1022-107 Outcome of Different Reperfusion Strategies in Thrombolytic “Eligible” versus “Ineligible” Patients with Acute Myocardial Infarction

Pts considered “not eligible” for inclusion in most early U.S. thrombolytic trials because of advanced age, late presentation, prior CABG or shock have avery poor prognosis; thus, some have suggested broadening the criteria for lyric eligibility. To examine the role of different reperfusion strategies in pts traditionally considered lytic “eligible” vs. “ineligible” (age>70, MI onset>4 hours, or prior CABG), we examined the PAMI database in which 395 pts of any age within 12 hours onset of MI were randomized to t-PA or primary PTCA (pts with shock were excluded). Compared to lyric eligible pts, ineligible pts were o1der(67 vs. 56 yrs, p<0.0001). more frequently female (38% vs. 20%, P<0.0001), diabetic (17% vs. 10%, P=0.03), had prior CABG (8% vs. 0%, P<0.0001), presented later (4.4 vs. 2.2 hours, p<0.0001), and were more likely to present in CI-1F (20% vs. 11%, P=0.01). Endpoints included death (D), reinfarction (R), recurrent ischemic events (RIE) and stroke:Thrombolytic eligibleThrombolytic ineligiblePTCA (n=127)t-PA (n=117)PPTCA (n=68)t-PA (n=83)Pin-hosp. D2.4%1.7%NS2.9%13.3%0.025in-hosp. D or R5.5%9.4%NS4.4%15.7%0.026in-hosp. RIE11.8%29.1%0.00087.4%26.6%0.002in-hasp. stroke0%1.7%NS0%6.0%0.046 month D3.9%1.7%NS2.9%15.7%0.0096 month D or R8.7%12.8%NS7.4%22.9%0.009In conclusion: Pts traditionally considered thrombolytic eligible comprise a low risk cohort, and have a favorable prognosis whether treated with primary PTCA or t-PA. In contrast, pts historically excluded from most early lytic trials because of advanced age, late presentation or prior CABG are at increased risk, and may have improved survival with primary PTCA rather than thrompresented laterbolysis

1022-103 Does Primary Angioplasty Improve the Prognosis of Patients with Diabetes and Acute Myocardial Infarction?

To examine the effect of different reperfusion modalities in pts with DM, the multicenter PAMI database was analyzed, in which 395 pts within 12 hours onset of acute MI were prospectively randomized to treatment with t-PA (n=200) vs. primary PTCA (n=195). DM was present in 50 (13%) pts. Compared to pts without DM, pts with DM were older (65 vs. 59 yrs, p=0.002), more often female (40% vs. 25%, p=0.03), more frequently had HTN (68% vs. 39%, P=0.0001), prior CHF (8% vs. 1%, P=0.0001). multivessel disease (76% vs. 51%, P=0.01) and presented later (3.8 vs. 3.0hours, p=0.03).In-hospital mortality was 10.0% in pts with DM vs. 3.8% in pts without DM (p<0.05). By multivariate analysis of 16 variables, however, advanced age and treatment by PTCA rather than t-PA, but not DM correlated with in-hospital mortality.Mortality stratified by treatment appears in the graph. Despite the apparently improved prognosis of pts with DM treated with PTCA vs. t-PA, the p value forthe x2 test for interaction effect between DM and treatment modality was 0.86; most of the benefit of PTCA was present in the elderly population.In conclusionPts with DM and acute MI have increased mortality, primarily because of advanced age. The outcome after PTCA compared to t-PA is improved in DM largely because of PTCA's beneficial effect in the elderly