Thrombolysis and Angioplasty in Acute

Topol EJ, Califf RM, George BS, et al., and the Thrombolysis and Angioplasty in Acute Myocardial Infarction Study Group. A randomized trial of immediate vs. delayed elective angioplasty after intravenous tissue plasminogen activator in acute myocardial infarction. N Engl J Med 1987 317 581-588. 

Brochier, M. L. Evaluation of flurbiprofen for prevention of reinfarction and reocclusion after successful thrombolysis or angioplasty in acute myocardial infarction. The Flurbiprofen French Trial, Eur. Heart J. 1993, 14, 951-957. 

Harrington RA, Sane DC, Califf RM, Sigmon KN, Abbottsmith CW, Candela RJ, Lee KL, Topol EJ. Clinical importance of thrombocytopenia occurring in the hospital phase after administration of thrombolytic therapy for acute myocardial infarction. The Thrombolysis and Angioplasty in Myocardial Infarction Study Group. J Am CoU Cardiol 1994 23(4) 891-8. 

Ross AM, Coyne KS, Reiner JS, et al. A randomized trial comparing primary angioplasty with a strategy of short-acting thrombolysis and immediate planned rescue angioplasty in acute myocardial infarction The PACT trial. J Am CoU Cardiol 1999 34 1954-1962. 

De ite differmces in their mechanisms of action and in vitro activities, pentasaccharide, DX-9065a and TAP have been shown to be effective antithrombotic agents in experimental models of venous thrombosis, coronary artery occlusion, arterial thrombolysis and acute reocclusion, restenosis after angioplasty, dialysis, and DIG. Pentasaccharide has also demonstrated measurable antithrombotic effects in human trials. Both TAP and DX-9065a produce measurable in vitro anticoagulant effects. In contrast, pentasaccharide does not produce an anticoagulant effect by the typical clot based assays. Thus, with fector Xa inhibitors there is not necessarily a correlation between current lab assays and antithrombotic efficacy as there is with heparin. 

M. S. Flynn, M. J. Kern, F. V. Aguirre, R. G. Bach, E. A. Caracciolo and T. J. Donohue, Alterations in coronary blood flow velocity during intracoronary thrombolysis and rescue coronary angioplasty for acute myocardial infarction, Cath Cardiovasc Diag 31, 219-224 (1994). 

The indications for PTCA have been provided by the ACC/AHA and now span single- or multivessel disease as weU as asymp-tomatic and symptomatic patients (see Table 15-7). PTCA generally is not useful if only a small area of viable myocardium is at risk, when ischemia cannot be demonstrated, with borderline (<50%) stenosis or with lesions that are difficult to dilate, or in patients who are at high risk for morbidity or mortality or both (e.g., left main or equivalent disease or three-vessel disease). PTCA alone or in conjunction or sequentially with thrombolysis for acute Ml is discussed in Chap. 16. Stent placement accompanies balloon angioplasty in about 80% of cases in the United States. The current recommendations for PCI are provided in Table 15-7 based on class of angina. 

Acute infarct artery PCI was demonstrated initially to be feasible in conjunction with intracoronary thrombolysis in a small registry study reported in 1982 (43). The approach evolved quickly to one in which the intracoronary thrombolysis component was abandoned. The separation of mechanical and pharmacological approaches was reinforced by results in a small (56-patient), but very influential, randomized trial comparing primary PCI with administration of intracoronary streptokinase in 1986 (44). Primary PCI led to greater recovery of left ventricular function. Results from another relatively small, randomized trial (n = 142) were concordant. They demonstrated greater recovery of left ventricular function with primary PCI compared with intravenous streptokinase (45). The Primary Angioplasty in Myocardial Infarction... 

Williams DO, Ruocco NA, Forman S, and the TEVII Investigators. Coronary angioplasty after recombinant tissue-type plasminogen activator in acute myocardial infarction a report from the Thrombolysis in Myocardial Infarction (TIMI) trial. J Am Coll Cardiol 1987 10 45B-50B. 

Le May M, Michel LeMay, for the CAPITAL AMI Investigators. Combined Angioplasty and Pharmacological Intervention versus Thrombolysis Alone in Acute Myocardial Infarction (CAPITAL-AMI) trial. Presented at ACC Scientific Sessions, New Orleans, LA, March 8,2004. 

Thrombosis in stenosed human coronary arteries is one of the most common thrombotic diseases leading to unstable angina, acute myocardial infarction or sudden death. Treatment with angioplasty, thrombolysis, or bypass grafts can expose new thrombogenic surfaces and re-thrombosis may occur. The mechanisms responsible for this process include interactions of platelets with the damaged arterial wall and platelet aggregation. 

In the UAE, as well as many countries in western Europe and North America, primary PCI for treatment of patients with STEMI was and still is not readily available in many hospitals. We believe the case for performing primary PCI in most such patients is not yet compelling. The impact of time to treatment on mortality after prehospital thrombolysis or primary angioplasty (CAPTIM study) has shown that prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after onset of symptoms. Conversely, the DANish Multi-Center Randomized Study on Eibrinoljdic Therapy versus Acute Myocardial Infarction (DANAMI-2) report showed a reduction in cardiac events in patients treated with primary angioplasty compared with those treated with fibrinolytic agents for STEMI (13,14). The critics of that study have pointed out that the trial included only 37% of the population with STEMI and excluded patients with... 

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