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Cock, C.C. de

Veen, G.

Verheugt, F.W.A.

Radboud Repository

Regression of culprit coronary lesions demonstrated by repeat quantitative coronary angiography within three months after thrombolysis for acute myocardial infarction

Veen, Gerrit

de Cock, Carel C.

Verheugt, Freek W.A.

Elsevier - Publisher Connector 

Regression of culprit coronary lesions demonstrated by repeat quantitative coronary angiography within three months after thrombolysis for acute myocardial infarction 

332A JACC February 1996 
ABSTRACTS - POSTER 
' ]  o f  Unstab le  Ang ina  Therapy  
Wednesday, March 27, 1996, 9:00 a .m. -11:00 a.m. 
Orange County Convent ion Center, Hall E 
Presentation Hour:  9:00 a.m.-10:00 a.m. 
~ Failure of  Present Algorithms Clinical of  
Intravenous Heparln Adjustment to Maintain Stable 
Therapeutic Anticasgulatlon in a Coronary Cam 
Unlt Settlng 
Joseph B. Muhtestein, Tami L Balr, Labme A. Karagounis, Jeffrey 
L Anderson. University o! Utah, LDS Hospital, Salt Lake City,, Utah 
Intravenous hepadn anticoagulation I the coronary care unit Is very common. 
Although awide variety of anticoaguletion algorithms, with and without welght 
adjustment, have been described, their efficacy Is In question. To determine 
the effectiveness of presuntly existin;~ clinical hepadnlzatlon protocols, we 
studied the results of 3,745 consecutive patients (mean age: 64 yrs, males: 
72%, average weight: 82 kg, edmltted with acute MI: 63%) receiving IV 
heparin In the LDS HOspital CCU. lime from Initiation of hepadn to the first 
therapeutic PTT (defined as 60-20 sac) (TFTPTT), % of PTT's < 60, % of 
PTT's • 90, and the total % of PTT's outside the therapeutic range (%OTR) 
were evaluated for the entire group and for subsets of patients in which the 
initial weight adjusted dosing was within three ranges of < 12 U/kg/hr, 12-17 
U/kg/hr, and > "7 U/kg/hr. Results are: 
Initial Hepadn Dose TFTPTT %PTT'a < 60 %PTT's > 90 %OTR 
< 10 U~l~11r (n- 1348) 10.6 4-11.8hr 48228% 21~23% 69-~ 24% 
12..-17 U/kg~r (n - 2CO0) 7.8 ± 9.0hr 35±24% 31±25% 664-24% 
> 17 LI/kg/hr (n - 337) 7.I 4- 7.5hr 31~ 24% 38 =l: ~ 674-22% 
Entire Group (n - 3745) 9.5 4- 9.9hr 39 4- 26% 28 :t= 24% 67 :l: 24% 
Conclusion: Two thirds or more of PTT's obtained in the CCU in all groups 
of patients on IV hepadn were found to be out ol range. Although patients 
treated in the mere aggressive weight adjustment ranges tended to reach a 
therapeutic PTT sooner than those treated in the lower range, this difference 
is likely not large enough to show clinical relevance, This study underscores 
the difficoity of maintaining stable adequate anticoagulation i clinical practice 
using IV hepadn, regardless of whether weight adjustment is used, and the 
need to evaluate altemative more stable anticoeguletion strategies. 
~"~'~ l"matrnent of  Intracaronsry Thrombus: Successful 
Lysis Wilh Intra-Coransry t.PA 
Bany L Sharer, George R. McKeodafl, Ted W. Love, Robert Bersln, 
David Talley, David O. William3 for the Intracoronary t-PA Investigators. 
RIl~e Island Hospital, Brown University,, Providence, Rhode Island 
In order to assess the efficacy of Intrecoronary (IC) t-PA we reviewed in a core 
labemtory the coronaw angiograrns at baseline, 20, 40, 60 minutes (rain) and 
24 hours a~er treatment of 1 20 patients (lots) with acute coronary syndromes 
and IC thrombus. Thrembus was scored as none (0), possible {1 ) and definite 
(2-4) with discrete intra-lumlnal filling defects of Increasing size (small < 1/2, 
moderate > 1/2 + < 2, end large > 2 vessel diameters respectively). Five IC 
t.PA Infusion eb'ateglas were assessed (20 mg holu3, 20 mg over 20 rain, 20 
mg over 40 rain, 40 mg over 20 rain and 40 mg ever 40 rain). For the entire 
coho~ percent ~i',o~.Ls (84 ± 15 baseline vs 75 ± 20 at 24 hr) and TIMI flow 
(58% with grade 3 baseline vs 69% at 24 hr) improved with lherepy. 
~=Jtgk~caphtc Outcome Baseline 60 n~n 24 hr 
No clot (%) 7 15 26 
Oar, nits clot (%) 79 63 47 
Large clot (%) 33 21 11 
ProCedural and angfogrephl¢ vadablas were analyzed to predict successful 
lyre, A decrease of > 2 thmmbus oores at 24 hr was noted In 55% of pts 
with TIMI 3 flow at baseline compared to 33% of pts with TIMI 0-2 flow (p = 
0.06). A decrease of > 2 thrornbus cores at24 hrwas noted in 56% of pts 
rol led wl~ high dose (40 rag) t-PA compared to 46% of pte treated with low 
dole (20 rag) t-PA (p ,, 0.14). We conclude that IC t-PA relieves coronary 
nanowin~ Imlxovas flow, successfully lyses IC clot at low dose with some 
benefit from t~ dose and that its effectiveness is dependent on 
pm-natmant flow. 
• Regression of Culprit Coronary Lesions 
Demonstrated by Repeat Quantitative Coronary 
Anglography Within Three Months After 
Thrombolysls for  Acute Myocardial infarction 
Gerflt Veen, Carel C. de Cock, Freek W.A. Verheugt. Department of 
Cardiology, Free University Hospital, Amsterdam, The Netherlands 
Little is known about the natural histowy of coronary lesions after successful 
thrombelysls (1") for acute myocardial Infarction (MI). In the APRICOT-study 
we performed coronary angiogrephy within 48 hours after T and patients 
(tots) with a patent Infarct-raleted artery underwent a second angiography 
after 3 months. Initial visual assessment showed hlgh-greda stenosis to 
be an independent predictor of reooolusion. We also found that 15% of 
complex lesions showed remodelling to smooth and less severe lesions. 
Quantitative coronary angiography (QCA) was performed to obtain accurate 
data concoming reecolusion and regression of culpdt lesions. 
In 230 of 248 pts the anglograms ware suitable for QCA. In this group 66 
pts showed rancolusion. The mean diameter etenosls of the culprit lesions 
in pte with recccluslon was 61.4 ± 10.7% compared to 54.4 -;- 11.7% in 
pte without reocoluslon {p < 0.0001). The table shows data of 161 pts 
without rancolusion. Three subgroups were studied according to changes in 
morphology. (Only three lesions changed from smooth to complex and were 
no! considered in this analysis). 
Morphol. change Mean diameter stenosls (%) p 
Anglo I Anglo 2 
CO-* CO (N= 41) 55.8-;-11.2 50.54-10.9 0.002 
CO --* SM (N - 38) 52.6 • 12.1 40.3 -~- 16.3 0,00001 
SM .-* SM (N = 82.) 54.4 ± 12.0 51.2 :t: 14.0 0.01 
SM = smooth; CO - complex 
Conclusion: QCA confirms that stenosts sevedty measured eady after 
successful T for acute MI is associated with reocclusion. In pts without 
reocolusion reduction in stenosis severity occurs in most lesions. However, 
the largest reduction is seen in lesions changing from complex to smooth, 
implicating that these lesions are especially subject to ongoing thmmbus 
resolution and plaque repair. 
~ Identmcatlon of  High-Risk Patients With Unstable 
Angina 
Giorgio Ghlglletti, Claudlo Brunelli, Luca Coreiglia, Paolo Spaliomssa, 
Alessandro lannone, Salvatore Caponnetto. Department of Cardiology, 
Ganova, Italy 
Early revasculadzetlon has been proposed in patients with unstable angina 
(UA) who have In-hospital recurrence of symptomatic iechemia despite bed 
rest and aggressive medical therapy. In our ward, mean waiting times for 
revasoularization of over 2 weeks allowed for assessment of: t) the risk in 
delaying revascolarizetlon for more than 72 to 96 hrs, and 2) whether patient 
risk for recurrent schemla could be defined. We graded recurrent angina as 
refractory (Group 1) when pts had >_. one Isohamic episode/day over con- 
secutive 48 hours and > live episodes total, and as occasional (Group 2) 
when pts had >_ one Issheml¢ episode without the previous features. Of 335 
consecutive pts with UA who were admitted to our ward, 109 (32.6%) had 
recurrent Ischemla (33 pts in Group 1, 76 in Group 2). Slgnitlcant differences 
(p < 0.05) between pts In Groups t and 2 were found for females (46% 
vs 29%), insulln-depsodant diabetes (9% vs 1%), triple/taft main coronary 
disease (43% vs 23%), mean ejection fraction (57 ± 17% vs 64 ± 12%), 
and eplsndee of Ischemla: lasting more than 20 rain (94% ve 40%), with ar- 
rythmlas (27% ve 11%) or requiring tnotropic drug (!8% vs 4%). The waiting 
times for revasculadzalton were similar (22.4- 13 vs 17 4- 7 days). In Group 
1, 11 of 17 pts treated medically ware angina-free after 16 4- 8 dayG, but 
six (18.1%) had intercurrent events (two deaths within 96 hrs despite rescue 
revesculadzetfon); the remalnlng 16 pte underwent revascoladzetlan safely. 
In Group 2, 62 of 67 pts treated medically had resolution of Isohamta fter 5 
=1= 5 days, but five patients (6.6%) had events (two within 96 hrs of admls- 
slan); the 10 remaining pts had successful revescolarization. Conclusions: 
1) patients with recurrent isohomla after 48 hrs of medical therapy should be 
referred for immediate anglugrephy; 2) delaying revesculadzation i  these 
patients mere than 96 hrs increases the risk of cardiac events; 3) refractory 
UA may be defined by the persistence of iechemio episodes despite 4 to 7 
days of medical therapy. 


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Regression of culprit coronary lesions demonstrated by repeat quantitative coronary angiography within three months after thrombolysis for acute myocardial infarction

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