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A Randomized Trial of Immediate versus Delayed Elective Angioplasty after Intravenous Tissue Plasminogen Activator in Acute Myocardial Infarction

List of authors.
  • Eric J. Topol, M.D.,
  • Robert M. Califf, M.D.,
  • Barry S. George, M.D.,
  • Dean J. Kereiakes, M.D.,
  • Charles W. Abbottsmith, M.D.,
  • Richard J. Candela, M.D.,
  • Kerry L. Lee, Ph.D.,
  • Bertram Pitt, M.D.,
  • Richard S. Stack, M.D.,
  • William W. O'Neill, M.D.,
  • and The Thrombolysis and Angioplasty in Myocardial Infarction Study Group*

Abstract

We compared the efficacy of immediate coronary angioplasty after acute myocardial infarction with that of elective angioplasty at 7 to 10 days in patients treated initially with intravenous tissue plasminogen activator.

The plasminogen activator (150 mg) was administered 2.95±1.1 hours after the onset of symptoms, to 386 patients with acute myocardial infarction. Ninety minutes later, patency of the coronary artery serving the area of the infarct was demonstrated by coronary angiography in 288 patients (75 percent). Bleeding problems were frequently encountered, as evidenced by an average drop in hematocrit of 11.7±6.5 points from base line to nadir and by a need for transfusion not related to bypass surgery in 70 patients (18 percent). After successful thrombolysis, 197 patients with a patent but severely stenotic vessel suitable for angioplasty were randomly assigned to immediate angioplasty (n = 99) or, if indicated 7 to 10 days after infarction, to deferred (elective) angioplasty (n = 98).

The incidence of reocclusion was similar in the two groups: 11 percent in the group assigned to immediate angioplasty and 13 percent in the group assigned to elective angioplasty. Neither group had a significant improvement in global left ventricular function, and regional wall motion in the infarct zone improved to a similar extent in the two groups. In the elective-angioplasty group, the rate of crossover to emergency angioplasty for recurrent ischemia was 16 percent (whereas 5 percent of the immediate-angioplasty group required emergency repeated angioplasty; P = 0.01). In 14 percent of the patients in the elective group, the stenosis was substantially reduced by the time of the seven-day follow-up angiography, obviating the need for angioplasty.

We conclude that in patients with initially successful thrombolysis and suitable coronary-artery anatomy, immediate angioplasty offers no clear advantage over delayed elective angioplasty. (N Engl J Med 1987; 317: 581–8.)

Funding and Disclosures

Presented in part at the American Heart Association 59th Scientific Session, Dallas, Tex., November 17–20, 1986.

Supported in part by Genentech, South San Francisco, Calif.

Author Affiliations

From the Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor; the Division of Cardiology, Department of Medicine, Duke University, Durham, N.C.; the Riverside Methodist Hospital, Columbus, Ohio; and Christ Hospital, Cincinnati. Address reprint requests to Dr. Topol at B1–F245, University of Michigan Hospital, 1500 E. Medical Center Dr., Ann Arbor, MI 48109.

* The members of the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) Study Group were the following: University of Michigan — Eric J. Topol, M.D. (Principal Investigator), William W. O'Neill, M.D., Joseph A. Walton, M.D., Eric R. Bates, M.D., Stephen G. Ellis, M.D., Patrick D.V. Bourdillon, M.D., M. Anthony Schork, Ph.D., Eva Kline, R.N., B.S.N., Laura Gorman, R.N., B.S.N., Raymond Worden, B.S., and Bertram Pitt, M.D.; Foote Hospital, Jackson, Mich. — Gregory Baumann, M.D., John Maino, MD., Mary Ann Mengleson, M.D., Constance Doyle, M.D., and Patricia Lamb, M.D.; South Macomb Hospital, Warren, Mich. — Stanley Wolfe, M.D., Leonard Bayer, D.O., Armando Madrazo, M.D., and Robert Moore, M.D.; Duke University — Robert M. Califf, M.D. (Co-Principal Investigator), Richard S. Stack, M.D., Harry R. Phillips III, M.D., Tomoaki Hinohara, M.D., Robert H. Peter, M.D., Ken Morris, M.D., Victor Behar, M.D., Y. Kong, M.D., Charles Simonton, M.D., Thomas Bashore, M.D., Eric Carlson, M.D., and Susan Mantell, R.N., B.S.; Riverside Methodist Hospital — Barry S. George, M.D., Richard J. Candela, M.D., Joanne Dillon, R.N., B.S., and Ramona Maseck, R.N., B.S.; Christ Hospital — Dean J. Kereiakes, M.D., Charles W. Abbottsmith, M.D., Linda Anderson, R.N., B.S.N., and Linda Martin, R.N., B.S.N.; William Beaumont Hospital — Gerald C. Timmis, M.D., Renato Ramos, M.D., V. Gangadharan, M.D., and Cindy Tollis, R.N., B.S.N.; Duke University Biostatistical Core Laboratory — Kerry L. Lee, Ph.D., Lynne Aronson, B.S., Jane M. Boswick, M.P.H., and Robert M. Califf, M.D.; University of Michigan Core Angiographic Laboratory — Raymond Worden, B.S., Cindy L. Grines, M.D., Mark Sanz, M.D., and Eric J. Topol, M.D.; Data Monitoring Committee — Mark Hlatky, M.D., Daniel B. Mark, M.D., M.P.H., and Kerry L. Lee, Ph.D.; and University of Vermont Core Hematology Laboratory — David Stump. M.D., Desire Collen, M.D., Ph.D., and Dagnija Thornton, B.S.

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