In patients with acute myocardial infarction, primary angioplasty results in a smaller infarct size and a better preserved myocardial function compared with patients randomized to receive treatment with intravenous streptokinase. This is probably due to early and optimal blood flow through the infarct-related vessel, as can be accomplished in a very high percentage of patients undergoing primary coronary angioplasty.

Objective-To investigate the feasibility of primary coronary angioplasty as a treatment option in patients with acute myocardial infarction after initial diagnosis in a local community hospital. Setting-Referral centre for interventional treatment of coronary artery disease. Methods-During a five year period, 520 candidates for primary coronary angioplasty were treated in our institution, 104 after transfer from a community hospital. The transferred patients and the nontransferred patients (n = 416) were compared with regard to baseline clinical characteristics, time interval from symptom onset to treatment, and clinical outcome at six months. Results-In this setting, the influence of transportation on total ischaemic time was limited, and there was no diVerence in clinical outcome between the transferred and the non-transferred patients. Clinical outcome was mainly dependent on the indication for transfer. Conclusions-Safe and expedient transportation may facilitate the more widespread use of primary angioplasty in patients with acute myocardial infarction. A large randomised multicentre trial is needed to compare the relative merits of intravenous thrombolytic treatment in a local hospital with primary angioplasty after transfer in selected high risk patients with acute myocardial infarction.

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SummaryBuckground: Previous studies have demonstrated the prognostic value of radionuclide ventriculography at rest and exercise in patients post myocardial infarction (MI). The number of studies in patients treated with modem reperfusion techniques, including thrombolysis or primary angioplasty, however, is limited.H.yporhesis: The aim of this study was to evaluate the prognostic significance of predischarge radionuclide ventriculography at rest and exercise in patients with acute MI treated with thrombolysis or primary angioplasty.Methods: A total of272 consecutive patients with acute MI who were randomized to thrombolysis or primary coronary angioplasty underwent predischarge resting and exercise radionuclide ventriculography. Left ventricular ejection fraction at rest, decrease in ejection fraction during exercise >5 units below the resting value, angina pectoris, ST-segment depression, and exercise test ineligibility were related to subsequent cardiac events (cardiac death, nonfatal reinfarction) during Results: During a mean follow-up of 30 f I0 months, cardiac death occurred in 11 (4%) patients and nonfatal reinfarction in 14 (5%) patients. Resting left ventricular ejection fraction was the major risk factor for cardiac death. In patients follow-up. with an ejection fraction < 40% cardiac death occurred in 16% compared with 2% in those with an ejection fraction 2 40% (p = 0.0004). In addition, cardiac death tended to be higher in patients ineligible than in those eligible for exercise testing (1 1 vs. 3%, p = 0.08). None of the other exercise variables (decrease in ejection fraction during exercise >S units below the resting value, angina pectoris or ST-segment dcpression) were predictive for cardiac death. When all exercise test variables in each patient were combined and expressed as a risk score, a low risk (n = 185) and a higher risk (n = 87) group of patients could be identified, with cardiac death occurring in 1 and lo%, respectively. As the predictive accuracy of a negative test was high, radionuclide ventriculography was of particular value in identifying patients at low risk for cardiac death. Radionuclide ventriculography was not able to predict recurrent nonfatal MI.Conclusion: In patients with MI treated with thrombolysis or primary angioplasty, radionuclide ventriculography may be helpful in identifying patients at low risk for subsequent cardiac death. In this respect, left ventricular ejection fraction at rest was the major determinant. Variables retlecting residual myocardial ischemia were of limited prognostic value. Identification of a large number of patients at low risk allows selective use of medical resources during follow-up in this subgroup and has significant implications for the cost e f t ctiveness of reperfusion therapies.

Patency of the infarct-related vessel is associated with a more favorable long-term prognosis after acute myocardial infarction (AMI). High infarct vessel patency is reported for early reperfusion therapy, but data on patency and its possible effect on clinical outcome are less abundant for patients presenting late after the acute event. The aim of this study was to investigate whether time to reperfusion is related to infarct-vessel patency and clinical outcome. This study compares 268 patients who presented with symptoms of AMI within six hours after the onset of symptoms (Early) with 33 patients who had reperfusion therapy for signs of ongoing ischemia more than six hours after the start of chest pain (Late). At follow-up coronary angiography, flow through the infarct-related vessel was assessed according to the thrombolysis in myocardial infarction (TIMI) classification. Vessels were considered occluded if TIMI flow grade 0 or 1 was present. Follow-up angiography was performed in 95% of patients after a mean of forty-eight days. The infarct-related vessel was occluded in 41% of the late-entry patients (13 of 32), and in 17% of those presenting early (44 of 252), (P = 0.01; relative risk [RR]: 2.50; 95% confidence interval [CI]: 1.26 to 6.83). This was associated with a higher rate of recurrent myocardial infarction in late-entry patients: 27% (9 of 33), compared with 9% (25 of 268) in the early group (P = 0.005; RR: 2.94; 95% CI: 1.50 to 5.81). Thus, in the present study, late reperfusion therapy (after six hours) was associated with a higher recurrent myocardial infarction rate and a lower infarct vessel patency rate, compared with early treatment of patients.