A comparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. Myocardial Infarction Triage and Intervention Investigators

Achieving the earliest possible reperfusion in patients with acute coronary syndrome: a current overview

Acute coronary syndrome (ACS) remains one of the leading causes of mortality worldwide. Appropriate management of ACS will lead to a lower incidence of cardiac arrest. Percutaneous coronary intervention (PCI) is the first-line treatment for patients with ACS. PCI techniques have become established. Thus, the establishment of a system of health care in the prehospital and emergency department settings is needed to reduce mortality in patients with ACS. In this review, evidence on how to achieve earlier diagnosis, therapeutic intervention, and decision to reperfuse with a focus on the prehospital and emergency department settings is systematically summarized. The purpose of this review is to generate current, evidence-based consensus on scientific and treatment recommendations for health care providers who are the initial points of contact for patients with signs and symptoms suggestive of ACS.

Comparing mortality between fibrinolysis and primary percutaneous coronary intervention in patients with acute myocardial infarction: a systematic review and meta-analysis of 27 randomized-controlled trials including 11 429 patients

OBJECTIVES

We aimed to improve the limitations encountered in previously published studies and then compare mortality in patients with acute myocardial infarction (AMI) who were treated with either fibrinolysis or a primary percutaneous coronary intervention (PPCI).

METHODS

EMBASE, MEDLINE, and the Cochrane databases were searched for trials comparing fibrinolysis with PPCI in patients with AMI. The only endpoint that was assessed in this analysis was all-cause mortality. Therefore, in-hospital, short-term, mid-term, and long-term mortality were analyzed, whereby odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the RevMan 5.3.

RESULTS

A total of 11 429 patients obtained from 37 studies (involving 27 trials) were included. The results of this analysis showed that fibrinolytic therapy was associated with significantly higher in-hospital and mid-term mortality (OR: 0.61; 95% CI: 0.46-0.82, P=0.001 and OR: 0.73; 95% CI: 0.54-0.99, P=0.04, respectively). Short-term and long-term mortality were also significantly higher in the fibrinolytic group (OR: 0.76; 95% CI: 0.65-0.90, P=0.001, and OR: 0.82; 95% CI: 0.71-0.96, P=0.01, respectively) compared with PPCI.

CONCLUSION

This analysis of 11 429 patients showed a significantly higher mortality rate to be associated with fibrinolysis compared with PPCI in these patients with AMI. Hence, compared with fibrinolysis, PPCI is expected to be the preferred method of revascularization in patients with AMI, especially in PCI-capable centers.

Reperfusion Damage - A Story of Success, Failure, and Hope

Tissue salvage of severely ischemic myocardium requires timely reperfusion by thrombolysis, angioplasty, or bypass. However, recovery of left ventricular function is rare. It may be absent or, even worse, reperfusion can induce further damage. Laboratory studies have shown convincingly that reperfusion can increase injury over and above that attributable to the pre-existing ischemia, precipitating arrhythmias, suppressing the recovery of contractile function ("stunning") and possibly even causing cell death in potentially salvable ischemic tissue. The mechanisms of reperfusion injury have been widely studied and, in the laboratory, it can be attenuated or prevented. Disappointingly, this is not the case in the clinic, particularly after thrombolysis or primary angioplasty. In contrast, excellent results have been achieved by surgeons by means of cardioplegia and hypothermia. For the interventionist, the issue is more complex as, contrary to cardiac surgery where the cardioplegia can be applied before ischemia and the heart can be stopped, during an angioplasty the heart still has to beat to support the circulation. We analyze in detail all these issues.

Door to Needle Times Bulls' Eye or Just Bull? The Effect of Reducing Door to Needle Times on the Appropriate Administration of Thrombolysis: Implications and Recommendations

The provision of thrombolysis in a timely fashion is the mainstay of treatment for acute myocardial infarction. With the publication of the National Service Framework (NSF) for Coronary Heart Disease increasing efforts have been put into the reduction of the ‘pain to needle time’. Of the various parts of the patient journey the time delays in hospital are the easiest to resolve. Published research shows that the time taken for the patient to call for help is intractable at present. Therefore, the obvious target for the reduction in the overall time from pain to treatment is the in hospital portion of the delay (the door to needle time). There are several methods that have been recommended for the reduction of the door to needle time. However, the increasing focus on the door to needle time is leading health care providers away from other issues such as the safety and accuracy of assessment by a non-cardiologist. Furthermore, the standards for audit of the door to needle time have not been set by the NSF and this has led to the presentation of selected data and the avoidance of discussing issues of accuracy and appropriateness.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

Evaluation of Acute Myocardial Infarction In-hospital Mortality Using a Risk-adjustment Model Based on Japanese Administrative Data

This study aimed to develop a new risk-adjustment method to assess acute myocardial infarction (AMI) in-hospital mortality. Risk-adjustment was based on variables obtained from administrative data from Japanese hospitals, and included factors such as age, gender, primary diagnosis and co-morbidity. The infarct location was determined using the criteria of the International Classification of Diseases (10th version). Potential co-morbidity risk factors for mortality were selected based on previous studies and their critical influence analysed to identify major co-morbidities. The remaining minor co-morbidities were then divided into two groups based on their medical implications. The major co-morbidities included shock, pneumonia, cancer and chronic renal failure. The two minor co-morbidity groups also demonstrated a substantial impact on mortality. The model was then used to assess clinical performance in the participating hospitals. Our model reliably employed the available data for the risk-adjustment of AMI mortality and provides a new approach to evaluating clinical performance.

Economic evidence of interventions for acute myocardial infarction: a review of the literature

AIMS

The aims of this review are to identify and evaluate studies exploring the cost-effectiveness of primary angioplasty (PPCI) vs. thrombolysis (TL) for treating acute myocardial infarction (AMI).

METHODS AND RESULTS

A comprehensive free-text searching identified economic evaluation studies that were reviewed with respect to their effectiveness data, identification, measurement and valuation of resource data, measurement and valuation of health outcomes (clinical and QALYs) and uncertainty analysis. A total of 14 studies were included in the review: seven were economic evaluations alongside RCTs, two community-based studies or registries and five decision-analytical models. PPCI was found to be cost-effective when compared with TL in eight studies, cost-saving in three, cost-neutral in one, and not significantly different in terms of both cost and benefits in two studies.

CONCLUSIONS

The cost-effective evidence available is mainly derived from RCTs with stringent inclusion criteria using established catheter laboratories for providing PPCI treatment; these two components might restrict the generalisability of their "for managing patients with STEMI in hospital" settings. In order to aid policy makers on the real costs and benefits of the PPCI and TL, it is necessary to conduct more analyses with data from the real world in which there are more strategies evaluated for delivering PPCI than merely those in established catheter laboratories.

Impact of cardiac care variation on ST-elevation myocardial infarction outcomes in Malaysia

Developing countries face challenges in providing the best reperfusion strategy for patients with ST-segment elevation myocardial infarction because of limited resources. This causes wide variation in the provision of cardiac care. The aim of this study was to assess the impact of variation in cardiac care provision and reperfusion strategies on patient outcomes in Malaysia. Data from a prospective national registry of acute coronary syndromes were used. Thirty-day all-cause mortality in 4,562 patients with ST-segment elevation myocardial infarctions was assessed by (1) cardiac care provision (specialist vs nonspecialist centers), and (2) primary reperfusion therapy (thrombolysis or primary percutaneous coronary intervention [P-PCI]). All patients were risk adjusted by Thrombolysis In Myocardial Infarction (TIMI) risk score. Thrombolytic therapy was administered to 75% of patients with ST-segment elevation myocardial infarctions (12% prehospital and 63% in-hospital fibrinolytics), 7.6% underwent P-PCI, and the remainder received conservative management. In-hospital acute reperfusion therapy was administered to 68% and 73% of patients at specialist and nonspecialist cardiac care facilities, respectively. Timely reperfusion was low, at 24% versus 31%, respectively, for in-hospital fibrinolysis and 28% for P-PCI. Specialist centers had statistically significantly higher use of evidence-based treatments. The adjusted 30-day mortality rates for in-hospital fibrinolytics and P-PCI were 7% (95% confidence interval 5% to 9%) and 7% (95% confidence interval 3% to 11%), respectively (p = 0.75). In conclusion, variation in cardiac care provision and reperfusion strategy did not adversely affect patient outcomes. However, to further improve cardiac care, increased use of evidence-based resources, improvement in the quality of P-PCI care, and reduction in door-to-reperfusion times should be achieved.

Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation Bias

Background—

Meta-analysis of registries (comparative effectiveness research) shows that primary angioplasty and fibrinolysis have equivalent real-world survival. Yet, randomized, controlled trials consistently find primary angioplasty superior. Can unequal allocation of higher-risk patients in registries have masked primary angioplasty benefit?

Methods and Results—

First, we constructed a model to demonstrate the potential effect of allocation bias. We then analyzed published registries (55022 patients) for allocation of higher-risk patients (Killip class ≥1) to determine whether the choice of reperfusion therapy was affected by the risk level of the patient. Meta-regression was used to examine the relationship between differences in allocation of high-risk patient to primary angioplasty or fibrinolysis and mortality. Initial modeling suggested that registry outcomes are sensitive to allocation bias of high-risk patients. Across the registries, the therapy receiving excess high-risk patients had worse mortality. Unequal distribution of high-risk status accounted for most of the between-registry variance (adjusted R 2 meta =83.1%). Accounting for differential allocation of higher-risk patients, primary angioplasty gave 22% lower mortality (odds ratio, 0.78; 95% confidence interval, 0.64–0.97; P =0.029). We derive a formula, called the number needed to abolish, highlighting situations in which comparative effectiveness studies are particularly vulnerable to this bias.

Conclusions—

In ST-segment elevation myocardial infarction, clinicians’ preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.

Primary coronary intervention versus thrombolytic therapy in myocardial infarction patients in the Middle East

BACKGROUND

Little is known about predictors and outcome differences of primary percutaneous coronary intervention (PPCI) and thrombolytic therapy (TT) in ST-segment elevation myocardial infarction (STEMI) patients in the Middle East.

OBJECTIVE

To compare predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients in six Middle Eastern countries.

SETTING

Sixty-five hospitals (covering at least 85 % of the population) in Oman, United Arab Emirates, Qatar, Bahrain, Kuwait and Yemen.

METHODS

This was a prospective, multinational, multicentre, observational survey of consecutive acute coronary syndrome patients who were admitted to 65 hospitals during May 8, 2006 to June 6, 2006 and from January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were performed using univariate and multivariate statistical techniques.

MAIN OUTCOME MEASURES

Predictors as well as in-hospital outcomes of PPCI and TT in STEMI patients.

RESULTS

Out of 2,155 STEMI patients admitted to hospitals within 12 h of symptoms onset, 92 % received reperfusion (8 % PPCI and 84 % TT). TT use included reteplase (43 %), tenecteplase (30 %), streptokinase (25 %), and alteplase (2 %). Median age of the study cohort was 50 (44-58) years with majority being males (90 %). There were no significant differences in median onset time to presentation between the TT and PPCI groups (130 vs. 120 min; P = 0.422). Median door-to-needle time and door-to-balloon time were 45 min (29-75) and 75 min (58-120), respectively. Predictors of PPCI included prior PCI, hospitals with catheterization laboratory facilities as well as those involved with academia. Multivariate logistic regression model demonstrated that patients that had PPCI were less likely to have recurrent ischemic attacks than those that had TT (odds ratio, 0.18; 95 % CI, 0.06-0.56; P = 0.003).

CONCLUSIONS

The main reperfusion strategy for STEMI patients in the Arab Middle East region is thrombolytic therapy. Predictors of primary percutaneous coronary intervention included prior percutaneous coronary intervention, hospitals with catheterization laboratory facilities as well as those involved with academia. Primary percutaneous coronary intervention resulted in significant reductions in recurrent ischemic events when compared to thrombolytic therapy.

Comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies

BACKGROUND

Primary percutaneous coronary intervention (PCI) is more effective on average than fibrinolytic therapy in the treatment of ST-segment-elevation myocardial infarction. Yet, most US hospitals are not equipped for PCI, and fibrinolytic therapy is still widely used. This study evaluated the comparative effectiveness of ST-segment-elevation myocardial infarction regionalization strategies to increase the use of PCI against standard emergency transport and care.

METHODS AND RESULTS

We estimated incremental treatment costs and quality-adjusted life expectancies of 2000 patients with ST-segment-elevation myocardial infarction who received PCI or fibrinolytic therapy in simulations of emergency care in a regional hospital system. To increase access to PCI across the system, we compared a base case strategy with 12 hospital-based strategies of building new PCI laboratories or extending the hours of existing laboratories and 1 emergency medical services-based strategy of transporting all patients with ST-segment-elevation myocardial infarction to existing PCI-capable hospitals. The base case resulted in 609 (95% CI, 569-647) patients getting PCI. Hospital-based strategies increased the number of patients receiving PCI, the costs of care, and quality-adjusted life years saved and were cost-effective under a variety of conditions. An emergency medical services-based strategy of transporting every patient to an existing PCI facility was less costly and more effective than all hospital expansion options.

CONCLUSION

Our results suggest that new construction and staffing of PCI laboratories may not be warranted if an emergency medical services strategy is both available and feasible.

Implications of the mechanical (PCI) vs thrombolytic controversy for ST segment elevation myocardial infarction on the organization of emergency medical services: the Boston EMS experience

With the many advances in rapid reperfusion therapy for management of acute ST segment elevation myocardial infarction (STEMI), there is a need to revisit the current plan for prehospital triage (point of entry). Until recently in Boston, and nationwide, there has been a policy that patients with suspected acute MI were brought to the nearest hospital. Then, if ST segment elevation was present, patients were treated with either thrombolytic therapy or primary percutaneous coronary intervention (PCI). Recent data, however, have shown that with advances in interventional devices, techniques and institutional experience, primary PCI is associated with improved outcomes compared with thrombolytic therapy for all patients with STEMI when provided at expert centers with high institutional volumes, with experienced interventional cardiologists as the operators, and with relatively short time to treatment. We describe the rationale for and the implementation of the Boston EMS STEMI Triage Plan and Treatment Registry. Many of the issues that prompted the implementation of the Boston STEMI plan are relevant to all EMS systems. Among these issues are the accuracy of prehospital identification of STEMI patients, the availability of mechanical reperfusion therapy, the appropriate triage of patients with complicated myocardial infarction or shock, as well as the local consensus regarding strength of the evidence favoring mechanical reperfusion. This article describes the history of the Boston EMS STEMI Triage Plan and Treatment Registry and suggests the need for other EMS systems to develop a systematic approach to patients with STEMI.

Outcomes Among Patients With ST-Segment–Elevation Myocardial Infarction Presenting to Interventional Hospitals With and Without On-Site Cardiac Surgery

Background— Primary percutaneous coronary intervention (pPCI) is the preferred reperfusion strategy for patients with ST-segment–elevation myocardial infarction (STEMI). The quality of care and safety and efficacy of pPCI at hospitals without on-site open heart surgery (No-OHS hospitals) remains an area of active investigation.

Methods and Results— The National Registry of Myocardial Infarction enrolled 58 821 STEMI patients from 214 OHS hospitals (n=54 076) and 52 No-OHS hospitals (n=4745) with PCI capabilities from 2004 to 2006. Patients presenting to OHS hospitals had substantially lower in-hospital mortality (7.0% versus 9.8%, P <0.001) and were more likely to receive any form of acute reperfusion therapy (80.8% versus 70.8%, P <0.001). Patients who presented to OHS hospitals were more likely to receive guideline recommended medications within 24 hours of arrival. In a propensity score model matching for patient characteristics and transfer status, in-hospital mortality remained significantly lower among patients presenting to OHS hospitals (7.2% versus 9.3%, P =0.025). When this model was further adjusted for differences in the use of acute reperfusion therapy, medications administered within 24 hours and hospital characteristics, the mortality difference was of borderline significance (hazard ratio, 0.87; 95% CI, 0.75 to 1.01; P =0.067). When the propensity score analysis was restricted to patients who underwent pPCI, there was no significant difference in mortality (3.8% versus 3.3%, P =0.44).

Conclusions— STEMI patients presenting to No-OHS hospitals have substantially higher mortality, are less likely to receive guideline recommended medications within 24 hours, and are less likely to undergo acute reperfusion therapy, although this difference was of borderline significance after adjusting for hospital and treatment variables. There was no difference in mortality among patients undergoing pPCI.

Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access

BACKGROUND

In primary angioplasty (primary percutaneous coronary intervention [PPCI]) for acute myocardial infarction, institutional logistical delays can increase door-to-balloon times, resulting in increased mortality.

METHODS

We moved from a thrombolysis (TL) service to 24/7 PPCI for direct access and interhospital transfer in April 2004. Using autonomous ambulance diagnosis with open access to the myocardial infarction center catheter laboratory, we compared reperfusion times and clinical outcomes for the final 2 years of TL with the first 3 years of PPCI.

RESULTS

Comparison was made between TL (2002-2004, n = 185) and PPCI (2004-2007, n = 704); all times are medians in minutes (interquartile range): for TL, symptom to needle 153 (85-225), call to needle 58 (49-73), first professional contact (FPC) to needle 47 (39-63), door to needle 18 (12-30) (mortality: 7.6% at 30 days, 9.2% at 1 year); for interhospital transfer PPCI (n = 227), symptom to balloon 226 (175-350), call to balloon 135 (117-188), FPC to balloon 121 (102-166), first door-to-balloon 100 (80-142) (mortality: 7.0% at 30 days, 12.3% at 1 year); for direct-access PPCI (n = 477), symptom to balloon 142 (101-238), call to balloon 79 (70-93), FPC to balloon 69 (59-82), door to balloon 20 (16-29) (mortality: 4.6% at 30 days, 8.6% at 1 year). There was no difference between direct-access PPCI and TL times for symptom to needle/balloon. Direct-access PPCI was significantly quicker for the group than in-hospital thrombolysis for door to needle/balloon times due to the lack of any long wait patients (P < .001).

CONCLUSIONS

Interhospital transfer remains slow even with rapid institutional door-to-balloon times. With autonomous ambulance diagnosis and open access direct to the catheter laboratory, a median door-to-balloon time of <30 minutes day and night was achieved, and >95% of patients were reperfused within 1 hour.

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

Background— Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.

Methods and Results— We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.

Conclusions— Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.

Severity of residual stenosis of infarct-related lesion and left ventricular function after single-vessel anterior wall myocardial infarction: implication of ST-segment elevation in lead aVL of the admission electrocardiograms

BACKGROUND

The relationship between the severity of chronic-phase stenosis of infarct-related lesions (IRLs) and chronic left ventricular function in anterior acute myocardial infarctions (AMI) has not been adequately investigated.

HYPOTHESIS

This study investigated whether ST elevation in lead aVL of admission electrocardiogram (ECG) would be a determinant factor of the relationship between the severity of stenosis of the IRL and chronic left ventricular function after anterior wall AMI.

METHODS

One month after AMI, the IRL was evaluated by coronary angiography in 98 patients with anterior AMI, and left ventricular ejection fraction (LVEF) was determined using multigated radionuclide angiocardiography. Patients were classified according to the severity of the IRL: patients with 100% occlusion (Group O), patients with 90 to 99% stenosis (Group H), and patients with < or =75% stenosis (Group L). Patients with ST elevation > or =0.1 mV in the aVL lead on their admission ECG were included in the ST-elevation group, and those with ST elevation <0.1 mV were included in the non-ST-elevation group.

RESULTS

The LVEF was greater in the non-ST-elevation group than in the ST-elevation group (p<0.0001), and the LVEF in a whole group as follows: Group L LVEF>Group H LVEF>Group O LVEF (p = 0.0160). In the ST-elevation group, LVEF was higher in Group L than in the other groups (p = 0.0251). There were three independent predictors of a reduced LVEF: ST-elevation in aVL [odds ratio (OR): 3.38, p = 0.0044], IRL stenosis > or =90% (OR: 2.90, p = 0.0044), and the IRL occurring in the left anterior descending artery proximal to the first diagonal branch (OR: 6.31, p = 0.0024).

CONCLUSION

Left ventricular function was preserved, regardless of the severity of residual stenosis, in patients without ST elevation in aVL if the IRL was not totally occluded. In patients with ST elevation in aVL, LVEF was lower in patients with more severe stenosis, even if the IRL was patent.

[Treatment of acute coronary syndrome in a small volume center: "survival rate in hospital and at 2 years of follow up"]

We report our experience of the treatment of the coronary syndrome ST+ in a small volume center.

PATIENTS AND METHODS

For a period of 1 year (September 2004 to September 2005), 110 patients were treated by emergency coronarography at the hospital in Vichy (France). These patients were followed up for a period of 2 years.

RESULTS

This population was relatively elderly: 43.6% of the patients were above 75 years of age. One hundred patients (91%) were treated by emergency angioplasty with a success rate of 88%. The average waiting time for treatment in the coronarography ward is 55 minutes and 35 seconds. Mortality in hospital is 6.36% for the totally of the population. It should be noted that 10.9% of these patients were admitted in a state of cardiogenic shock (12 patients), 3 of whom (25%) have died. 3 of these received a CPIA. At the end of an average follow-up of 21.44 months the survival rate is 83.6%, including and incident-free survival rate of 61.8%.

CONCLUSION

These results, comparable with what has been published in the literature, confirm the effectiveness of emergency coronary angioplasty as a method of revascularization even in a small volume center, in respect both of the survival rate in hospital and also of incident-free survival at 2 years.

[Results of percutaneous coronary intervention in a hospital with a low case load]

Since efficacy of small volume centers performing coronary and angioplasty is questioned, we present our data for 2003. In 2003, 669 coronary examinations were performed in our unit (average age 68 years, 67% men) with 215 angioplasties. We take charge essentially Acute Coronary Syndrome (99%), with 37% ACS ST +. The radical approach was taken in 15% of cases. We used anti GP IIb/IIIa in 67% of cases (only abciximab), the rate of stenting was 84% with 43.6% of Direct Stenting. The primary angiographic results were good in 98% of cases. The rate of Restenosis was 6%. The hospital mortality was 2.8%. So we think that coronary and angioplasty in a small volume center can be performed with safety and a level of success in accordance with the data of the literature.

Characteristics and outcome of patients with ST-elevation infarction in relation to whether they received thrombolysis or underwent acute coronary angiography: are we selecting the right patients for coronary angiography?

BACKGROUND

During the last decade, there has been an on-going debate with regard to whether percutaneous coronary intervention (PCI) or thrombolysis should be preferred in patients with ST-elevation acute myocardial infarction (AMI). Some studies clearly advocate PCI, while others do not.

HYPOTHESIS

The study aimed to describe the characteristics and to evaluate outcome of patients with suspected ST-elevation or left bundle-branch block infarction in relation to whether they received thrombolysis or had an acute coronary angiography aiming at angioplasty.

METHODS

The study included all patients admitted to Sahlgrenska University Hospital in Göteborg, Sweden, with suspected acute myocardial infarction who, during 1995-1999, had ST-elevation or left bundle-branch block on admission electrocardiogram (ECG) requiring either thrombolysis or acute coronary angiography. A retrospective evaluation with a follow-up of 1 year after the intervention was made.

RESULTS

In all, 413 patients had thrombolytic treatment and 400 had acute coronary angiography. The patients who received thrombolysis were older (mean age 70.3 vs. 64.1 years). Mortality during 1 year of follow-up was 20.9% in the thrombolysis group and 16.6% in the angiography group (p = 0.12). Among patients in whom acute coronary angiography was performed, only 85% underwent acute percutaneous coronary intervention (PCI). There was a mortality of 12.1 vs. 41.7% among those who did not undergo acute PCI. Development of reinfarction, stroke, and requirement of rehospitalization was similar regardless of type of initial intervention. The thrombolysis group more frequently required new coronary angiography (36.9 vs. 20.6%; p<0.0001) and new PCI (17.8 vs. 11.9%; p = 0.01). Despite this, after 1 year symptoms of angina pectoris were observed in 27% of patients in the thrombolysis group and in only 14% of those in the angiography group (p = 0.0002).

CONCLUSION

In a Swedish university hospital with a high volume of coronary angioplasty procedures, we found no significant difference in mortality between patients who had thrombolysis and those who underwent acute coronary angiography. However, requirement of revascularization and symptoms of angina pectoris 1 year later was considerably less frequent in those who had undergone acute coronary angiography. However, distribution of baseline characteristics was skewed and efforts should be focused on the selection of patients for the different reperfusion strategies.

Ultrasound-induced cavitation: applications in drug and gene delivery

Ultrasound, which has been conventionally used for diagnostics until recently, is now being extensively used for drug and gene delivery. This transformation has come about primarily due to ultrasound-mediated acoustic cavitation - particularly transient cavitation. Acoustic cavitation has been used to facilitate the delivery of small molecules, as well as macromolecules, including proteins and DNA. Controlled generation of cavitation has also been used for targeting drugs to diseased tissues, including skin, brain, eyes and endothelium. Ultrasound has also been employed for the treatment of several diseases, including thromboembolism, arteriosclerosis and cancer. This review provides a detailed account of mechanisms, current status and future prospects of ultrasonic cavitation in drug and gene delivery applications.

Door-to-balloon delays with percutaneous coronary intervention in ST-elevation myocardial infarction

The benefits of reperfusion in ST-elevation myocardial infarction are time-dependent no matter if epicardial blood flow is restored with primary percutaneous coronary intervention (PCI) or fibrinolysis. Rapid, sustained, and early restoration of flow in the infarct-related artery is necessary to minimize myocardial damage and to improve clinical outcomes. Though fibrinolytic therapy is widely available, it is limited by unpredictable efficacy, reinfarction, and intracranial hemorrhage. PCI has predictable success in opening the artery but is limited by delays in implementation, particularly in transfer patients. The selection of PCI or fibrinolytic therapy for ST-elevation myocardial infarction should be based on knowledge of the benefits and limitations of each strategy. While PCI is the superior strategy if employed rapidly by competent personnel, fibrinolytic therapy should be considered when significant delays to implementation of PCI are anticipated. Continued efforts, aimed at reducing the time to therapy with PCI and fibrinolysis, are of paramount importance.

Impact of infarct location on left ventricular ejection fraction after correction for enzymatic infarct size in acute myocardial infarction treated with primary coronary intervention

BACKGROUND

Left ventricular function and infarct size are strong predictors for prognosis after acute myocardial infarction (MI). Anterior MI is associated with greater reduction of left ventricular ejection fraction (LVEF) and worse prognosis. Our objective was to study whether the impact of infarct size on global LVEF is dependent of infarct location.

METHODS

We analyzed 888 patients treated with primary percutaneous coronary intervention for acute MI. Enzymatic infarct size and LVEF within 1 week were measured. In 490 patients (55%), LVEF was measured a second time at 6 months.

RESULTS

Every 1000 U/L of cumulative lactate dehydrogense release corresponded to a decrease of 4.7% (95% CI 4.1-5.3) in LVEF measured within 1 week post MI for left anterior descending coronary artery (LAD)-related infarcts and to a decrease of 2.4% (95% CI 1.7-3.1) in LVEF measured within 1 week post MI for non-LAD-related infarcts (P < .0001). Left ventricular ejection fraction measured 6 months post MI showed a decrease for every 1000 U/L cumulative lactate dehydrogense release of 4.8% (95% CI 4.2-5.3) for LAD and 2.4% (95% CI 1.7-3.1) for non-LAD-related infarcts (P < .0001). Multivariate correction for relevant clinical and angiographic data did not change these results.

CONCLUSION

In patients with a first acute MI treated with primary percutaneous coronary intervention, LAD-related infarcts show for a similar amount of myocardial necrosis as determined by enzymatic infarct size, a lower residual LVEF when compared with non-LAD-related infarcts.

Effect of coronary occlusion site on angiographic and clinical outcome in acute myocardial infarction patients treated with early coronary intervention

In acute myocardial infarction that is treated with thrombolysis, proximal coronary artery occlusion is associated with worse prognosis, irrespective of the infarcted artery. Primary percutaneous coronary intervention (PCI) is currently the treatment of choice for ST-segment elevation acute myocardial infarction. Therefore, we evaluated the prognostic significance of proximal versus distal coronary artery occlusion in patients with acute myocardial infarction that was treated with primary PCI. Between 1994 and 2001, patients with a first acute myocardial infarction that was treated with primary PCI were analyzed. A lesion was considered proximal if it was located proximal to the first diagonal branch in the left anterior descending coronary artery (LAD), the first marginal obtuse branch in the left circumflex coronary artery, and the first right acute marginal branch in the right coronary artery. Lesions distal of these side branches were considered distal. In total, 1,468 patients were analyzed. Left ventricular ejection fraction (LVEF) for proximal LAD lesions was lower than that for distal ones (37 +/- 11% vs 42 +/- 11%, p <0.0001). Adjusted relative risk of 3-year mortality for proximal versus distal LAD was 4.04 (95% confidence interval 1.95 to 8.38). In patients with infarcts related to the right or left circumflex coronary artery, no significant association between lesion location and LVEF or mortality was seen. No difference was seen in adjusted 3-year mortality between distal LAD and non-LAD-related infarcts (p = 0.145). In conclusion, our analysis shows that, even in patients with acute myocardial infarction that is treated with primary PCI, infarcts related to the proximal LAD have the worst 3-year survival and lowest residual LVEF compared with distal LAD or non-LAD-related infarcts.

Does time matter? A pooled analysis of randomized clinical trials comparing primary percutaneous coronary intervention and in-hospital fibrinolysis in acute myocardial infarction patients

AIMS

Although outcomes after acute myocardial infarction (AMI) seemed to be superior with primary percutaneous coronary intervention (PPCI) relative to fibrinolysis (FL), the extent to which treatment delay modulates this treatment effect is unclear.

METHODS AND RESULTS

Twenty-five randomized trials (n = 7743) testing the efficacy of PPCI vs. FL were identified in journal articles and abstract listings published between 1990 and 2002. Of these, individual patient data from 22 trials (n = 6763) were pooled, and multi-level logistic regression assessed the relationship among treatment, treatment delay, and 30-day mortality. Treatment delay was divided into 'presentation delay' [symptom onset to randomization; FL: median 143 (IQR: 91-225) min; PPCI: 140 (91-220) min] and hospital-specific 'PCI-related delay' [median time from randomization to PPCI minus median time to FL per hospital; median 55 (IQR: 37-74) min]. PPCI was associated with a significant 37% reduction in 30-day mortality [adjusted OR, 0.63; 95% CI (0.42-0.84)]. Although, there was no heterogeneity in the treatment effect by presentation delay (pBreslow-Day = 0.88), the absolute mortality reduction by PPCI widened over time (1.3% 0-1 h to 4.2% >6 h after symptom onset). When the PCI-related delay was <35 min, the relative (67 vs. 28% pBreslow-Day = 0.004) and absolute (5.4 vs. 2.0%) mortality reduction was significantly higher than those with longer delays.

CONCLUSION

PPCI was associated with significantly lower 30-day mortality relative to FL, regardless of treatment delay. Although logistic and economic constraints challenge the feasibility of 'PPCI-for-all', the benefit of timely treatment underscores the importance of a comprehensive, unified approach to delivery of cardiac care in all AMI patients.

A multistate comparison of patient characteristics, outcomes, and treatment practices in acute myocardial infarction

The primary purpose of this study was to examine variations in patient characteristics, outcomes, and treatment practices in acute myocardial infarction (AMI) across 11 states. Data from 11 states were extracted from the Healthcare Cost and Utilization Project State Inpatient Dataset. Patients who had a primary diagnosis of AMI (International Classification of Diseases, Ninth Revision, Clinical Modification, code 410.x1) from 11 states were extracted from the Healthcare Cost and Utilization Project 1999 dataset. Bivariate comparisons were conducted to examine the characteristics, treatment practices, and outcomes of patients who had AMI. Multivariate regression models were used to examine the association between geographic location (and other factors) and the likelihood of in-hospital mortality, undergoing coronary artery bypass grafting (CABG), or percutaneous coronary interventions (PCIs). Results revealed considerable variations across states in practice patterns and treatment outcomes. New York had the highest average length of stay (8.2 days, p <0.01), rate of patients who had AMI being transferred (20.7%, p <0.01), and in-hospital case fatality rate (10.7%, p <0.01) and the lowest rate of alive discharges being routine (65.6%, p <0.01). PCI was performed 2 times as often as CABG for patients who had AMI (23.9% vs 11.3%, p <0.01), with patients who underwent CABG being transferred more often. Multivariate analyses showed that state of residence, age, female gender, transfer status, and number of co-morbidities were predictors of in-hospital mortality and the likelihood of undergoing CABG or PCI. In conclusion, large differences in practice patterns and treatment outcomes exist across states.

Trends in reperfusion therapy of ST segment elevation myocardial infarction in Switzerland: six year results from a nationwide registry

OBJECTIVE

To document the trends in reperfusion therapy for ST segment elevation myocardial infarction (STEMI) in Switzerland.

DESIGN

National prospective multicentre registry, AMIS Plus (acute myocardial infarction and unstable angina in Switzerland), of patients admitted with acute coronary syndromes.

SETTING

54 hospitals of varying size and capability in Switzerland.

PATIENTS

7098 of 11 845 AMIS Plus patients who presented with ST segment elevation or left bundle branch block on the ECG at admission.

MAIN OUTCOME MEASURES

In-hospital mortality and its predictors at admission by multivariate analysis.

RESULTS

The proportion of patients treated by primary percutaneous coronary intervention (PCI) progressively increased from 1997 to 2002, while the proportion with thrombolysis or no reperfusion decreased (from 8.0% to 43.1%, from 47.2% to 25.6%, and from 44.8% to 31.4%, respectively). Overall in-hospital mortality decreased over the study period from 12.2% to 6.7% (p < 0.001). Main in-hospital mortality predictors by multivariate analysis were primary PCI (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.33 to 0.81), thrombolysis (OR 0.63, 95% CI 0.47 to 0.83), and Killip class III (OR 3.61, 95% CI 2.49 to 5.24) and class IV (OR 5.97, 95% CI 3.51 to 10.17) at admission. When adjusted for the year, multivariate analysis did not show PCI to be significantly superior to thrombolysis for in-hospital mortality (OR 1.2 for PCI better, 95% CI 0.8 to 1.9, p = 0.42).

CONCLUSION

Primary PCI has become the preferred mode of reperfusion for STEMI since 2002 in Switzerland, whereas use of intravenous thrombolysis has decreased from 1997 to 2002. Furthermore, there was a major reduction of in-hospital mortality over the same period.

Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

The rupture of an atherosclerotic plaque in an epicardial coronary artery with subsequent occlusive coronary thrombosis has been established as the decisive event in the pathogenesis of an acute coronary syndrome, which encompasses the clinical entities of unstable angina, non-ST- and ST-elevation myocardial infarction. This article focuses on contemporary treatment strategies for patients with acute ST-elevation myocardial infarction and reviews the role of pharmacologic thrombolysis and mechanical reperfusion by percutaneous transluminal approaches. Statements of the latest guidelines for the treatment of ST-elevation myocardial infarction are included, as well as some recently distributed information not covered by the guideline publications. Finally, some future perspectives for the treatment of acute ST-elevation myocardial infarction are outlined.

High Serum Erythropoietin Level Is Associated With Smaller Infarct Size in Patients With Acute Myocardial Infarction Who Undergo Successful Primary Percutaneous Coronary Intervention

OBJECTIVES

We investigated whether a higher serum erythropoietin (EPO) level in patients with acute myocardial infarction (MI) subjected to successful primary percutaneous coronary intervention (PCI) can predict a smaller infarct size determined by creatine kinase (CK) release.

BACKGROUND

Erythropoietin has been shown to protect cardiomyocytes from ischemia-reperfusion injury in rodents.

METHODS

We prospectively studied 101 patients with first MI who received successful primary PCI within 12 h from the onset of MI. Blood samples were collected to examine the serum EPO level after the primary PCI and within 24 h from the onset of MI.

RESULTS

The peak CK level and cumulative CK release were significantly lower in the above-median EPO group than in the below-median EPO group. Thrombolysis In Myocardial Infarction (TIMI) grades and collateral grades before PCI, infarct-related coronary arteries, time to the successful reperfusion from the onset of MI, and serum creatinine levels were similar in the two EPO groups. A stepwise multiple regression analysis revealed that the absolute serum EPO level (mU/ml) as well as TIMI grades after PCI and preinfarction angina was an independent predictor for the cumulative CK release.

CONCLUSIONS

These data suggest that a high endogenous EPO level can predict a smaller infarct size in patients with acute MI subjected to successful primary PCI. This might be attributed to the potentially protective effect of endogenous EPO against ischemia-reperfusion injury in humans.

[Long-term follow-up after primary angioplasty: is stenting beneficial?]

BACKGROUND

Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI).

OBJECTIVES

The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction.

METHODS

We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR).

RESULTS

The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different.

CONCLUSION

In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.

Primary percutaneous coronary intervention versus thrombolytic treatment: long term follow up according to infarct location

OBJECTIVES

To study the clinical significance of infarct location during long term follow up in a trial comparing thrombolysis with primary angioplasty.

DESIGN

Retrospective longitudinal cohort analysis of prospectively entered data.

SETTING

Patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI).

PATIENTS

In the Zwolle trial 395 patients with acute STEMI were randomly assigned to intravenous streptokinase or PCI.

MAIN OUTCOME MEASURES

Survival according to infarct location and treatment after 8 (2) years of follow up.

RESULTS

105 patients died: 63 patients in the streptokinase group and 42 patients in the primary PCI group (relative risk (RR) 1.6, 95% confidence interval (CI) 1.0 to 2.6; p = 0.03). In patients with non-anterior STEMI there was no difference in mortality between streptokinase and PCI treated patients (RR 1.1, 95% CI 0.6 to 2.1; p = 0.68) but the streptokinase group had significantly more major adverse cardiac events (MACE) than the PCI group (RR 2.1, 95% CI 1.2 to 3.6). The number needed to treat to prevent one MACE was four. In patients with anterior STEMI, mortality was higher in the streptokinase group than in the PCI group (RR 2.7, 95% CI 1.4 to 5.5; p = 0.004). The number needed to treat to prevent one death was five. Kaplan-Meier analysis confirmed the benefits of primary angioplasty in the first year and showed additional benefit of PCI compared with streptokinase between 1-8 years after the acute event.

CONCLUSIONS

Patients with anterior STEMI have better long term survival when treated with PCI than with streptokinase. In patients alive one year after the acute event, PCI confers a significant additional survival benefit, probably due to better preserved residual left ventricular function.

Recommendations of the International Guidelines 2000 Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care: An Overview

The greatest potential for survival of sudden cardiac arrest can be achieved only by providing early intervention using evidence-based therapies that have been studied over time. Emergency cardiac care and the 2000 advanced cardiac life support guidelines encompass all therapies that have been shown to improve outcomes in patients who experience life-threatening events that involve the cardiovascular, cerebrovascular, and pulmonary systems. Early recognition of warning signs, activation of emergency medical systems within the community, basic cardiopulmonary resuscitation, early defibrillation, airway management, and intravenous medication administration are key factors in improving resuscitation outcomes.

Primary angioplasty in acute myocardial infarction: Hypothetical estimate of superiority over aspirin or untreated controls

BACKGROUND

Primary percutaneous transluminal coronary angioplasty (PTCA) in the setting of ST-segment-elevation myocardial infarction has been compared with intravenous thrombolysis, but its effects versus no treatment are not known. Knowledge of the effects of PTCA in this setting is useful as a substantial minority of patients do not receive thrombolysis because of contraindications.

METHODS

A hypothetical primary PTCA versus placebo/control odds ratio was computed using a recently described statistical technique that employed the logarithm of the odds ratios of the pooled results of meta-analyses of PTCA versus thrombolysis and thrombolysis versus placebo or controlled trials.

RESULTS

Using data from 30 trials, the synthesized odds ratio for mortality for primary PTCA versus placebo/untreated controls is 0.56 (95% confidence interval [CI]: 0.46 to 0.68; P <0.00001), consistent with a 44% reduction. Primary PTCA and aspirin reduces mortality by 69% versus no aspirin (OR = 0.31; 95% CI: 0.21 to 0.45; P <0.00001). In a high-risk group of otherwise eligible patients with thrombolysis contraindications, the absolute benefit is estimated as 93 per 1000 treated (95% CI: 53 to 132 per 1000 treated). The risk of stroke is reduced with primary PTCA (OR = 0.46; 95% CI: 0.30 to 0.71; P = 0.0004).

CONCLUSION

In this setting, primary PTCA would hypothetically reduce the short-term risk of death by 44%. Despite the use of aggressive antithrombotic regimens, the risk of stroke would also be reduced substantially with primary PTCA.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Improved performance of a new thrombus aspiration catheter: Outcomes from in vitro experiments and a case presentation

Thrombus vacuum catheter (TVAC) is a new thrombus aspiration catheter. The catheter has a beak-shaped distal tip and a shaft with spring support. Based on in vitro tests, these design features showed improved ability to pass through a simulated coronary artery model with a bend and to aspirate gel. TVAC has an outer diameter of 4.5 Fr and is available with a 7 Fr guide. We report a case of acute myocardial infarction that was successfully treated with TVAC after use of other aspiration devices failed in its treatment. Since protection of microcirculation in coronary reperfusion may be essential in acute myocardial infarction, TVAC is a promising device to help achieve this goal.

Impact of Prehospital Thrombolysis for Acute Myocardial Infarction on 1-Year Outcome

Background— Limited data are available on the impact of prehospital thrombolysis (PHT) in the “real-world” setting.

Methods and Results— Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (≤48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment–elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; P =0.05). When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; P =0.08). In patients with PHT admitted in ≤3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%.

Conclusions— The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.