[Thrombolytic therapy in acute myocardial infarct].
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Angioplasty, Balloon↗
Biomedical subjects
H Blanke
Publications and source records attributed to H Blanke.
Long-term follow-up after intracoronary streptokinase therapy for acute myocardial infarction.
This article describes the effects on patients treated with intracoronary streptokinase during acute myocardial infarction and long-term follow-up. The mortality and the incidence of cardiac events were assessed during a follow-up period of 35 +/- 5 months. Coronary artery bypass grafting was undertaken in 37% of the patients. Hospital mortality was 11%, (n = 8); none of these deaths was due to myocardial rupture. The postdischarge mortality was 10%; three of these patients experienced sudden death. Serial assessment of left ventricular function in 35 patients showed an increase of angiographic ejection fraction prior to intervention from 50 +/- 4% to 58 +/- 12% (p = 0.005) 36 +/- 53 days later. Gated-blood pool imaging after 16 +/- 7 months (n = 35) and 32 +/- 9 months (n = 31) revealed no change in ejection fraction. Angina pectoris recurred in four of the 35 patients. We studied a historical comparison group, that consisted of 66 patients, who were treated at the same institution prior to the advent of intracoronary intervention techniques; this group was followed for 48 +/- 9 months. Baseline clinical and angiographic parameters were comparable in the two groups. Coronary artery bypass grafting was performed in only 18 of these patients. Mortality during hospitalization and postdischarge was not significantly different in the two groups. Ejection fraction decreased significantly in the comparison group from the first to the second evaluation and remained unchanged during the follow-up period. We conclude that no major adverse effects were associated with intracoronary streptokinase infusion over a long follow-up period. This may be related to the high frequency of coronary artery bypass surgery following reperfusion.
Aged↗
Changes in collateral channel filling immediately after controlled coronary artery occlusion by an angioplasty balloon in human subjects.
Transluminal coronary angioplasty can serve as a model for controlled coronary artery occlusion and reperfusion which enables assessment of short-term changes in collateral vessel filling in patients with severe atherosclerotic coronary artery disease. In 16 patients with isolated left anterior descending or right coronary artery disease (greater than or equal to 75% stenosis) and normal left ventricular function, collateral filling to the artery being dilated was visualized by contrast injection into the contralateral artery using a second arterial catheter. During balloon inflation, contralateral dye injection was performed as soon as the patient developed angina or ST-T changes or at 90 seconds in those patients without symptoms or signs of ischemia. Grades of collateral filling from the contralateral vessel were: 0 = none; 1 = filling of side branches of the artery to be dilated via collateral channels without visualization of the epicardial segment; 2 = partial filling of the epicardial segment via collateral channels; 3 = complete filling of the epicardial segment of the artery being dilated via collateral channels. At baseline angiography, nine patients had grade 0 collateral filling, seven had grade 1 and none had grade 2 or 3. During coronary occlusion by balloon inflation, collateral filling improved by one grade in eight patients, two grades in five patients, three grades in two patients and remained the same in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Prevalence and significance of residual flow to the infarct zone during the acute phase of myocardial infarction.
Residual flow to the infarct zone was assessed by coronary angiography during the acute phase of myocardial infarction in 130 patients. In 36 patients, the infarct-related coronary artery was not completely obstructed, thereby providing residual anterograde flow to the infarct area (Group I). Complete obstruction of the infarct vessel with residual flow to the infarct zone by means of collateral circulation was observed in 56 patients (Group II). Complete obstruction of the infarct vessel without residual flow was seen in 38 patients (Group III). Ejection fraction during the acute phase of infarction was found to be significantly higher in Group I (55 +/- 13%) than in either Group II (48 +/- 13%) or Group III (50 +/- 10%) (p less than 0.05). Group II patients had a longer history of angina pectoris (14.2 +/- 21.4 months) than did Group III patients (0.7 +/- 3.1 months) (p less than 0.01). Patients in Group I and Group II were more likely to be taking antianginal medication (56 and 54%, respectively) than were the patients in Group III (16%) (p less than 0.01). Thirty-seven patients in whom reperfusion techniques were not employed had repeat angiography in the chronic phase of infarction, enabling assessment of spontaneous changes in left ventricular function and coronary morphology.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Long-term follow-up after intracoronary streptokinase therapy for acute myocardial infarction.
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Coronary Artery Bypass↗
[Significance of precordial ST segment depressions in acute inferior infarct--correlation with coronary angiography and ventriculography findings in the acute infarct phase].
Thirty-two patients presenting with acute transmural inferior wall myocardial infarction underwent cardiac catheterization and angiography within 12 hours of onset of symptoms. Twelve lead electrocardiograms performed within 11/2 hours of catheterization revealed the following: Seventeen patients exhibited ST-segment depression in the anterior precordial leads in addition to inferior wall changes (group A). Fifteen patients did not manifest any ST-segment changes in the anterior precordial leads (group B). Clinical, arteriographic, and ventriculographic variables were compared between the two groups. No significant differences were observed with regard to age, sex, risk factors for coronary disease, duration of symptoms prior to angiography, Killip class, number of inferior leads with ST-segment elevation, or initial creatine kinase. The extent of coronary artery disease as well as the prevalence of severe disease in the left anterior descending artery were similar for both groups. Biplane left ventriculography revealed no significant differences between the two groups with regard to global or local left ventricular function.
Arrhythmias, Cardiac↗
[Relation between electrocardiography and coronary angiography findings in the infarct stage].
One hundred and fifty-two patients underwent cardiac catheterization and coronary arteriography within 6.3 +/- 6.0 hours from onset of acute myocardial infarction. All had a standard 12-lead electrocardiogram recorded within 1.5 hours of cardiac catheterization. The electrocardiographic abnormalities present were correlated with the infarct related artery as determined by coronary arteriography. ST segment elevation was the most common finding in patients with the left anterior descending (LAD), or right coronary artery (RCA) as the infarct related artery. ST segment depression was the most common abnormality in patients with left circumflex artery (CX) as the infarct related artery. A typical pattern of anterior acute myocardial infarction was seen in 93% of all patients with the LAD as the infarct related artery. A typical pattern of acute inferior myocardial infarction was seen in 53% of all patients with RCA or CX narrowing taken as one group. The pattern of true posterior or posterolateral wall acute myocardial infarction in the absence of typical changes in the inferior leads was highly specific and predictive of CX narrowing. In contrast, the pattern of an inferior wall myocardial infarction, in the absence of true posterior or lateral wall changes, was highly specific and predictive of right coronary artery narrowing. Fifty-six percent of patients with CX artery as the infarct related artery presented with non-classical electrocardiographic abnormalities. The electrocardiographic pattern in patients with subtotal occlusions were similar to those of patients with total occlusions. Thus the electrocardiogram obtained in the first few hours of acute myocardial infarction is reliable in localizing the LAD as the infarct related artery.(ABSTRACT TRUNCATED AT 250 WORDS)
Arrhythmias, Cardiac↗
Effects of intracoronary streptokinase and intracoronary nitroglycerin infusion on coronary angiographic patterns and mortality in patients with acute myocardial infarction.
We randomly assigned patients with a clinical diagnosis of acute myocardial infarction to one of four treatment groups: intracoronary streptokinase, intracoronary nitroglycerin, intracoronary streptokinase and intracoronary nitroglycerin, or conventional therapy without initial angiography. Of 124 patients 122 sustained acute myocardial infarction. Initial angiography revealed total occlusion of the coronary artery responsible for infarction in 67 per cent (61 of 91). Acute recanalization occurred in 74 per cent (32 of 43) of patients receiving streptokinase but in only 6 per cent (1 of 18) of patients treated with nitroglycerin alone (P less than 0.01). At angiography of all four groups on Day 10 to 14 the vessel responsible for acute myocardial infarction was patent in 77 per cent (71 of 92) of patients; there was no difference among groups, indicating gradual, endogenous thrombolysis in patients not treated with streptokinase. Patients with subtotal obstruction initially had significant improvement in left ventricular function, significantly lower peak creatine kinase levels, and a trend toward lower mortality than patients with total occlusion initially. Mortality at six months in patients receiving streptokinase (21 per cent, 13 of 62) did not differ significantly from that in patients not treated with streptokinase (10 per cent, 6 of 61). Additional studies will be necessary to assess treatment effects in the angiographic subsets identified by this trial.
Angiography↗
Electrocardiographic and coronary arteriographic correlations during acute myocardial infarction.
One hundred fifty-two patients underwent cardiac catheterization and coronary arteriography within 6.3 +/- 6.0 hours from the onset of acute myocardial infarction (AMI). All had standard 12-lead electrocardiograms recorded within 1 hour of cardiac catheterization. The electrocardiographic abnormalities present were correlated with the infarct-related artery as determined by coronary arteriography. ST-segment elevation was the most common finding in patients with the left anterior descending (LAD) or right coronary artery as the infarct-related artery. ST-segment depression was the most common abnormality in patients with the left circumflex (LC), artery as the infarct-related artery. A classic pattern of anteroseptal AMI was seen in 93% of all patients with the LAD as the infarct-related artery. A classic pattern of inferior AMI was seen in 53% of patients with right of LC narrowing taken as 1 group. The pattern of true posterior and isolated lateral wall AMI in the absence of classic changes in the inferior leads was highly specific and predictive of LC narrowing. In contrast, the pattern of an inferior wall AMI, in the absence of true posterior or lateral wall changes, was highly specific and predictive of right coronary artery narrowing. Fifty-six percent of patients with LC artery as the infarct-related artery presented with non-classic electrocardiographic abnormalities. The electrocardiographic patterns in patients with subtotal occlusions were similar to those of patients with total occlusions. Thus, the electrocardiogram obtained in the first few hours of AMI is reliable in localizing the LAD as the infarct-related artery.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Patterns of creatine kinase release during acute myocardial infarction after nonsurgical reperfusion: comparison with conventional treatment and correlation with infarct size.
Coronary arteriography and biplane ventriculography were performed in 51 patients during the acute (mean of 6.6 hours after onset of symptoms) and chronic (1 to 3 months after admission) phase of myocardial infarction. Twenty-four patients were treated in a conventional manner. In 27 patients, reperfusion was achieved with intracoronary streptokinase after 24 +/- 20 minutes of infusion. Peak creatine kinase and cumulative creatine kinase release were derived from serial creatine kinase measurements. Ejection fraction and the length of the akinetic or dyskinetic segments were calculated in the chronic phase. The time interval between onset of symptoms and peak creatine kinase was significantly shorter for the streptokinase-treated patients as compared with the conventionally treated patients (13.5 +/- 5.3 versus 22.9 +/- 7.4 hours, p = 0.0001). Significant linear correlations were obtained for both streptokinase-treated and control patients, relating: 1) peak creatine kinase value to both length of the noncontracting segment and ejection fraction in the chronic phase, and 2) cumulative creatine kinase release to both length of the noncontracting segment and ejection fraction in the chronic phase. Patients treated with streptokinase experienced a relatively greater release of enzyme for a given infarct size as compared with those treated in a conventional manner. The difference in enzyme release between the two groups increased as infarct size increased. These observations may be explained by enhanced washout of enzyme from the infarct zone, secondary to reperfusion after intracoronary streptokinase therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Coronary Circulation↗
Implications of precordial ST segment depression during acute inferior myocardial infarction. Arteriographic and ventriculographic correlations during the acute phase.
Thirty two patients presenting with acute transmural inferior wall myocardial infarction underwent cardiac catheterisation and angiography within 12 hours of the onset symptoms. Twelve lead electrocardiograms performed within one hour of catheterisation showed ST segment depression in the anterior precordial leads in addition to inferior wall changes in 17 patients and no ST segment changes in the anterior leads in 15. When the clinical, arteriographic, and ventriculographic variables were compared between the two groups no significant differences were noted with regard to age, sex, risk factors for coronary disease, duration of symptoms before angiography, Killip class, number of inferior leads with ST segment elevation, or initial serum creatine kinase activity. The extent of coronary artery disease as well as the prevalence of severe disease in the left anterior descending artery were similar for both groups. Biplane left ventriculography showed no significant differences between the two groups with regard to global ejection fraction or to the prevalence of posterolateral or anterior segmental wall motion abnormalities.
Coronary Angiography↗
[Spontaneous regression of residential stenosis of the infarct vessel following successful percutaneous transluminal coronary recanalization].
In 64 out of 90 patients with thrombolysis by intracoronary streptokinase (PTCR) in the acute stage of myocardial infarction coronary angiography was performed in the chronic stage after 28 +/- 20 days. 52 of 56 successfully treated patients had a patent infarct vessel in the chronic stage. 36 of these patients showed a spontaneous regression from the subacute to the chronic stage. In 49 of the 56 patients (age: 53.4 +/- 10.4 years) a residual stenosis of more than 75% after PTCR was found; in the chronic stage only 31 patients had a stenosis of more than 75%. Of 10 patients with a spontaneous regression of 25% or more (age: 48.0 +/- 14.9 years) 8 had a one-vessel disease. The infarct vessel was in 6 patients the left anterior descending, in 4 patients the right coronary artery and in no case the left circumflex branch. The results suggest that the indication for invasive interventions, such as acute coronary angioplasty or bypass surgery, does not only depend on the degree of the residual stenosis directly after reperfusion. If possible, the decision for further invasive treatment should depend on the clinical follow-up.
Adult↗
Angiographic study of the infarct-related coronary artery in the chronic stage of acute myocardial infarction.
We and others have demonstrated a high prevalence of total coronary occlusion during the acute phase of myocardial infarction (MI). This study reports the angiographic appearance of the infarct-related artery (IRA) in 130 patients with a history of MI, who underwent cardiac catheterization 2 weeks to more than 12 months afterwards. The IRA was the left anterior descending in 47%, the right coronary artery in 50%, and the circumflex in 3% of cases. Total coronary occlusion was found in 80% of patients studied 2 to 4 weeks after MI, and decreased gradually reaching 40% of those studied after 12 months of MI. In those patients with a patent IRA, severe stenosis remained: 99% obstruction at 2 to 4 weeks, decreasing to 85.9% obstruction after 12 months (p less than 0.005). The prevalence of total coronary occlusion (TCO) and the severity of stenosis in those without TCO was similar in those with transmural or nontransmural MI and in those with one-, two- or three-vessel disease. This study suggests that endogenous lysis is probably a slow process, and that severe coronary narrowing persists in those with recanalization.
Adult↗
Thrombolysis in acute experimental myocardial infarction.
Lysis of thrombi by intracoronary application of streptokinase has become a new therapeutic approach in patients with acute myocardial infarction. To simulate the clinical situation of myocardial infarction a new experimental model was developed, which was based on a thrombotic coronary occlusion at the site of a high degree stenosis created by a constrictor. In 20 dogs, two ligations 15 mm apart were prepared at the left anterior descending or circumflex coronary artery. After closure of the distal ligation, 2 IU of thrombin was injected through a catheter directly in front of the proximal ligation. The catheter was withdrawn and the proximal ligation was closed. Occlusion time ranged from 1 to 6 hours. At 1, 2, 4 and 6 hours after occlusion, streptokinase was infused for 1 hour (100,000 IU in 200 ml of saline solution) into the left main coronary artery. Hemodynamic variables and coronary blood flow to the ischemic and normal myocardial areas were recorded continuously. Myocardial perfusion was measured six times with tracer microspheres. Reinstatement of blood flow, as well as normalization of myocardial perfusion in the ischemic area, was achieved by streptokinase at 5 minutes after 1 hour of occlusion, 8 minutes after 2 hours, 15 minutes after 4 hours, and 30 minutes after 6 hours; no hyperemic flow occurred. Postmortem staining of infarct size revealed more than 50% of viable myocardium in the perfusion area of the thrombotic vessel even after 6 hours of occlusion. Hemorrhage occurred only after 6 hours of occlusion and was limited to the central area of necrosis in the subendocardial layer. Serious reperfusion arrhythmias occurred only after 1 and 2 hours of occlusion and seemed to be independent of the mode of reperfusion; however, the total number of episodes of ventricular fibrillation after reperfusion was probably decreased compared with that after sudden and hyperemic reflow.
Animals↗
Electrocardiographic changes after streptokinase-induced recanalization in patients with acute left anterior descending artery obstruction.
ECG changes were assessed in 15 patients in whom intracoronary streptokinase recanalized a totally occluded left anterior descending artery during acute myocardial infarction. These results were compared retrospectively with those in 22 comparable conventionally treated patients who underwent catheterization during the acute stage of infarction. Before angiography no significant differences were found in the sum of ST elevation (sigma ST increase V1-V6), the sum of R waves (sigma RV1-V6), or the number of Q waves (nQV1-V6) in leads V1 through V6. sigma ST increase V1-V6 was significantly lower in the streptokinase group than in control patients at all times after angiography. sigma RV1-V6 declined and nQV1-V6 increased in both groups during the first 12 hr, but there was no further change in the control group, whereas in the streptokinase group a significant increase in sigma RV1-V6 and decrease in nQV1-V6 followed. There was a significant correlation between long-term electrocardiographic (sigma RV1-V6; nQV1-V6) and angiographic findings (ejection fraction, akinetic segment length). Thus, the Q wave regression and increase in sigma RV1-V6 after streptokinase suggest, in accordance with angiographic findings, that jeopardized myocardium was salvaged by reperfusion.
Aged↗
Percutaneous transluminal coronary artery recanalization in evolving myocardial infarction.
A brief description of recanalization of the thrombotic coronary artery is provided, including the historical background and our own first experience of recanalization during the event of an acute catheter complication. Mechanical recanalization of occluded coronary arteries as initially performed by us is described. The subsequent use of intracoronary infusion of streptokinase is also detailed. An account is given of the angiographic and clinical results in a study of 59 patients. We then consider the encountered and potential complications of percutaneous transluminal coronary artery recanalization (PTCR) based on a study of 232 acute infarction patients treated in four different centers. A discussion of the potential benefits of the intervention is provided, including lower mortality in a patient subgroup that underwent successful recanalization, as well as improved left ventricular function as seen angiographically in successfully recanalized patients. Use of intracoronary thallium injections before and after recanalization is discussed. It is stated that precise delineation of efforts will require randomized control trials. Finally, we provide some suggestions as to the potential follow-up treatment and future development of the technique.
Angioplasty, Balloon↗
Effects of nonsurgical coronary reperfusion on the left ventricle in human subjects compared with conventional treatment. Study of 18 patients with acute myocardial infarction treated with intracoronary infusion of streptokinase.
Left ventricular function was assessed sequentially with biplane cineventriculography in 18 patients with acute myocardial infarction, in whom nonsurgical reperfusion was achieved within 8.2 +/- 6.9 hours (mean +/- standard deviation) after the onset of chest pain with intracoronary infusion of streptokinase (2,000 units/min for 66 +/- 16 minutes). Ejection fraction increased from 51.4 +/- 9.8 percent before reperfusion to 55.9 +/- 9.0 percent immediately after completion of streptokinase infusion (n = 13, p less than 0.01); the length of the akinetic myocardial segment decreased from 10.2 +/- 6.1 to 7.1 +/- 4.9 cm (p less than 0.025). Left ventricular function data before reperfusion and in the chronic stage of infarction (before surgery) were compared with data obtained in two medically treated groups that were matched retrospectively: control group I, nine patients with permanent obstruction of the infarcted vessel; control group II, nine patients with spontaneous recanalization of the initially obstructed vessel. In the acute stage of infarction, ejection fraction and akinetic segment length were comparable in the three groups. In the chronic stage ejection fraction was higher in the study group (57.4 +/- 12.7 percent) than in control group I (43.4 +/- 7.6 percent, probability [p] less than 0.05); the akinetic segment was shorter in the study group (4.5 +/- 6 versus 9.4 +/- 5.5 cm, p less than 0.025). Preservation of R waves was more extensive in the study group. Intraoperative inspection in 10 study group patients and transmural biopsy performed in 3 of these patients revealed the bulk of reperfused myocardium to be viable. It is concluded that jeopardized myocardium was preserved by nonsurgical reperfusion during the acute stage of coronary occlusion.
Aged↗
[Bullous angiolymphoid hyperplasia with eosinophilia].
Two patients are described having a bullous variant of angiolymphoid hyperplasia with eosinophilia on the head. This disease is characterized by inflammatory, infiltrated, plaque-like lesions with recurring bullous eruptions. At the same time there may be prurigo-like papules on the trunk and arms. The course is a characteristic histological pattern revealing cutaneous lymphocytic infiltrate, lymphoid follicle formation, and atypical vascular proliferation associated with tissue eosinophilia. Blister formation takes place subepidermally.
Eosinophilia↗