Direct angioplasty versus initial thrombolytic therapy for acute myocardial infarction: long-term follow-up and changes in practice pattern

Gender-related differences in reperfusion treatment allocation and outcome for acute myocardial infarction

Gender-related differences in outcome after myocardial infarction may relate to biased treatment allocation. To address this concern we analyzed 573 patients presenting with ST-segment elevation acute myocardial infarction (AMI), and treated within 6 hours with reperfusion therapy. Two-hundred eighty patients (49%) received direct coronary angioplasty, whereas 293 (51%) received thrombolytics followed by angioplasty (p = NS). Seventy-four percent were men and 26% were women (p = NS for differences in sex distribution between the 2 treatment groups). Women were older in both groups (p < 0.01). Inferior AMI was seen more often in women (64% of direct angioplasty, 71% of lytic first) than in men (51% and 59%, respectively; p < 0.03). There was no gender-related differences in presence of multivessel coronary artery disease, prior AMI, prior bypass surgery, baseline ejection fraction, percentage of patients with ejection fraction < or = 40%, number of narrowings dilated, or angioplasty success. Patients who underwent direct angioplasty had more multivessel disease (p < 0.001) and prior coronary artery bypass surgery (p = 0.002). After a mean follow-up of 129 +/- 113 weeks, no gender-related differences were seen in the need for cardiac catheterization, documented restenosis, AMI, coronary artery bypass surgery, clinical ischemia, or death. Patients treated with direct angioplasty were more likely to undergo coronary artery bypass surgery (p < 0.05) or to die (p < 0.01). Thus, women undergoing reperfusion therapy for ST-segment elevation were older than men, with a higher frequency of inferior wall AMI. No specific gender-related bias in treatment allocation was evident.

Comparison of results of coronary angioplasty during acute myocardial infarction with and without previous coronary bypass surgery

Six hundred one consecutive patients undergoing reperfusion within 6 hours of acute myocardial infarction were studied with regard to impact of previous coronary artery bypass grafting (CABG) on direct coronary angioplasty performance and results. Forty-nine patients (8%) had previously undergone CABG, whereas 552 (92%) had not. Direct angioplasty was used for reperfusion in 35 patients (71%) in the CABG group, and in 258 (47%) in the non-CABG group (p < 0.01). No significant differences between these groups were noted with regard to gender, age, infarction site, time to reperfusion or angioplasty success (34 of 35 CABG patients [97%] vs 236 of 258 non-CABG patients [92%]). CABG patients were more likely to have had previous infarction (17 of 35 [49%] vs 35 of 258 [14%] [p < 0.001]), multivessel disease (34 of 35 [97%] vs 127 of 258 [49%] [p < 0.001]) and lower mean ejection fraction (0.36 +/- 0.13 vs 0.46 +/- 0.12, p < 0.001). Over a mean follow-up of 151 weeks, 24 patients (69%) in the CABG group were restudied versus 112 (43%) in the non-CABG group (p < 0.01). Restenosis occurred in 14 patients (40%) in the CABG group versus 58 (22%) in the group without previous CABG (p = 0.04). In the CABG group, restenosis occurred significantly more often in saphenous vein grafts than in native vessels (12 of 17 [71%] vs 2 of 11 [18%] [p < 0.02]). There was no significant difference in the overall performance of repeat angioplasty between the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)