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J Am Coll Cardiol, 1998; 32:1312-1319
© 1998 by the American College of Cardiology Foundation
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CLINICAL STUDIES

Importance of time to reperfusion for 30-day and late survival and recovery of left ventricular function after primary angioplasty for acute myocardial infarction

Bruce R. Brodie, MD, FACCa,c, Thomas D. Stuckey, MD, FACCa,c, Thomas C. Wall, MD, FACCa,c, Grace Kissling, PhD* c, Charles J. Hansen, MAa,c, Denise B. Muncy, BSNa,c, Richard A. Weintraub, MD, FACCa,c and Thomas A. Kelly, MD, FACCa,c

a Department of Medicine, The Moses H. Cone Memorial Hospital, The Department of Mathematical Sciences, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
* Department of Medicine, The Moses H. Cone Memorial Hospital, The Department of Mathematical Sciences, Division of Statistics, University of North Carolina at Greensboro, Greensboro, North Carolina, USA
c LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina, USA

Manuscript received March 18, 1998; revised manuscript received June 19, 1998, accepted July 6, 1998.

Address for correspondence: Dr. Bruce R. Brodie, 520 North Elam Avenue, Greensboro, North Carolina 27403

Objectives. The purpose of this study was to evaluate the importance of time to reperfusion for outcomes after primary angioplasty for acute myocardial infarction.

Background. Survival benefit of thrombolytic therapy for acute myocardial infarction is strongly dependent on time to treatment. Recent observations suggest that time to treatment may be less important for survival with primary angioplasty.

Methods. Consecutive patients (n = 1,352) with acute myocardial infarction treated with primary angioplasty were followed for up to 13 years. Paired acute and follow-up ejection fraction data were obtained at cardiac catheterization in 606 patients.

Results. Reperfusion was achieved within 2 h in 164 patients (12%). Thirty-day mortality was lowest with early reperfusion (4.3% at <2 h vs. 9.2% at ≥2 h, p = 0.04) and was relatively independent of time to reperfusion after 2 h (9.0% at 2 to 4 h, 9.3% at 4 to 6 h, 9.5% at >6 h). Thirty-day–plus late cardiac mortality was also lowest with early reperfusion (9.1% at <2 h vs. 16.3% at ≥2 h, p = 0.02) and relatively independent at time to reperfusion after 2 h (16.4% at 2 to 4 h, 16.9% at 4 to 6 h, 15.6% at >6 h). Improvement in left ventricular ejection fraction was greatest in the early reperfusion group and relatively modest after 2 h (6.9% at <2 h vs. 3.1% at ≥2 h, p = 0.007).

Conclusions. Time to reperfusion, up to 2 h, is important for survival and recovery of left ventricular function. After 2 h, recovery of left ventricular function is modest and survival is relatively independent of time to reperfusion. These data suggest that factors other than myocardial salvage may be responsible for survival benefit in patients treated with primary angioplasty after 2 h.

Abbreviations and Acronyms
  GUSTO = global utilization of streptokinase and tPA for occluded coronary arteries
  PAMI = primary angioplasty in myocardial infarction (trial)
  PTCA = percutaneous transluminal coronary angioplasty
  TIMI = Thrombolysis in Myocardial Infarction (trial)
  tPA = tissue plasminogen activator




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Relationship of Symptom-Onset-to-Balloon Time and Door-to-Balloon Time With Mortality in Patients Undergoing Angioplasty for Acute Myocardial Infarction
JAMA, June 14, 2000; 283(22): 2941 - 2947.
[Abstract] [Full Text] [PDF]

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 JAMAHome page
M. S. Lauer
Primary Angioplasty--Time Is of the Essence
JAMA, June 14, 2000; 283(22): 2988 - 2989.
[Full Text] [PDF]

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 Eur Heart JHome page
P. Widimsky, L. Groch, M. Zelizko, M. Aschermann, F. Bednar, and H. Suryapranata
Multicentre randomized trial comparing transport to primary angioplasty vs immediate thrombolysis vs combined strategy for patients with acute myocardial infarction presenting to a community hospital without a catheterization laboratory. The PRAGUE Study
Eur. Heart J., May 2, 2000; 21(10): 823 - 831.
[Abstract] [PDF]

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 NEJMHome page
E. Boersma, M. Akkerhuis, M. L. Simoons, F. Zijlstra, M.-J. de Boer, D. P. Faxon, and J. W. Heger
Primary Angioplasty versus Thrombolysis for Acute Myocardial Infarction
N. Engl. J. Med., March 23, 2000; 342(12): 890 - 892.
[Full Text]

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 J Am Coll CardiolHome page
T. J. Ryan, E. M. Antman, N. H. Brooks, R. M. Califf, L. D. Hillis, L. F. Hiratzka, E. Rapaport, B. Riegel, R. O. Russell, E. E. Smith III, et al.
1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)
J. Am. Coll. Cardiol., September 1, 1999; 34(3): 890 - 911.
[Full Text] [PDF]

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 SEMIN CARDIOTHORAC VASC ANESTHHome page
C. E. Chambers, S. T Riebel, and M. Kozak
Interventional Cardiology: Advances in Percutaneous Techniques for the Treatment of Cardiac Disease
Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 109 - 125.
[Abstract] [PDF]

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 CirculationHome page
N. Danchin, L. Vaur, N. Genes, S. Etienne, M. Angioi, J. Ferrieres, and J.-P. Cambou
Treatment of Acute Myocardial Infarction by Primary Coronary Angioplasty or Intravenous Thrombolysis in the "Real World" : One-Year Results From a Nationwide French Survey
Circulation, May 25, 1999; 99(20): 2639 - 2644.
[Abstract] [Full Text] [PDF]


 
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