Circulation, Vol 87, 1531-1541, Copyright © 1993 by American Heart Association
JK Harrison, RM Califf, LH Woodlief, D Kereiakes, BS George, RS Stack, SG Ellis, KL Lee, W O'Neill and EJ Topol
BACKGROUND. Contrast ventriculograms of 542 patients treated with
intravenous thrombolytic agents for acute myocardial infarction were
examined to define changes in left ventricular ejection fraction and
regional wall motion that occur during the first week after reperfusion
therapy for acute myocardial infarction and define clinical, acute
angiographic and treatment variables related to improvement in global and
regional left ventricular function. METHODS AND RESULTS. Intravenous
tissue-type plasminogen activator and/or urokinase was administered to 805
patients during acute myocardial infarction. Mean time from symptom onset
to thrombolytic therapy was 3 hours (22 patients received therapy within
the first hour). Acute and 7-day catheterization were performed. Paired
left ventricular ejection fraction and centerline regional wall motion were
available in 542 patients (67%). Stepwise, multivariable analysis of
clinical, acute angiographic and treatment variables was used to develop
two models: One related to improvement in left ventricular ejection
fraction, and the second related to improvement in infarct zone regional
function. Left ventricular ejection fraction did not change (51.2 +/- 11.1%
for acute versus 51.9 +/- 11.0% for 1 week, p = 0.19). Improvement in
infarct zone regional function was modest (14%) at 1 week (-2.54 +/- 1.07
standard deviation per chord for acute versus -2.17 +/- 1.24 at 1 week, p
< 0.001). Subgroup analysis demonstrated modest improvement in ejection
fraction (1.4 +/- 9.5%) and greater improvement in infarct zone function
(19%) in patients with successful sustained reperfusion at 1 week.
Depressed left ventricular ejection fraction and infarct zone regional wall
motion at the acute study were strongly associated with improvement of
these parameters at 1 week. Resolution of chest pain before acute
catheterization, infarct-related artery flow at acute catheterization, and
depressed regional wall motion in the noninfarct zone were associated with
improvement in both ejection fraction and regional infarct zone function at
1 week. Notably, the time from the onset of symptoms to initiation of
thrombolytic treatment was not related to subsequent improvement in
ventricular function. CONCLUSIONS. Dramatic improvement in left ventricular
systolic function is not common after thrombolytic therapy for acute
myocardial infarction. Improvement in global and regional systolic function
is most closely related to acutely depressed ventricular function and
successful acute coronary recanalization. Thus, patients with the most
myocardium in jeopardy and successful coronary reperfusion demonstrate the
greatest improvement in global and infarct zone ventricular function.
Overall, the magnitude of this improvement is modest, suggesting that the
benefits of coronary reperfusion are not solely related to improvement in
systolic left ventricular function.
ARTICLES
Systolic left ventricular function after reperfusion therapy for acute myocardial infarction. Analysis of determinants of improvement. The TAMI Study Group
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
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