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Late Thrombolytic Therapy Preserves Left Ventricular Function in Patients

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Late Thrombolytic Therapy Preserves Left Ventricular Function in Patients View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector 58 JACC Vol . 14, No . I July 18 58-64 Late Thrombolytic Therapy Preserves Left Ventricular Function in Patients With Collateralized Total Coronary Occlusion Primary End Point Findings of the Second Mount Sinai-New York University Reperfusion Trial K. PETER RENTROP, MD, FACC,* FREDERICK FELT, MD, FACC,t WARREN SHERMAN, MD, FACC,* PETER STECY, MD, FACC,t SUSAN HOSAT, MS,* MARC COHEN, MD, FACC,* MARIANO REY, MD, FACC,t JOHN AMBROSE, MD, FACC,* MARK NACHAMIE, MD,t WILLIAM SCHWARTZ, MD, FACC,* WILLIAM COLE, MD,t ROBERT PERDONCIN, MD,* JOHN C . THORNTON, PHD New York, New York The change in left ventricular ejection fraction from prein- icant improvement over those without collateral flow in the tervention to predischarge was prospectively assessed in streptokinase (5 .4 ± 2.5%) and streptokinase-nitroglycerin 33 patients with acute myocardial infarction . Within 12 h (10 .6 ± 2 .7 %) arms, but not in the nitroglycerin arm . Time of symptom onset (mean 6.3 ± 2 .7 h), patients were to treatment did not influence the change in ejection randomly assigned to a double-blind intracoronary infusion fraction . In patients with initial subtotal occlusion, throm- of streptokinase, nitroglycerin, both streptokinase and ni- bolytic therapy was of no short-term benefit because ejec- troglycerin or conventional therapy without acute cardiac tion fraction increased by 6% in all three intervention catheterization . Treatment effects were also assessed in arms. prospectively defined angiographic subsets . These findings indicate that relatively late thrombolytic There was a significant interaction between streptoki- therapy results in significant myocardial salvage in those nase and nitroglycerin (p < 0 .01), resulting in an increase patients with collateralized total coronary occlusion . This in ejection fraction of 3 . percentage units in the combined benefit is potentiated by concomitant nitroglycerin therapy . treatment arm (p < 0 .001) . Patients with collateral flow to (J Am Coll Cardiol 18 ;1458-64) a totally obstructed infarct-related artery showed a signif- Thrombolytic therapy is the treatment of choice for patients in experimental animals (4,5), it is still undefined in human with acute myocardial infarction who present within 3 h of patients . Several studies (6-8) suggest that the efficacy of pain onset (1-3) . Whereas the time limit for benefit from thrombolytic therapy, as assessed by the change in left interventions in evolving infarction has been clearly defined ventricular function, is dependent on initial angiographic status . Furthermore, it has been suggested (,10) that the benefit of thrombolytic therapy can be enhanced by adjuvant From the *Departments of Medicine, Mount Sinai School of Medicine and tNew York University School of Medicine, New York, New York . This study therapy . Therefore, we performed a prospective randomized was supported by the Cardiac Diseases Branch, Division of Heart and double-blind trial to assess the effects of intracoronary Vascular Diseases, National Heart, Lung, and Blood Institute, National streptokinase, intracoronary nitroglycerin or their combina- Institutes of Health, Bethesda, Maryland (Grant R01HL28843) . It was pre- sented in part at the 35th Annual Scientific Session of the American College of tion, administered within 12 h of the onset of chest pain . The Cardiology, March 186, Atlanta, Georgia and the 5th Scientific Session of main end point was change in ejection fraction in angio- the American Heart Association, November 186, Dallas, Texas . The strep- tokinase and the placebo were donated by Kabi Vitrum, Stockholm, Sweden . graphic subsets defined prospectively on the basis of results Manuscript received October 17, 188 ; revised manuscript received of the Registry of the European Society of Cardiology (6) January 18, 18, accepted February 21, 18 . and the First Mount Sinai-New York University Reperfusion Address for reprints ~ K . Peter Rentrop, MD, St . Vincent's Hospital and Medical Center of New York, 153 West 11th Street . New York, New York Trial (). Patients were enrolled in three New York City 10011 . hospitals and followed up for a minimum of 2 years . ©18 by the American College of Cardiology 0735-107/8/$3 .50 JACC Vol . 14, No . I RENTROP ET AL . 5 July 18 58-64 LATE THROMBOLYSIS AND COLLATERAL FLOW Methods laboratory in a side by side fashion ; the core laboratory was unaware which study represented the pretreatment or end Study design and patients . A two by two factorial design point nuclear ventriculogram . Change in ejection fraction was selected to detect any interaction between intracoronary was expressed in ejection fraction percentage units . Repro- infusions of streptokinase and nitroglycerin . We prospec- ducibility of the core laboratory's analyses was assessed by tively assessed the influence of baseline angiographic status recycling 10% of the raw data . Intraclass correlation coeffi- in the patients in the intervention arms of the study as cients (13) in the recycled studies yielded reliabilities of 0 .6 follows total versus subtotal occlusion of the infarct-related for both preintervention and end point ejection fraction . artery, and presence or absence of collateral flow to the Coronary angiography . The infarct-related coronary ar- infarct vessel (6) . The study protocol was approved by the tery was classified as totally obstructed if there was com- committees on human research in the participating institu- plete cessation of anterograde flow, or as patent if there was tions . any degree of anterograde filling beyond the culprit lesion . All patients with suspected acute myocardial infarction Collateral vessels were determined to be present if any were screened in the participating hospitals . Patients <78 segment of the infarct-related artery filled in other than a years of age were eligible if they presented within 12 h of the continuous anterograde fashion . The extent of collateral onset of myocardial ischemic pain of ?30 min duration and filling was not further graded . demonstrated either a new ST segment elevation or depres- Electrocardiograms . The sum of R wave height and the sion over 0 .1 mV persisting 0 .08 s after the J point or number of pathologic Q waves were assessed from precor- pathologic Q waves in two contiguous leads of the screening dial leads V, to V6 in patients who had anterior wall electrocardiogram (ECG) . Exclusion criteria have been pub- infarction, and leads II, III and aVF in patients who had lished elsewhere () . inferior wall infarction . Treatment arms . After signing informed consent, pa- Statistical analysis . This trial was analyzed by intention tients were prospectively stratified according to duration of to treat . Continuous variables were expressed as mean pain ; Group A <2 h, Group B 2 to 12 h . They were values ± SD, except where SEM was used . Differences in randomly assigned to one of four treatment arms 1) intra- the distribution of baseline variables among the four treat- coronary infusion of streptokinase, 2,000 U/min ; 2) intracor- ment arms were compared using analysis of variance for onary infusion of nitroglycerin, 0 .01 mg/min ; 3) combined continuous variables and chi-square analysis for categorical infusion of streptokinase, 2,000 U/min and nitroglycerin, variables . 0.01 mg/min ; or 4) a control group receiving conventional The null hypothesis that the average change in ejection therapy without acute catheterization . A radionuclide ven- fraction was the same for the four treatment arms was tested triculogram at rest and a standard 12 lead ECG were by analysis of covariance . All changes in ejection fraction obtained before cardiac catheterization . In the three inter- reported are adjusted changes derived from the analysis of vention arms, aortic pressures were recorded before dye covariance (14) . The following were considered as possible injection . Intracoronary drug infusions were double-blind covariates age, preintervention ejection fraction, infarct and were maintained for a minimum of 75 min . If recanali- location, prior myocardial infarction, preintervention use of zation occurred, the intracoronary infusion was continued beta-blockers and duration of pain prior to infusion . In for at least an additional 30 min to a maximum of 120 min . addition, the number of diseased vessels was considered as Concomitant therapy . All patients underwent full antico- a possible covariate in the intervention groups . agulant therapy with intravenous heparin followed by war- In the mortality analysis, age, preintervention heart rate farin for 3 months . Nitrates, calcium channel antagonists and and ejection fraction were used as covariates . beta-adrenergic blockers were not administered routinely in the first 72 h . Percutaneous transluminal coronary angio- plasty or coronary artery bypass surgery was performed in Results 5% of the study patients before end point data acquisition . Patient profile. Of the 3,62 patients with suspected End point radionuclide ventriculograms and a 12 lead ECG myocardial infarction who were screened, 551 met the were obtained on day 10 to 14 . eligibility criteria . One hundred fifty-eight eligible patients Technical aspects of data acquisition and evaluation . were not enrolled, primarily because they refused to partic- Radionuclide ventriculography . Red blood cells labeled with ipate (n = 78) or because a complete study team was not 30
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