Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction.

OBJECTIVES: The objective of this study was to obtain preliminary data on the relative clinical utility of direct coronary angioplasty compared with that of intravenous thrombolytic therapy for patients with acute myocardial infarction. BACKGROUND: The relative merits of intravenous thrombolytic therapy and direct coronary angioplasty as treatment for acute myocardial infarction are incompletely understood, and randomized trials of these treatments have been extremely limited. METHODS: One hundred patients with ST segment elevation presenting to a single high volume interventional center within 6 h of the onset of chest pain were randomized to receive either streptokinase (1.2 million U intravenously over 1 h) or immediate catheterization and direct coronary angioplasty. Patients were excluded for age > or = 75 years, prior bypass surgery, Q wave infarction in the region of ischemia or excessive risk of bleeding. All patients were then treated with aspirin (325 mg orally/day) and heparin (1,000 U intravenously/h) for 48 h until catheterization was performed to determine the primary study end point, namely, infarct-related artery patency at 48 h. Secondary end points were in-hospital death, left ventricular ejection fraction at 48 h and time to treatment. RESULTS: There was no difference in the baseline characteristics of the two treatment groups. Overall patient age was 56 +/- 10 years, 83% of patients were male, 11% had prior infarction, 40% had anterior infarction and 97% were in Killip class I or II. Although time to treatment was delayed in the angioplasty group (238 +/- 112 vs. 179 +/- 98 min, p = 0.005), there was no difference in 48-h infarct-related artery patency or left ventricular ejection fraction (patency 74% vs. 80%; ejection fraction 59 +/- 13% vs. 57 +/- 13%; angioplasty vs. streptokinase, p = NS for both). There were no major bleeding events, and the mortality rate with angioplasty (6%) and streptokinase (2%) did not differ (p = NS). CONCLUSIONS: These results suggest that intravenous thrombolytic therapy might be preferred over coronary angioplasty for most patients because of the often shorter time to treatment.

[Treatment of pulmonary thromboembolism with extrinsic plasminogen activator. A case report]. / Tratamento do tromboembolismo pulmonar com ativador extrínseco do plasminogênio. Relato de caso.

A 49 year-old woman with acute pulmonary thromboembolism and severe hemodynamic impairment was successfully treated with tissue-type plasminogen activator (r-TPA). She did not have previous pulmonary or cardiac diseases. Thirty days after immobilization of the right ankle, she had a sudden onset of dyspnea, epigastrial pain and syncope. As heparin therapy was unsuccessful, 90 mg of IV r-TPA was administered. There was rapid clinical and hemodynamic improvement of her condition. Pulmonary scanning one week later was normal and she was discharged without symptoms 12 days after the acute episode.

[Detection of myocardial ischemia during dobutamine stress echocardiography. Correlation with coronary cineangiography]. / Detecção de isquemia miocárdica através de ecocardiografia de estresse com dobutamina. Correlação com cinecoronariografia.

PURPOSE: To detect myocardial ischemia during dobutamine stress echocardiography (DSE). METHODS: Two hundred and seventy one patients were studied; 63 (23%) underwent coronary angiography within a month of DSE. Angiograms were analyzed independently by 3 angiographers, and coronary lesions larger than 50% of luminal occlusion were considered likely to cause ischemia. RESULTS: The global sensitivity and specificity were 95% and 75% respectively, with 89% accuracy. Of 43 patients showing obstructive coronary artery disease, there were 2 false negatives. One of 5 false positives had ischemic cardiomyopathy and another a technically difficult exam. The symptoms and side effects in decreasing order of occurrence are as follows: palpitation 46%; arrhythmia 24%; mild hypotension 24%; chest pain 8%; hypertension 5%; facial paresthesia 4%; chills 1.8%; nausea 1.8%; headache 1.4%; dyspnea 0.4% and severe hypotension 0.4%. CONCLUSION: Considering the results, the small number of complications and the feasibility, DSE seems to be a safe and promising method for detecting myocardial ischemia.

[Thrombolysis with intravenous APSAC in patients with acute myocardial infarction]. / Trombólise com apsac endovenoso em pacientes com infarto agudo do miocárdio.

PURPOSE: Analysis of the first 20 patients with acute myocardial infarction (AMI) who were treated with intravenous APSAC. METHODS: Twenty patients with AMI less than 6 hours of duration of symptoms were treated with IV APSAC bolus of 30 mg. Seventeen were males, ages ranging between 40 and 73 (mean 54) years. The first angiographic study was performed in 90 minutes and 5-7 days after drug administration. RESULTS: In the angiographic study performed at 90 minutes the infarct--related artery were left anterior descending (LAD) in 7 patients (35%), right coronary artery (RCA) in 9 (45%) and left circumflex (LCX) in 4 (20%). In 14 (70%) of the patients had patent infarct-related artery and the mean of left ventricular ejection fraction (LVEF) was 0.49 +/- 0.15. In six non recanalized patients the mean LVEF was 0.40 +/- 0.14. No complications were observed, and in the second angiographic study one patient showed reocclusion of the infarct-related artery. CONCLUSION: Because of easy application (IV bolus), no complication and high rate of early recanalization, IV APSAC seems to be an efficient thrombolytic agent in the treatment of patients with AMI.

[Thrombolysis in acute myocardial infarction. Streptokinase or r-TPA?]. / Trombólise no infarto agudo do miocárdio. Estreptoquinase ou r-TPA?

PURPOSE: To compare the results of intravenous thrombolytic therapy with streptokinase (SK), with those of the recombinant human tissue-type plasminogen activator (r-TPA), in acute myocardial infarction (AMI). MATERIAL AND METHODS: One hundred patients with AMI of less than 6 hours duration were randomized in two groups: 50 patients were allocated to 1.200.000 IU of SK (Group SK) and 50 patients received 100 mg of r-TPA over 180 minutes. The two groups were similar respecting age, sex, location and previous infarction. The angiographic study was performed 48 h after the thrombolytic therapy. RESULTS: In the angiographic study, 85% of the Group SK vs 66% of Group r-TPA had patient infarct-related vessel (p = 0.025). Reocclusion was 6.6% in Group SK vs 19% in Group r-TPA and hospital mortality was similar in the two groups. CONCLUSION: In the late angiographic evaluation (48 h), the frequency of coronary patency was found to be higher after intravenous SK than after intravenous r-TPA.