Implications of recurrent ischemi after reperfusion therapy in acute myocardial infarction: comparison of thrombolytic therapy and primary angioplasty

Objectives. The purpose of this study was to examine the incidence and implications of recurrent ischemi after different reperfusion strategies in acute myocardial infarction. Background. The rates and effects of recurrent ischemi after reperfusion with thrombolytic therapy and with primary percutaneous transluminal coronary angioplasty have not been compared. Methods. At 12 centers 395 patients presenting within 12 h of the onset of acute myocardial infarction were prospectively randomized to receive recombinant tissue-type plasminogen activator (rt-PA) or primary coronary angioplasty. Sixteen clinical variables were examined by using univariate and multiple logistic regression analysis to identify the predictors of recurrent ischemia. The relation of recurrent ischemic events to patient outcome was analyzed. Results. Recurrent ischemi developed in 76 patients (19.2%) before hospital discharge, resulting in reinfarction in 18 patients (4.6%) and death in 5 (2.6%). Recurrent ischemi occurred in 56 patients (28.0%) after rt-P but in only 20 patients (10.3%) after coronary angioplasty (p < 0.0001), directly contributing to higher rate of death or reinfarction (7.5% vs. 3.1%, p = 0.05), catheterization and revascularization procedures and prolonged hospital stay after thrombolysis. By multivariate analysis, treatment with coronary angioplasty rather than rt-P was the strongest predictor of freedom from recurrent ischemia. Although the incidence of recurrent ischemi after angioplasty and after rt-P was similar within the 1st 2 days of admission (9.2% vs. 14.5%, p = 0.11), after hospital day 2 recurrent ischemi occurred in only 2 patients who received primary angioplasty compared with 27 patients who received rt-P (1.1% vs. 13.5%, p < 0.0001). Conclusions. The development of recurrent ischemi adversely affects patient outcome, increasing morbidity, mortality and resource utilization. The much lower rate of recurrent ischemi after primary coronary angioplasty than after rt-P results in improved survival without reinfarction and allows shorter, less complicated hospital stay. Given the extremely low rate of recurrent ischemi after hospital day 2, safe early discharge on day 3 after primary coronary angioplasty should be feasible in selected patients with acute myocardial infarction.