Circulation, Vol 90, 1706-1714, Copyright © 1994 by American Heart Association
A Meijer, FW Verheugt, MJ van Eenige and CJ Werter
BACKGROUND: After successful thrombolysis for acute myocardial infarction,
reocclusion is observed in about 30% of patients after 3 months and usually
occurs without reinfarction. We studied the impact of reocclusion without
reinfarction on global and regional left ventricular function and on
remodeling during that period. METHODS AND RESULTS: The patients for this
analysis constituted a subset of those enrolled in the APRICOT-trial, which
was designed to study the efficacy of antithrombotics on the prevention of
reocclusion. Patients were selected who had a left anterior descending- or
right coronary artery- related myocardial infarction, had an
angiographically patent infarct- related vessel when studied < 48 hours
after intravenous thrombolysis, and underwent repeat cardiac
catheterization at 3 months. Paired contrast ventriculograms of quality
sufficient to analyze regional wall motion, global ejection fraction, and
ventricular volumes were analyzed in 129 patients. Enzymatic infarct size
and baseline left ventricular function as well as other baseline
characteristics were similar in patients with (n = 34) and without (n = 95)
reocclusion. Ejection fraction improved in anterior infarction without
reocclusion from 47 +/- 10% to 54 +/- 13% (P = .0001) but not with
reocclusion (baseline, 48 +/- 13%; 3 months, 48 +/- 16%). No improvement
was seen in inferior infarction with or without reocclusion. Persistent
patency allowed preservation of end-systolic volume index (ESVI) at 3
months (37 +/- 14 mL/m2) to baseline level (38 +/- 13 mL/m2), with a better
chance for improvement of > 10 mL/m2 without reocclusion in those with
baseline values > 40 mL/m2. After reocclusion, in contrast, ESVI
increased from 37 +/- 14 to 43 +/- 20 mL/m2 (P = .08). Comparable mean
changes of ESVI in response to persistent patency or reocclusion were seen
in anterior versus inferior infarction. Recovery of infarct zone
contractility was impaired by reocclusion, both in terms of abnormality of
segment shortening and expressed in the number of segments showing abnormal
wall motion. In anterior but not in inferior infarction, infarct zone
contractility was better with good collaterals to the reoccluded artery
compared with poor collaterals. CONCLUSIONS: After successful thrombolysis
for acute myocardial infarction, reocclusion without reinfarction withholds
salvaged myocardium from regaining contractility. This has deleterious
consequences for regional and global left ventricular function and for
remodeling. To further optimize prognosis in patients after thrombolysis,
future research should focus on the prevention of reocclusion and should
evaluate revascularization therapy in patients with reocclusion.
ARTICLES
Left ventricular function at 3 months after successful thrombolysis. Impact of reocclusion without reinfarction on ejection fraction, regional function, and remodeling
Department of Cardiology, Free University Hospital, Amsterdam, The Netherlands.
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