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Reperfusion Therapy in Inferior Myocardial Infarction

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Reperfusion Therapy in Inferior Myocardial Infarction View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector 44A JAW ““I 12. No h Dccemhcr iYXX:44&5lA Reperfusion Therapy in Inferior Myocardial Infarction ERIC R. BATES, MD. FACC Am Arbor, Mkltipor This review summarizes the multicenter trial results of reperfusion therapy for treatment of inferior myocardial infarction, Therapy with intracoronzy streptokinase or intravenous recombinant tissue plasminogen activator (rt- PA) produced higher patency rates than did intravenous streptokinase. Reocchtsion was more common when the right coronary artery was the infarct-related artery, irre- spective of treatment strategy. LeR ventricular ejection fraction was improved compared with that in control patients, especially when the time from symptom onset was brief or when patency rates were high. Enzymatic infarct size was redmod in treated patients. A trend toward mortality reduction in treated patients was found in four studies and was statistically significant in the Second Inter- national Study of Infarct Survival (ISIS-2) trial. Precordlal ST segment depression in inferior myocar- The use of thrombolytic therapy in patients with inferior Multicenter Tiwumbolytic Trial Designs myocardial infarction has been a controversial subject. Eleven multicenter trials have publisheddata concerning Whereas it is generally acknowledged that patients with inferior myocardial infarction before March 1988.The trials anterior myocardial infarction benefit from thrombolytic can be grouped into intracoronary streptokinase trials, intra- therapy, the utility of treating patients with inferior infarc- venous streptokinase trials and intravenous recombinant tion, in whom the clinical course tends io be relatively tissue plasminogenactivator (r&PA) trials (Table I). benign. has been more difficult for many clinicians to accept. Consequently, some investigators (I) have recommended Intracoronary streptokinnse trials. The Western Wash- that thrombolytic therapy be limited to patients with anterior ington lntracoronary Streptokinase (WWlCS) trial (2-7) myocardial infarction. carolled 134patients with inferior infarction among a total of When examined in aggregate, however, a substantial 250 study patients in 14hospitals from July 1981to February amount of data from conlrolled randomized multicenter 1983. Patients admitted within 12 h of symptom onset trials supports the use of thrombolytic therapy in inferior underwent cardiac catheterization, and those randomized to infarction. The purpose of this report is to summarize the intracoronary streptokinase therapy received an average of results of those trials. When these data are analyzed in the 286,000U infused over 72 min. Mean time to randomization context of time to treatment, coronary patency and reocclu- was 4.6 h; only 22% of patients were randomized in <3 h. sion rates and ischemic burden, strong support for the Mechanical revascularization (angioplasty or bypass graft application of thrombolytic therapy in most patients with surgery) was accomplishedin 10% of patients within 30 days inferior infarction becomes apparent. and in 26% of patients by I year. All patients were treated with heparin, followed by warfarin. The Nerherktnds Inferrtniversiry friul (8-18) entered 287 From the Dwsion of Cnrdrology. Department of Internal Medicine, patients with inferior myocardial infarction amonga total of Unwer~~ly of Mlchq,an. Ann Arbor. Micblgan. 533 study patients in five hospitals from June 1981to March -for Eric R. Bates. MD, Division ofCardmlogy. Univer- sdy Hospital. 1500 East Medical Cenler Drive. 3910 ‘Taubman. Ann Arbor. 1985.Patients with symptoms ~4 h in duration were eligible Michigan 481139-0366. to undergo cardiac catheterization and an intracoronary 819118 by the Amerlcsn Collcgc of Cadmlogy 073.5.loY7/88/$3.50 JACC VOI. IL i-4” 6 BATES Dcccmhcr 1988 44A-(IA KL-PERI ,#il<)N IN INFERKIR MYrJCARDI,L INFARCTION SK/n-PA Do* Intracoronary SK WWICS (2-7) 7iHI IO 21x3 I4 XI I? 4.6 Netherland\ 6lXl I” 3/x5 5 573 4 13 o!-Inl lnlr.ivenous SK GISSI ,I%??) 2,R.l 1‘1 NH IX liwl 12 ISAM 123-25) l/X2 111 3/x9 1x I 741 6 ?!z !26! XIX4 1” Xillh 4 IF’, 4 30 WWIVS 127) Y/X1 10 7/X6 27 IhX 6 3.5 TIMI-I I%-301 xix4 lo 28s II II9 7 4.8 Inlraven”“> r&PA TIMI-I I?&30) 8W4 to .?M 13 II? 7 46 3 TAMI-I (31. 321 1215 l” lwl 4 1X6 6 2.9 6 10 X Hopkins 133) 12184 to 3/X7 3 13x 4 3.2 TIC0 (34) 5 105 25 1.9 Auslraba (35) 5186 lo XI87 5 I44 .I 3.3 GlSSl = Gmppo ltallano per lo Study” della Streptochmdv nell’lnfano Miwardico; !MI = mfenor myocardlai mhrclion: ISAM = Intravenous Streptokmace I” Acute Myocardlal Inhrct~on. NZ = New Zealand; PIS = pauents. r&PA = recombmant tw”r plasmmogen actwator: Rx = watment: SK = weptokmaw: TAM1 = Thrombalyrlc and Angmplssty in Myocardral Infdrcllon. TIC0 = Thrombolyrar I” Acule Coranrry Occlwon: TIM1 = Tbrombolyc~r m Myocardial Infarction: WWICS = Wertern Wa,hmgt”n Intracoronary Strept”k,nasse trial: WWIVS = Wesrem Washington intravenous Streptokmase trial. streptokinase infusion of 250,000 U over I h. Control pa- hospuals from March 1982to March 1985.Patients admitted tients did not undergo emergency cardiac catheterization. within 6 h of symptom onset and randomized to streptoki- Elective cardiac catheterization was performed in 76% of the nase received I.5 million U over I h. Half of the patients total patient group just before hospital discharge. Forty-four Yere treated within 3 h. Emergency cardiac catheterization percent of the treatment group were pretreated with 500.000 was not performed, but 53% underwent cardiac catheteriza- IJ of intravenous streptokinase and 17% underwent emer- tion 4 weeks later. Patients were treated with aspirin, gency angioplasty. Mean time to treatment was 3.3 h. heparin and an oral anticoagulant agent. Mechanical revas- Mechanical revascularization was performed in 15% of the cularization was undertaken in I I% of patients by 7 months. control patients and 3% of the treatment patients by I year. The NW Zealand trial (26) enrolled 91 patients with Patients were also treated with aspirin, heparin and an oral inferior infarction among a total of I55 study patients with a anticoagulantagent. first myocardial infarction in four hospitals from August 1984 Intravenous streptokioaw trials. The Gruppo Italian0 per to August 1986.Patients admittedwithin 4 h and randomized lo Studio della Streptochinasi nell’lnfarto Miocardico to intravenous strep:okinase received I.5 million U over 30 (GISSI) trial (N-22) enrolled 4,013 patients with inferior min. Mean time to treatment was 3 h. Cardiac catheteriza- myocardial infarction among a total of Il.806 study patients tion was performed 3 weeks later. Patients were also treated in 176 coronary care units from February 1984to June ,485. with aspirin, dipyridamole and heparin. Patients admitted within I2 h of symptom onset and random- The Western Washington Intravenous Streptokinase in ized to treatment received I.5 million U of intravenous Acrrte Myocardial Ittfarction trial (27) enrolled 234 patients streptokinase over 60 min. Half of the patients were treated with inferior infarction amonga total of 368 study patients in within 3 h. Cardiac catheterization was not performed. Ten 27 hospitals from September 1983 to July 1986. Patients percent of the patients were older than 75 years and 50% randomizedwithin 6 h to streptokinase received 1.5 million were older than 65 years. Only 20% received heparin and U over I h. Mean time to treatment was 3.5 h. Streptokinase- 14% received aspirin. Fewer than 4% of patients underwent treated patients were also treated with heparin and warfarin. mechanical revascularization, making the control group a Mechamcal revascularization was performed in 11% of pa- cohort of medically treated patients followed up for I year tients before hospital discharge. after acute myocardial infarction. Intravenous tissue plasminogen activator trials. The The Intravenotrs Streptokinase in Actrte Myocardial Iv- Thrombolysis in Myocardial Infarction (TIMI) phase I trial firction (HAM) trial (23-25) entered 877 patients with (28-30) entered I I9 patients with inferior infarction amonga inferior infarction among a total of I.741 study patients in 38 total of 232 study patients with occluded infarct-related 46A BATES ,ACC ““I. 12. NO. 6 REPERF”S,“N IN INFERIOR MYDCARDIAL INFARCTION Dccemher 19RR:44A-51A arteries in 13 hospitals from August 1984to February 1985. Table2. Acute PatencyRates in Inferior and Anterior Patients were treated within 7 h and received either I.5 Myocardialinfarction million U of imravenous streptokinase over I h or 80 mg of Patency (%) double chain rt-PA over 3 h. Mean time to treatment was 4.8 Time to NO. Rx(h) IMI AMI h. Patients were also treated with aspirin, dipyridamole and - heparin. Mechanical revascularization was performed in lntracoronary SK WWICS (2) 134 4.6 -68 -68 24% of patients before hospital discharge. Nerherlands (13) 287 3.3 88 83 The Thrombolysis and Angioplasty in Myocardial Infarc- tntravenous SK rioa (TAM/) trial (31,32) enrolled 223 patients with inferior ISAM (25) 877 3 -34 -48 infarction among a total of 386 study patients in four hospi- TIMI-I (28) 57 4.8 35 28 iais fiOlX Deccmbc: .,.,>lo*< !o Cc!ober !9Rh All patients lnlravenous r&PA received 150mg of singlechain r&PA intravenously within 6 TIMI-I (28) 62 4.8 53 7: h of symptom onset. Mean time to treatment was 2.9 h. TAMI-I (37) 233 2.9 68 (91) 77 (%) Suitablepatients were randomized to immediateor delayed AM1 = anterior myocardial infarction: other abbreviations as in Table I. angioplasty. Patients were also treated with aspirin, dipyri- Figures in parentheses represent palency ratesafter addition of immediate damoleand heparin. Mechanical revascularization was per- angioplasty to thrombolytic therapy. formed in 67% of patients before hospital discharge. Three smaller placebo-controlled trials evaluated the ef- fect of earlv treatment with r&PA on left ventricular function with inferior infarction versus 48% of those with anterior after acute myocardial infarction.
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