studies was reported as 40%,3 36%,4 42%,5 34%,6 41%7 our patients with CHF associated with coronary artery and 1 3%.8 A third heart sound heard by 2 physicians was disease. Patients with abnormal LV ejection fraction had present in 37% of our patients with CHF and normal a similar prevalence of hypertension as patients with nor- systolic function. The prevalence of an audible third heart mal LV ejection fraction. Patients with CHF and normal sound in patients with CHF and normal systolic function LV ejection fraction were older than patients with CHF was reported in other studies as 45%,3 41%4 and 21%.6 and abnormal LV ejection fraction.

Echocardiography, especially when combined with Doppler studies, is important in the management of pa- tients with CHF.3,6,13 Determination of LV systolic func- tion and causative mechanisms of CHF is important in determining long-term therapy of CHF. In our popula- tion of 247 patients with CHF, valvular heart surgery was recommended to patients with CHF on the basis of Dopp- ler echocardiographic studies. Digitalis was not adminis- tered to patients with normal systolic function unless atria1 fibrillation was present. Vasodilators were adminis- tered to patients with abnormal systolic function unless severe or moderate aortic stenosis was present, and to patients with normal systolic function only if needed in addition to diuretics to treat hypertension.

1. McKee PA, Cast& WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: The Framingham Study. N Eng[J A4ed 1971;285: I441 - 1446.

Data from our prospective study showed that LV ejec- tion fraction was the most important prognostic variable for mortality in elderly patients with CHF associated with coronary artery disease. Survival rates for patients with CHF associated with coronary artery disease and normal LV ejection fraction were 78% at 1 year, 62% at 2 years, 54% at 3 years and 44% at 4 years. Survival rates for patients with CHF associated with coronary artery disease and abnormal LV ejection fraction were 53% at 1 year, 29% at 2 years, 22% at 3 years and 15% at 4 years. Cohn and Johnson8 observed that the average annual mortality in the Vasodilator Heart Failure Trial was 8% for patients with CHF and a normal LV ejection fraction and 19% for patients with CHF and an abnormal LV ejection fraction.

In addition to LV ejection fraction, hypertension and age were independent variables that predicted death in

2. Franc&a JA, Wile” M, Ziesche S, Cohn JN. Survival in men with severe chronic left ventricular failure due to either coronary heart disease or idiopathic dilated cardiomyopathy. Am J Car&l 1983;51:831-836. 3. Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive heart failure: echocardiographic insights. Anz J Med 1983;75:750-755. 4. Dougherty AH, Naccarelli GV, Gray EL, Hicks CH, Goldstein RA. Conges- tive heart failure with normal systolic function. Am J Cardiol 1984;54:778-782. 5. Soufer R, Wohlgelernter D, Vita NA, Amuchestegui M, Sostman HD, Berger HJ, &ret BL. Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol 1985;55:1032-1036. (i. Aguirre FV, Pearson AC, Lewen MK, McCluskey M, Labovitz AJ. Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure. Am J Cardiol 1989;63:1098-1102. 7. Wong WF, Gold S, Fukuyama 0, Blanchettc PL. Diastolic dysfunction in elderly patients with congestive heart failure. Am J Cardiol 1989;63:1526-I 528. 8. Cohn JN, Johnson G, and Veterans Administration Cooperative Study Group. Heart failure with normal ejection fraction. The V-Hem study. Circulation 1990;81(supp1 ITI):III-48-111-53. 9. Aronow WS, Kronzon I. Correlation of prevalence and severity of valvular aortic stenosis determined by continuous-wave Doppler echocardiography with physical signs of aortic stenosis in patients aged 62 to 100 years with aortic systolic ejection murmurs. Am J Cardiol 1987;60:399-401. 10. Aronow WS, Kronzon I. Correlation of prevalence and severity of mitrai regurgitation and mitral stenosis determined by Doppler echocardiography with physical signs of mitral regurgitation and mitral stenosis in 100 patients aged 62 to 100 years with mitral an&r calcium. Am J Cardiol 1987;60:1189-I 190. il. Aronow WS, Kronzon I. Correlation of prevalence and severity of aortic regurgitation detected by pulsed Doppler echocardiography with the murmur of aortic regurgitation in elderly patients in a long-term health care facility. Am J Cwdiol 1989;63:128-129. 12. Aronow WS, Epstein S, Koenigsberg M, Schwartz KS. Usefulness of ccho- cardiographic abnormal left ventricular ejection fraction, paroxysmal ventricular tachycardia and complex ventricular arrhythmias in predicting new coronary events in patients over 62 years of age. Am J Cardiol 1988;61:1349-1351. 13. Kessler KM. Heart failure with normal systolic function. Update of preva- lence, differential diagnosis, prognosis, and therapy. Arch Intern Med 1988; 148:2109-2111.

elayed Coronary Angioplasty Myocardial Infarction Thomas Little, MD, Kenneth Lee, MD, Diane Muktierjee, ?vlD, Mark Milner, MD, Joseph Lindsay, Jr., MU, and August0 D. Pichard, MD

The role for and timing of percutaneous transluminal coronary angioplasty (PTCA) after thrombolytic thera- py for acute myocardial infarction (AMI) remains con- troversial. Three large randomized trials1m3 have demon- strated no benefit from PTCA performed within 48 hours of thrombolysis. Delayed PTCA performed after 48 hours has not been as carefully studied. Some advocate its use only for patients with evidence of recurrent ischemia.3 In patients with unstable angina and angiographically

From the Department of Cardiology, Washington Hospital Center, Washington, DC 20010. Dr. Little’s current address: Two Rivers Cardi- ology, 123 South 22nd Street, Easton, Pennsylvania 18042. Manuscript received January 18, 1990; revised manuscript received and accepted July 9, 1990.

evident intracoronary thrombus, delaying PTCA until after a course of anticoagulation and antiplatelet therapy has improved PTCA success and reduced thromboembol- ic coronary occlusion.4 Whether delaying PTCA after thrombolysis for AMI produces similar benefits is un- known. We report our experience with delayed PTCA performed after thrombolysis for AMI.

Between November I986 and July 1989, 3,256 pa- tients were entered in a PTCA database. Of these, 151 consecutive patients who underwent PTCA of the in- farct-related artery 3 to 14 days (mean 6) after throm- bolysis .for AMI were identi$ed. The indication for PTCA was determined by each patient’s private cardiol- ogist. Only stenoses with >70% diameter narrowing were

THE AMERICAN JOURNAL OF CARDIOLOGY NOVEMBER 15, 1990

TABLE I Distribution of Coronary Stenoses and Angioplasty Success

Infarct-Related Arteries n (98) Success (%)

LAD 55 (36) 49 (89) LC 26 (17) 21(81) Right 66 (49 59 (89) SVG 4 (3) 4wQ

Total 151 (loo) 133 (88)

LAD = left anterior descending; LC = circumflex; Right = right coronary artery; SVG = saphenous vein graft.

considered for PTCA. PTCA was performed using stan- dard techniques. Aspirin and heparin were routinely ad- ministered before PTCA. Aspirin, heparin and a calcium channel blocker were routinely given after angioplasty.

PTCA was considered successful if the lesion was reduced to GO% diameter narrowing without a major complication (acute vessel closure, emergency bypass surgery, AMI, death). Hospital survival was determined by a review of medical records.

Among the 151 patients, I I6 (77%) were men (aged 35 to 80 years [mean 571). A similar number of patients had received streptokinase (48%) and tissue plasmino- gen activator (52%).

Ouerall, left ventricular ejection fraction was normal (>50%) in I9 (13%), mildly impaired (40 to 50%) in 94 (62%), moderately impaired (30 to 40%) in 26 (17%) and seuerely depressed (<30%) in I2 (8%). Sixty-nine patients (46%) had I -vessel coronary disease, 68 (45%) had 2-vessel disease and 14 (9%) had 3-vessel disease. PTCA of only the “infarct-related” stenosis was per- formed in IO6 (70%) patients. Multivessel PTCA was performed in 16 (11%) and multilesion PTCA in the remaining 29 (19%).

The results of PTCA are listed in Table I. Right coronary and left anterior descending artery dilatations were the procedures most frequently attempted. Suc- cessful dilatation was achieved in 133 of the 151 lesions (88%). Half of the unsuccessful attempts (9 of 18) oc- curred in the 23 patients with total coronary occlusions. The outcome of PTCA was similar for patients treated with streptokinase and tissue plasminogen activator. Se- rious complications were encountered in 9patients (6%). Acute vessel closure occurred in 5 patients (3%) requir- ing repeat PTCA in 3 and emergency bypass surgery in 2 other patients. Emergency coronary bypass surgery was performed in 3 other patients owing to intracoronary thrombusformation without evidence of ischemia. There was 1 myocardial infarction and 1 (0.7%) patient died in the hospital after bypass surgery.

This retrospective study of delayed angioplasty after thrombolysis for AMI demonstrates an 88% complica- tion-free success rate. This is comparable to the results generally achieved by elective PTCA. The results are also similar to the 94 and 84% success rates of delayed PTCA achieved in 2 small randomized trials.‘,5 The 3% emer-

gency bypass rate in the present study is identical to that reported in these trials. The observed 6% overall compli- cation rate compares favorably to the reported 20% oc- currence of reinfarction and ischemia after thrombolytic therapy without subsequent PTCA.2v5 When acute vessel closure does occur during delayed PTCA, it can be man- aged immediately by interventional techniques and by- pass surgery. Alternatively, untimely reinfarction after thrombolysis may produce a longer delay before interven- tional procedures are instituted and restoration of perfu- sion achieved.

Although early PTCA after thrombolysis has not been supported by randomized trials,1-3 emerging evi- dence suggests potential benefits from delayed PTCA. After successful thrombolysis, PTCA is necessary to im- prove exercise ejection fraction.6 Unsuccessful throm- bolysis with persistent vessel occlusion after AM1 is asso- ciated with a higher long-term mortality and lower left ventricular ejection fraction than if coronary patency is achieved even late after the acute period of infarction6T7 Although PTCA success for total occlusions was only 61% during this series, recent technical improvements have increased our success rate to 94% for recent occlu- sions.*

Unlike reported results of early PTCA after throm- bolysis, delayed PTCA was found to be safe and effective in this study. These results are subject to the limitations of a retrospective study and the potential for bias in patient referral and case selection at a tertiary care center. Pro- spective evaluation of delayed PTCA will bc required to confirm these results and evaluate the effects of antico- agulation and other factors on outcome.

1. Top01 EJ, Califf RM, George B, Kereiakes DJ, Abbottsmigh CW, Candda RJ, Lee KL, Pit 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 Engf J Med 1987;317:581-588, 2. Sirnoons ML, Betriu A, Co1 J, van Essen R, Lubsen J, Michel PL, Rutsch W, Schmidt W, Thery C, Vahanian A, Willems GM, Arnold AER, deBono DP, Dougherty FC, Lambertz H, Mcier B, Raynaud P, Sam GA, Surruys PW, Uebis R, Van de Werf F, Wood D, Verstraete M. Thrombolysis with tissue plasminogen activator in acute myocardial infarction: no additional benefit from immediate percutaneous coronary angioplasty. Lmcet 1988;1:1977203. 3. TIM1 Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. N Engl J Med 1989;320:618-627. 4. Hurley DV, Bresnahan DR, Holmes DR Jr. Staged thrombolysis and percuta- neous angioplasty for unstable angina and postinfarction angina. Cuthet Cardio- uasc Diagn 1989;18:67-72. 5. Guerci AD, Ferstenblith G, Brinker JA, Chandra NC, Gottlieb SO, Bahr RD. Weiss JL, Shapiro EP, Flaherty JT, Bush DE, Chew PH. Gotlieb SH, Halperin HR, Ouyang P, Walford GD, Bell WR, Fatterpaker AK, Llewellyn M, Topol EJ, Healy B, Siu CO, Becker LC, Weisfeldt M. A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty. N Engl J Med 1987;317:1613- 1618. 6. Schroder R, Neuhaus KL, Linderer T, Bruggemann T, Tebbc U, Wegscheider K. Impact of late coronary artery reperfusion on left ventricular function one month after acute myocardial infarction: results of the ISAM study. Am J Car- dial 1989;64:878-884. 7. Cigarroa RG, Lange R, Hillis LD. Prognosis after acute myocardial infarction in patients with and without residual anterograde coronary blood flow. Am J Cardiol 1989;64:155-160. 6. Little T, Rosenberg J, Seides S, Lee B, Lindsay J Jr, Picbard AD. Probe angioplasty of total coronary occlusion using the Probing Catheter Technique. Cathet Cardiouasc Diae in press.

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