une sub-occlusion thrombotique de l'IVA. Un train peut en cacher un autre !

The pheochromocytome is a localized tumor at the level of the medullosurrenale in 85% of the cases. The clinical presentation is very variable. Severe Heart failure presentation can be the mode of revelation in 2% of the cases. We present the case of a patient admitted for refractory cardiogenic shock correlated to pheochromocytome tumor. The difficulty of this rare clinical presentation was to confirm rapidly and in emergency this diagnosis in the same time when the patient presents a persistante and severe cardiogenic chock after finding a sub-occluded and thrombotic LAD coronary artery and which was treated by thrombectomy and coronary revascularization. The surgical treatment of this tumor is considered to be a quickly saving treatment. It allows a fast recovery of the cardiac function.

[Chronic total occlusions: Is there a woman specificity?] / Occlusions coronaires chroniques : existe-t-il une spécificité féminine ?

Many differences have been reported regarding gender in angioplasty procedures (PCI), but their potential influence on clinical outcomes after CTO PCI has not been elucidated. Aim of this paper is to analyse these potential differences starting from 2 clinical cases. The basic features found in the two clinical cases presented here, older age and presence of diabetes (that are more frequent in women), are in line with the differences identified in non-CTO studies on angioplasty. Furthermore, CTO in women are generally under-diagnosed and less frequently treated by angioplasty than in men. These features combined to the often atypical clinical presentation could explain why women are generally less frequently enrolled in CTO registries than men. Although data on the impact of gender on this topic are scarce, it appears that, despite a clear outcome difference in patients who have a successful CTO angioplasty and similar success rates, women are still under-referred for a CTO angioplasty. Indeed, CTO angioplasty seems a valid therapeutic option, in women as in men.

[Is coronary artery spasm a disease specific to women?] / Spasme coronaire, une pathologie de la femme ?

Vasospastic angina is considered rare in Europe but with a prevalence probably underestimated and affects preferentially men in published studies, mostly involving Asian populations. Vasospastic angina in the female population have specificities in terms of pathophysiology, clinical presentation and prognosis, as well as diagnostic strategies currently recommended, that we describe from a clinical case. Although known for over 50years, vasospastic angina remains a disease still insufficiently researched, probably even less in women. This form of angina must not however be forgotten, and the appropriate diagnostic strategy must be known and used to improve prognosis.

[Transfemoral TAVI procedure in women: Minimally-invasive technique]. / Procédure de TAVI par voie fémorale chez la femme : technique minimaliste.

Demographic data point to a substantial proportion of women in the population of elderly patients with an increasing prevalence of aortic stenosis. Implantation of an aortic bioprosthesis via an endovascular approach known as Transcatheter aortic valve implantation (TAVI) in patients presenting with a symptomatic tight aortic stenosis (severe aortic stenosis) (AS) is an alternative therapeutic option to surgical aortic valve replacement in patients at high surgical risk or ineligible for surgery. The literature has shown that this technique seems to be particularly beneficial in female patients. In the Partner A trial, the 1-year mortality rate was significantly lower in women compared to their male counterparts. Other data revealed that although women have a higher risk of experiencing periprocedural complications (vascular events, bleeding and stroke), their outcome is good and often better than that of men. These results are continuously improving thanks to the enhancement of techniques and devices. In view of the published reports reflecting the increasing experience of the teams, it clearly appears that the simplification of TAVI procedures has resulted in improved outcomes. We report here the case of a patient treated by means of a "minimalist" approach to TAVI allowing a reduction of the risks inherent in the procedure. This simplified strategy relies on an optimal use of CT scan findings prior to TAVI. The procedure is carried out under local anesthesia and the main access site is sutured percutaneously (Proglides). The radial artery is used as a secondary access site. Contrast medium is diluted and stimulation is administered via the intraventricular guidewire. Direct stenting is performed when deemed feasible on the basis of CT scan results. Simplified procedures such as these contribute to the improvement of TAVI outcomes. However, further studies focusing on female patients are warranted in order to corroborate these findings.

Elevated levels of shed membrane microparticles with procoagulant potential in the peripheral circulating blood of patients with acute coronary syndromes.

BACKGROUND: Apoptotic microparticles are responsible for almost all tissue factor activity of the plaque lipid core. We hypothesized that elevated levels of procoagulant microparticles could also circulate in the peripheral blood of patients with recent clinical signs of plaque disruption and thrombosis. METHODS AND RESULTS: We studied 39 patients with coronary heart disease, including 12 patients with stable angina and 27 patients with acute coronary syndromes (ACS), and 12 patients with noncoronary heart disease. We isolated the circulating microparticles by capture with annexin V and determined their procoagulant potential with a prothrombinase assay. The cell origins of microparticles were determined in an additional 22 patients by antigenic capture with specific antibodies. The level of procoagulant microparticles did not differ between stable angina patients and noncoronary patients (10.1+/-1.6 nmol/L phosphatidylserine [PS] equivalent versus 9.9+/-1.6 nmol/L PS equivalent, respectively). However, procoagulant microparticles were significantly elevated in patients with ACS (22.2+/-2.7 nmol/L PS equivalent) compared with other coronary (P<0.01) or noncoronary (P<0.01) patients. Microparticles of endothelial origin were significantly elevated in patients with ACS (P<0.01), which suggests an important role for endothelial injury in inducing the procoagulant potential. CONCLUSIONS: High levels of procoagulant endothelial microparticles are present in the circulating blood of patients with ACS and may contribute to the generation and perpetuation of intracoronary thrombi.

Efficacy of streptokinase, but not tissue-type plasminogen activator, in achieving 90-minute patency after thrombolysis for acute myocardial infarction decreases with time to treatment. PERM Study Group. Prospective Evaluation of Reperfusion Markers.

OBJECTIVES: We sought to examine the relation between time to treatment and 90-min patency rates in patients receiving intravenous streptokinase (SK) or accelerated tissue-type plasminogen activator (t-PA). BACKGROUND: Early patency of the infarct-related artery is a major determinant of survival after thrombolysis for acute myocardial infarction. Some data suggest that time to treatment may influence the efficacy of nonfibrin-specific thrombolytic agents in restoring early patency of the infarct-related vessel. METHODS: We performed a retrospective analysis of a cohort of 481 patients receiving thrombolytic therapy for acute myocardial infarction <6 h after pain onset, all of whom underwent 90-min coronary angiography. Patency of the infarct-related artery was graded by two observers who had no knowledge of the treatment received or the time between pain and therapy. RESULTS: There was no difference in baseline clinical or angiographic characteristics according to the timing or nature of treatment. Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 patency rate after SK correlated negatively with the time between onset of pain and thrombolysis (r = 0.8, p = 0.05), whereas the 90-min patency rate after t-PA appeared stable as a function of time to treatment. When patients were categorized as having received treatment <3 or > or = 3 h after pain onset, the patency rate was similar with t-PA, but significantly higher when SK was administered early rather than late, regardless of whether TIMI flow grades 2 and 3 were pooled (86.9% vs. 59.4%, p = 0.0001) or TIMI flow grade 3 alone was considered to indicate patency (81.7% vs. 53.6%, p = 0.0001). Multivariate logistic regression analysis showed a negative effect of time to treatment on the patency probability for SK (p = 0.0001) but not for t-PA. CONCLUSIONS: The efficacy of streptokinase but not t-PA in restoring early coronary patency after intravenous thrombolysis is markedly lower when patients are treated later after onset of pain.