Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction

E. M. Ohman, R. M. Califf, E. J. Topol, R. Candela, C. Abbottsmith, S. Ellis, K. N. Sigmon, D. Kereiakes, B. George, R. Stack

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414 Scopus citations

Abstract

To determine the clinical consequences of reocclusion of an infarct-related artery after reperfusion therapy, we evaluated 810 patients with acute myocardial infarction. Patients were admitted into four sequential studies with similar entry criteria in which patency of the infarct-related artery was assessed by coronary arteriography 90 minutes after onset of thrombolytic therapy. Successful reperfusion was established acutely in 733 patients. Thrombolytic therapy included tissue-type plasminogen activator (t-PA) in 517, urokinase in 87, and a combination of t-PA and urokinase in 129 patients. All patients received aspirin, intravenous heparin and nitroglycerin, and diltiazem during the recovery phase. A repeat coronary arteriogram was performed in 88% of patients at a median of 7 days after the onset of symptoms. Reocclusion of the infarct-related artery occurred in 91 patients (12.4%), and 58% of these were symptomatic. Angiographic characteristics at 90 minutes after thrombolytic therapy that were associated with reocclusion compared with sustained coronary artery patency were right coronary infarct-related artery (65% versus 44%, respectively) and Thrombolysis in Myocardial Infarction (TIMI) flow 0 or 1 (21% versus 10%, respectively) before further intervention. Median (interquartile value) degree of stenosis in the infarct-related artery at 90 minutes was similar between groups: 99% for reoccluded (value, 90/100%) compared with 95% for patent (value, 80/99%). Patients with reocclusion had similar left ventricular ejection fractions compared with patients with sustained patency at follow-up. However, patients with reocclusion at follow-up had worse infarct-zone function at -2.7 (value, -3.2/-1.8) versus -2.4 (SD/chord) (value, -3.1/-1.3) (p=0.016). The recovery of both global and infarct-zone function was impaired by reocclusion of the infarct-related artery compared with maintained patency; median Δ ejection fraction was -2 compared with 1 (p=0.006) and median Δ infarct-zone wall motion was -0.10 compared with 0.34 SD/chord (p=0.011), respectively. In addition, patients with reocclusion had more complicated hospital courses and higher in-hospital mortality rates (11.0% versus 4.5%, respectively; p=0.01). We conclude that reocclusion of the infarct-related artery after successful reperfusion is associated with substantial morbidity and mortality rates. Reocclusion is also detrimental to the functional recovery of both global and infarct-zone regional left ventricular function. Thus, new strategies in the postinfarction period need to be developed to prevent reocclusion of the infarct-related artery.

Original languageEnglish (US)
Pages (from-to)781-791
Number of pages11
JournalCirculation
Volume82
Issue number3
DOIs
StatePublished - 1990

Keywords

  • Clinical trials
  • Diltiazem
  • Heparin
  • Left ventricular function
  • Mortality
  • Myocardial infarction
  • Nitroglycerin
  • Patency
  • Thrombolysis
  • Tissue-type plasminogen activator
  • Urokinase

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

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