Sustained Coronary Patency After Fibrinolytic Therapy: APRICOT
Sustained Coronary Patency After Fibrinolytic Therapy: APRICOT
Background: Whether late coronary patency after myocardial infarction has prognostic impact independent of left ventricular function remains a matter of debate. Reocclusion rates in the first year after fibrinolysis vary between 20% and 30%. Of all reocclusions, about 30% present as clinical reinfarction, associated with a 2-fold-increased risk of mortality. The clinical impact of reocclusion that presents without reinfarction has not been studied; but an association has been demonstrated with impaired contractile recovery of left ventricular function, the strongest prognosticator of long-term outcome. We therefore studied the impact of 3-month coronary patency after successful fibrinolysis on 10-year cardiac survival.
Methods: In the APRICOT-1 trial, 248 ST-elevation myocardial infarction patients with an open infarct artery 24 hours after fibrinolysis had 3-month repeated angiography. Ten-year clinical follow-up was complete in 99.6%.
Results: The reocclusion rate was 29% (71/248). Of these reocclusions, 24% presented as clinical reinfarction (17/71). Cardiac survival at 10 years was 73% in patients with a reoccluded infarct artery and 88% in patients with sustained patency (P < .01). This difference was also present in patients in whom reocclusion was only detected as a result of systematic repeated angiography, that is, in the absence of reinfarction or ischemic symptoms between angiograms (70% vs 86%, P < .03). Multivariable analysis identified sustained patency at 3-month angiography as independent predictor of 10-year cardiac survival (hazard ratio 2.10, 95% CI 1.10-4.02) together with left ventricular ejection fraction.
Conclusions: Sustained infarct artery patency in the first 3 months after successful fibrinolysis is a strong predictor of 10-year cardiac survival, independent of left ventricular function. Notably, this also holds true when reocclusion occurs without signs of clinical reinfarction or recurrent ischemia. Therefore, future preventive strategies should also focus on "clinically silent" reocclusions. Additional studies on better antithrombotic regimens and the combination with a routine invasive strategy early after successful fibrinolysis are warranted.
Late coronary patency after myocardial infarction, and its potential prognostic impact independent of left ventricular (LV) function, remains an issue of ongoing debate. After primary percutaneous coronary intervention, reocclusion is infrequent, especially after the introduction of stenting. However, many patients with ST-elevation myocardial infarction are treated with fibrinolytic therapy; and reocclusion rates vary from 5% to 10% before hospital discharge to 20% to 30% in the subsequent year when adopting a conservative revascularization strategy. About 30% of these reocclusions result in clinical reinfarction. The incidence of clinical reinfarction is about 5% at 30 days, of which half occur within 48 hours after fibrinolysis. These early symptomatic reocclusions are associated with a 2-fold increase in mortality. Notably, systematic angiographic follow-up has revealed that about half of reocclusions occur without overt ischemic symptoms. When reocclusion occurs in the absence of clinical reinfarction, impaired LV contractile recovery has been demonstrated. In contrast, patients with sustained patency showed improvement in LV function, a key correlate of both short- and long-term outcomes.
To date, only one study after fibrinolysis demonstrated the adverse prognostic consequences of late reocclusion over a 6-year follow-up period, independent of LV function. Reocclusion was assessed 6 months after routine angioplasty, performed 10 days after fibrinolysis. Other studies on the impact of an open infarct artery reported contradicting findings and included a heterogeneous population of patients with persistently occluded and reoccluded infarct arteries, both with and without prior reperfusion therapy.
In light of the continuing interest in the concept of late coronary patency, we sought to assess its impact on 10-year cardiac survival in a well-defined population of myocardial infarction patients with a patent infarct artery 24 hours after fibrinolysis in whom a conservative ischemia-guided revascularization strategy was adopted.
Abstract and Introduction
Abstract
Background: Whether late coronary patency after myocardial infarction has prognostic impact independent of left ventricular function remains a matter of debate. Reocclusion rates in the first year after fibrinolysis vary between 20% and 30%. Of all reocclusions, about 30% present as clinical reinfarction, associated with a 2-fold-increased risk of mortality. The clinical impact of reocclusion that presents without reinfarction has not been studied; but an association has been demonstrated with impaired contractile recovery of left ventricular function, the strongest prognosticator of long-term outcome. We therefore studied the impact of 3-month coronary patency after successful fibrinolysis on 10-year cardiac survival.
Methods: In the APRICOT-1 trial, 248 ST-elevation myocardial infarction patients with an open infarct artery 24 hours after fibrinolysis had 3-month repeated angiography. Ten-year clinical follow-up was complete in 99.6%.
Results: The reocclusion rate was 29% (71/248). Of these reocclusions, 24% presented as clinical reinfarction (17/71). Cardiac survival at 10 years was 73% in patients with a reoccluded infarct artery and 88% in patients with sustained patency (P < .01). This difference was also present in patients in whom reocclusion was only detected as a result of systematic repeated angiography, that is, in the absence of reinfarction or ischemic symptoms between angiograms (70% vs 86%, P < .03). Multivariable analysis identified sustained patency at 3-month angiography as independent predictor of 10-year cardiac survival (hazard ratio 2.10, 95% CI 1.10-4.02) together with left ventricular ejection fraction.
Conclusions: Sustained infarct artery patency in the first 3 months after successful fibrinolysis is a strong predictor of 10-year cardiac survival, independent of left ventricular function. Notably, this also holds true when reocclusion occurs without signs of clinical reinfarction or recurrent ischemia. Therefore, future preventive strategies should also focus on "clinically silent" reocclusions. Additional studies on better antithrombotic regimens and the combination with a routine invasive strategy early after successful fibrinolysis are warranted.
Introduction
Late coronary patency after myocardial infarction, and its potential prognostic impact independent of left ventricular (LV) function, remains an issue of ongoing debate. After primary percutaneous coronary intervention, reocclusion is infrequent, especially after the introduction of stenting. However, many patients with ST-elevation myocardial infarction are treated with fibrinolytic therapy; and reocclusion rates vary from 5% to 10% before hospital discharge to 20% to 30% in the subsequent year when adopting a conservative revascularization strategy. About 30% of these reocclusions result in clinical reinfarction. The incidence of clinical reinfarction is about 5% at 30 days, of which half occur within 48 hours after fibrinolysis. These early symptomatic reocclusions are associated with a 2-fold increase in mortality. Notably, systematic angiographic follow-up has revealed that about half of reocclusions occur without overt ischemic symptoms. When reocclusion occurs in the absence of clinical reinfarction, impaired LV contractile recovery has been demonstrated. In contrast, patients with sustained patency showed improvement in LV function, a key correlate of both short- and long-term outcomes.
To date, only one study after fibrinolysis demonstrated the adverse prognostic consequences of late reocclusion over a 6-year follow-up period, independent of LV function. Reocclusion was assessed 6 months after routine angioplasty, performed 10 days after fibrinolysis. Other studies on the impact of an open infarct artery reported contradicting findings and included a heterogeneous population of patients with persistently occluded and reoccluded infarct arteries, both with and without prior reperfusion therapy.
In light of the continuing interest in the concept of late coronary patency, we sought to assess its impact on 10-year cardiac survival in a well-defined population of myocardial infarction patients with a patent infarct artery 24 hours after fibrinolysis in whom a conservative ischemia-guided revascularization strategy was adopted.
