2243
Editorial Comment
Balloon Angioplast for Acute
Myocardial Infarction
Was It Buried Alive?
Bernhard Meier, MD
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
In the setting of acute myocardial infarction,
balloon angioplasty was initially used as a complementary measure in patients with failure or
incomplete success of intracoronary thrombolysis
with streptokinase.1'2 Later, it was recommended for
the prevention of reocclusion after successful thrombolysis if a significant stenosis remained.3-6 Its superiority compared with intracoronary streptokinase
therapy was proved in a randomized trial,7 and it
quickly became the preferred and primary treatment
in many centers equipped for emergency coronary
angiography and angioplasty.8-10 Then the renaissance of intravenous fibrinolysis, triggered by the
advent of clot-specific fibrinolytic agents, laid it to an
See p 1910
early rest. When large-scale randomized trials11,12
invalidated smaller studies advocating a combined
approach,13-15 acute infarction angioplasty seemed
buried for good, much to the relief of spouses of
interventional cardiologists and directors of nonprofit
hospitals with facilities for interventional cardiology.
Currently, however, it is slipping back in through the
rear door under the alias of rescue angioplasty,16
looking for subgroups of patients treated by intravenous fibrinolysis who are in need of a mechanical
procedure.
The article by Kahn et al17 in this issue of Circulation is the latest in a series published by these
researchers on emergency balloon angioplasty for
acute myocardial infarction unassociated with fibrinolysis. The series started with the original report
introducing this concept8 and culminated in a flurry
of recent publications campaigning for the resurrection of acute infarction angioplasty.18-21 Though
there are definitely supporters of this therapy,22-24
others are rather skeptical.25
As with all new treatment modalities and indications, one has to prove that primary coronary angioplasty for treatment of evolving infarction is safe
The opinions expressed in this editorial comment are not necessarily those of the editors or of the American Heart Association.
From the Cardiology Center, University Hospital, Geneva,
Switzerland.
Address for reprints: Bernhard Meier, MD, Cardiology Center,
University Hospital, 1211 Geneva 4, Switzerland.
before one can set out to prove that it is salutary.
Hemorrhagic infarction is hardly an issue with pure
mechanical revascularization because it is not even
taken seriously with fibrinolytic agents. Some reperfusion arrhythmias may occur, but they are even more
manageable in the catheterization laboratory than
they are in the coronary care unit. They are subsumed
under "minor catheterization laboratory events" in
the report by Kahn et al17 and are hardly instrumental
in deterring physicians from primary angioplasty.
However, mechanical irritation of a freshly lysed
thrombus may give rise to new clot formation and
reclosure of the vessel. Such a situation was observed
in about 10% of patients in the various reports on the
combined utilization of fibrinolytic agents and angioplasty for acute infarction.2-4 In fact, this is the major
reason for the poor results of angioplasty when used
after thrombolysis. Direct angioplasty is less subject to
this drawback, because only about 15% of the vessels
will be patent at the beginning of the procedure
compared with about 70% in patients with prior
fibrinolysis. After fibrinolysis, the majority of abrupt
closures following balloon angioplasty count as complications (vessel opened by lytic agent and reoccluded by balloon). With primary angioplasty, they
only count as failures (vessel closed before and after
balloon) because the balloon did not really worsen the
situation. Hence, the beneficial influence of primary
angioplasty on late outcome of reducing residual
stenoses26 comes into play without an initial handicap.
About 90% of arteries will be free of significant
stenoses with angioplasty compared with about 20%
with fibrinolysis.7
What new insights do we get from the paper of
Kahn et al17 in this issue? Primary angioplasty yields,
in terms of vessel patency, results clearly superior to
those expected with fibrinolysis. Acute patency was
more than 90% and in-hospital reocclusion was less
than 10%. To keep things in perspective, these results
are of angioplasty in some of the most experienced
hands in the world. Nevertheless, similar data emerge
from a current prospective trial on primary angioplasty irrespective of randomly associated fibrinolySiS.27 Hospital mortality in the paper by Kahn et al was
5%, which is not significantly better than what we
expect from fibrinolysis, particularly if there is some
2244
Circulation Vol 82, No 6, December 1990
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
preselection of patients and the procedure is performed at a single center with all sophisticated facilities. Somewhat surprisingly, hospital results are similar regarding all major vessel areas. What is clearly an
improved outcome for a large infarction due to an
occlusion of a proximal left anterior descending coronary artery (LAD) may be just an average, if not
inferior, outcome compared with fibrinolysis, or even
the natural course if the left circumflex coronary
artery (LCx) is involved. A 10% incidence of need for
inotropic support, intra-aortic balloon pump, or urgent bypass surgery for infarctions involving the LAD
may seem acceptable, albeit not strikingly low. However, an 8% incidence for such a need in infarcts
involving the LCx is of some concern. Kahn et al
explain the high incidence as a preexisting grave
condition due to associated disease in other vessels in
54% of the LCx patients. The poor outcome of acute
angioplasty in right coronary artery (RCA) infarctions
reported recently,28 however, was not confirmed in
this paper-fortunately, I might say, as the reasons
were hard to understand in the first place.
At any rate, it was not the fear of acute complications in the catheterization laboratory that dug the
grave for primary angioplasty, as Kahn et al'7 surmise
in their introduction. It was the fact that acute
catheterization with angioplasty is logistically infinitely more demanding than intravenous fibrinolysis
followed by a period of "watchful waiting." It is
therefore not the relative innocuousness of angioplasty in this setting that will resuscitate interest but
its superiority in terms of results. The investment of
time and money is the same whether acute angioout for an LAD or for an LCx
infarction. Critical analysis of the current paper
suggests, and this is an important new insight, that
acute angioplasty in the LAD is certainly well invested but may be wasted in the smaller RCA or LCx.
In other words, the larger the infarction, the greater
the incentive to select the more laborious angioplasty
approach over a convenient intravenous fibrinolysis.
The authors'7 who chose the cumbersome direct
angioplasty rather than intravenous fibrinolysis in
96% of their infarct patients presenting from 1987 to
1989 deserve our respect for persevering in a stressful
and time-consuming mode of therapy that was lightly
abandoned by less dedicated interventionists on the
first indication that ordering the house staff to administer a fibrinolytic agent, replacing the receiver,
and turning over and back to sleep was perhaps safer
and just as effective.
It always was there in the back of the mind of many
an interventional cardiologist and Kahn et al17 have
proved it: should it come to our own big myocardial
infarction, it had best happen close to an angioplasty
laboratory with a highly experienced crew at hand.
Such messages need to be repeated as it is difficult
to overcome the inherent lethargy of humans inclined
to take it easy when easy it can be taken. Therefore,
we may forgive Kahn and his group for not conveying
their message in a single paper but rather inundating
plasty is carried
us with an avalanche of reports coming to uniform
conclusions. The conclusion that angioplasty is preferable to thrombolysis in all cases has to be amended.
It is preferable in cases of large infarctions and in
those having access to a well-staffed angioplasty
laboratory within 30 minutes. Other cases seem better off with immediate intravenous thrombolysis. The
other conclusion I sign without amendment: "Those
who have laid primary angioplasty for the treatment
of acute infarction to rest, get the shovel because,
yes, it has been buried alive."
References
1. Meyer J, Merx W, Schmitz H, Erbel R, Kiesslich T, Dorr R,
Lambertz H, Bethge C, Krebs W, Bardos P, Minale C,
Messmer BJ, Effert S: Percutaneous transluminal coronary
angioplasty after intracoronary streptokinase in evolving acute
myocardial infarction. Circulation 1982;66:905-913
2. Papapietro SE, MacLean WAH, Stanley AWH, Hess RG,
Corley N, Arciniegas JG, Cooper TB: Percutaneous transluminal coronary angioplasty after intracoronary streptokinase
in evolving acute myocardial infarction. Am J Cardiol 1985;55:
48-53
3. Serruys PW, Wijns W, van den Brand M, Ribeiro V, Fioretti P,
Simoons ML, Kooijman CJ, Reiber JHC, Hugenholtz PG: Is
transluminal coronary angioplasty mandatory after successful
thrombolysis? Quantitative coronary angiographic study. Br
Heart J 1983;50:257-265
4. Valeix B, Labrunie P, Puel J, Bertrand ME, Guarino L,
Monassier JP, Vilarem D, Lablanche JM, Morand P, Bounhoure JP, Levy S, Gerard R: L'angioplastie coronarienne
immediatement apres thrombolyse intracoronarienne en
phase aigue d'infarctus du myocarde. Arch Mal Coeur 1984;77:
1315-1321
5. Schroder R, Vohringer H, Linderer T, Biamino G, Bruggemann T, v Leitner ER: Follow-up after coronary arterial
reperfusion with intravenous streptokinase in relation to residual myocardial infarct artery narrowings. Am J Cardiol 1985;
55:313-317
6. Meyer J, Erbel R, Merx W, Pop T, Beck FJ, Messmer BJ,
Effert S: Postthrombotic therapy and patient follow-up-The
role of coronary balloon dilatation. Eur Heart J 1985;6(suppl
E):183-186
7. O'Neill W, Timmis GC, Bourdillon PD, Lai P, Ganghadarhan
V, Walton J Jr, Ramos R, Laufer N, Gordon S, Schork MA,
Pitt B: A prospective randomized clinical trial of intracoronary
streptokinase versus coronary angioplasty for acute myocardial
infarction. N Engl J Med 1986;314:812-818
8. Hartzler GO, Rutherford BD, McConahay DR, Johnson WL
Jr, McCallister BD, Gura GM Jr, Conn RC, Crockett JE:
Percutaneous transluminal coronary angioplasty with and
without thrombolytic therapy for treatment of acute myocardial infarction. Am Heart J 1983;106:965-973
9. Pepine CJ, Prida X, Hill JA, Feldman RL, Conti CR: Percutaneous transluminal coronary angioplasty in acute myocardial
infarction. Am Heart J 1984;107:820-822
10. Prida XE, Holland P, Feldman RL, Hill JA, MacDonald RG,
Conti CR, Pepine CJ: Percutaneous transluminal coronary
angioplasty in evolving myocardial infarction. Am J Cardiol
1986;57:1069-1074
11. Topol EJ, Califf RM, George BS, Kereiakes DJ, Abbottsmith
CW, Candela RJ, Lee KL, Pitt B, Stack RS, O'Neill WW: A
randomized trial of immediate versus delayed elective angioplasty after intravenous tissue plasminogen activator in acute
myocardial infarction. N Engl J Med 1987;317:581-588
12. Simoons ML, Arnold AER, Betriu A, Bokslag M, de Bono
DP, Brower RW, Col J, Dougherty FC, von Essen R, Lambertz H, Lubsen J, Meier B, Michel PL, Raynaud P, Rutsch W,
Sanz GA, Schmidt W, Serruys PW, Thery C, Uebis R,
Vahanian A, van der Werf F, Willems GM, Wood D, Verstraete M: Thrombolysis with rt-PA in acute myocardial
Meier Balloon Angioplasty for Acute MI
13.
14.
15.
16.
17.
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
18.
19.
20.
infarction: No beneficial effects of immediate PTCA. Lancet
1988;1:197-203
Holmes DR Jr, Smith HC, Vlietstra RE, Nishimura A, Reeder
GS, Bove AA, Breshnahan JF, Chesebro JH, Piehler JM:
Percutaneous transluminal coronary angioplasty, alone or in
combination with streptokinase therapy, during acute myocardial infarction. Mayo Clin Proc 1985;60:449-456
Erbel R, Pop T, Henrichs KJ, von Olshausen K, Schuster CJ,
Rupprecht HJ, Steuernagel C, Meyer J: Percutaneous transluminal coronary angioplasty after thrombolytic therapy: A
prospective controlled randomized trial. J Am Coll Cardiol
1986;8:485-495
Fung AY, Lai P, Juni JE, Bourdillon PDV, Walton JA Jr,
Laufer N, Buda AJ, Pitt B, O'Neill WW: Prevention of
subsequent exercise-induced periinfarct ischemia by emergency coronary angioplasty in acute myocardial infarction:
Comparison with intracoronary streptokinase. JAm Coil Cardiol 1986;8:496-503
Topol EJ, Interventions in acute myocardial infarctions, in
Meier B (ed): Interventional Cardiology. Toronto, Hogrefe &
Huber Publishers, 1990, pp 185-209
Kahn JK, Rutherford BD, McConahay DR, Johnson WL Jr,
Giorgi LV, Shimshak TM, Ligon RW, Hartzler GO: Catheterization laboratory events and hospital outcome with direct
angioplasty for acute myocardial infarction. Circulation 1990;
82:1910-1915
O'Keefe JH Jr, Rutherford BD, McConahay DR, Ligon RW,
Johnson WL Jr, Giorgi LV, Crockett JE, McCallister BD,
Conn RD, Gura GM, Good TH, Steinhaus DM, Bateman TM,
Shimshak TM, Hartzler GO: Early and late results of coronary
angioplasty without antecedent thrombolytic therapy for acute
myocardial infarction. Am J Cardiol 1989;64:1221-1230
Kahn JK, Rutherford BD: Direct infarct angioplasty: Therapy
for the 1990's. J Invas Cardiol 1990;2:1-5
Stone GW, Rutherford BD, McConahay DR, Johnson WL Jr,
Giorgi LV, Ligon RW, Hartzler GO: Direct coronary angio-
(Circulation 1990;82:2243-2245)
2245
plasty in acute myocardial infarction: Outcome in patients
with single vessel disease. JAm Coll Cardiol 1990;15:534-543
21. Kahn JK, Rutherford BD, McConahay DR, Johnson WL,
Giorgi LV, Ligon RW, Hartzler GO: Results of primary
angioplasty for acute myocardial infarction in patients with
multivessel coronary artery disease. JAm Coll Cardiol 1990 (in
press)
22. Rothbaum DA, Linnemeier TJ, Landin RJ, Steinmetz EF,
Hillis JS, Hallam CC, Noble RJ, See MR: Emergency percutaneous transluminal coronary angioplasty in acute myocardial
infarction: A 3-year experience. J Am Coll Cardiol 1987;10:
264-272
23. Flaker GC, Webel RR, Meinhardt S, Anderson S, Santolin C,
Artis A, Krol R: Emergency angioplasty in acute anterior
myocardial infarction. Am Heart J 1989;118:1154-1160
24. Ellis SG, O'Neill WW, Bates ER, Walton JA, Nabel EG,
Topol EJ: Coronary angioplasty as primary therapy for acute
myocardial infarction 6 to 48 hours after symptom onset:
Report of an initial experience. J Am Coll Cardiol 1989;13:
1122-1126
25. Brundage BH: Because we can, should we? JAm Coll Cardiol
1990;15:544-545
26. Schrdder R, Vdhringer H, Linderer T, Biamino G, Brfiggemann T, v Leitner ER: Follow-up after coronary arterial
reperfusion with intravenous streptokinase in relation to residual myocardial infarct artery narrowings. Am J Cardiol 1985;
55:313-317
27. O'Neill WW, Weintraub R, Kassab E, Strzelecki M, Friedman
HZ, Levine AB, Levin RN, Timmis GC: Interim analysis of
the streptokinase angioplasty myocardial infarction trial
(abstract). JAm Coll Cardiol 1990;15:63A
28. Gacioch GM, Topol EJ: Sudden paradoxic clinical deterioration during angioplasty of the occluded right coronary artery in
acute myocardial infarction. J Am Coll Cardiol 1989;14:
1202-1209
Balloon angioplasty for acute myocardial infarction. Was it buried alive?
B Meier
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
Circulation. 1990;82:2243-2245
doi: 10.1161/01.CIR.82.6.2243
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1990 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://circ.ahajournals.org/content/82/6/2243.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally
published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the
Editorial Office. Once the online version of the published article for which permission is being requested is
located, click Request Permissions in the middle column of the Web page under Services. Further
information about this process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Circulation is online at:
http://circ.ahajournals.org//subscriptions/