Role of percutaneous transluminal coronary angioplasty in acute myocardial infarction

The case of GISSI in changing the attitudes and practice of Italian cardiologists

This report first describes the efficiency achieved by a large scale clinical trial (GISSI), which is widely recognized as having made an important contribution to the therapy of AMI, and second emphasizes how a comprehensive research project based upon an innovative clinical trial methodology can influence the attitude and the scientific productivity of a professional community operating within a national health system. To understand the methodology of GISSI, one must appreciate both the cultural and institutional setting in which the first GISSI trial took place as well as the strong economic and scientific expectation surrounding the second GISSI trial.

Sudden paradoxic clinical deterioration during angioplasty of the occluded right coronary artery in acute myocardial infarction

The beneficial versus detrimental effects of emergency coronary angioplasty for achieving myocardial reperfusion remain controversial. We studied 83 consecutive patients treated with angioplasty of occluded (Thrombolysis in Myocardial Infarction trial [TIMI] grade 0 or 1 flow) infarct-related arteries. Seventy patients had unsuccessful intravenous thrombolytic therapy and subsequently had rescue angioplasty and 13 patients had direct angioplasty without prior thrombolytic therapy. Forty-six patients had occlusion of the right coronary artery and 37 of the left anterior descending coronary artery. These two patient groups were similar with respect to age, percent of men, history of prior myocardial infarction, known cardiac risk factors and elapsed time from onset of chest pain to reperfusion. Angioplasty was initially successful in achieving TIMI grade 2 or 3 flow in 87% of right coronary artery occlusions and 92% of left anterior descending artery occlusions (p = 0.47). At 1 week follow-up catheterization, vessel patency was 63% for right coronary and 85% for left anterior descending infarct-related arteries (p = 0.03). Patients with right coronary artery occlusion had a higher incidence of life-threatening complications during angioplasty than did patients with left anterior descending artery occlusion (p = 0.002) including, respectively: 1) the need for cardiopulmonary resuscitation in 16% versus 0% (p = 0.02), 2) sustained ventricular tachycardia or ventricular fibrillation requiring electric cardioversion in 9% versus 3% (p = 0.33), and 3) sustained hypotension requiring inotropic agents or balloon pump therapy in 11% versus 3% (p = 0.16).(ABSTRACT TRUNCATED AT 250 WORDS)