May 15, 1991
View Full PaperCoronary Angiography after Thrombolytic Therapy for Acute Myocardial Infarction
Key Result
Rescue coronary angioplasty after thrombolysis had higher technical success (86% vs 75%, P=0.03) and lower reocclusion (10.9% vs 26.8%, P<0.001) with nonspecific vs specific plasminogen activators.
Study Design
Type
Meta-Analysis
Multicenter
Yes
Structured PICO
What is the optimal timing and strategy for coronary angiography after intravenous thrombolytic therapy in acute myocardial infarction?
P
Population
Meta-analysis and review of trials evaluating coronary angiography strategies after intravenous thrombolytic therapy for acute myocardial infarction.
I
Intervention
Coronary angiography (emergency, urgent, routine, or selective) and rescue angioplasty
C
Comparator
Different angiography strategies (e.g., routine vs selective) and thrombolytic agents (nonspecific vs specific plasminogen activators)
O
Outcome
Technical success and reocclusion ratessurrogate
Following thrombolytic therapy for acute myocardial infarction, either selective or routine angiography is acceptable for uncomplicated patients, while emergency angiography is primarily for primary or rescue angioplasty.
Main Result
Absolute Event Rate: 86% vs 75%
p-value: p=0.03
Limitations
- Ability to noninvasively detect reperfusion, reocclusion, or viable but ischemic myocardium is limited at present
Abstract
PURPOSE: To review the status of emergency, urgent, routine, and selective angiography after intravenous thrombolytic therapy. DATA SOURCES: Relevant English-language articles published from January 1985 to July 1990 were identified through MEDLINE. STUDY SELECTION: For emergency angiography, four major randomized studies were reviewed and data from nine studies that incorporated rescue coronary angioplasty were pooled for meta-analysis. For urgent angiography, two controlled trials were reviewed. Comparisons of routine and selective angiography were done using data from two dedicated, large-scale, controlled trials and the ancillary findings of four other studies of reperfusion that incorporated angiography. DATA EXTRACTION: The review emphasizes the findings from multicenter, randomized, controlled trials. DATA SYNTHESIS: Emergency coronary angiography is done primarily in preparation for primary or rescue angioplasty; the value of rescue angioplasty has yet to be assessed in a randomized trial, but technical success and reocclusion improve significantly after therapy with nonspecific plasminogen activators compared with relatively specific agents (success rate, 86% compared with 75%, respectively; P = 0.03; reocclusion rate, 10.9% compared with 26.8%, respectively; P less than 0.001). Urgent coronary angiography has value for treating recurrent ischemia, but patients who develop this complication after thrombolysis are likely to have a suboptimal outcome despite aggressive care. Studies support the use of either selective or routine angiography in uncomplicated patients after thrombolytic therapy; either approach is acceptable, but the former is more practical and may prove to be cost effective. CONCLUSIONS: Optimal follow-up for patients with evolving myocardial infarction who receive thrombolysis may incorporate coronary angiography at various stages. Although our ability to noninvasively detect reperfusion, reocclusion, or viable but ischemic myocardium is limited at present, available data may assist in selecting a catheterization strategy.