Transcript “Prejunctive” Therapy • A strategy to promote very early patency for some patients (drug responders) and very high final patency rates (assured by.

“Prejunctive” Therapy
• A strategy to promote very early patency
for some patients (drug responders) and very
high final patency rates (assured by PTCA)
for all patients
PTCA
Diagnosis of
acute MI
Pharmacologic
therapy*
Immediate
angiography
Other Rx
*Antithrombin agents, antiplatelet agents, and fibrinolytic agents.
Plasminogen-Activator Angioplasty
Compatibility Trial (PACT)
Eligible acute infarct patients
n=606
ASA, IV heparin
Randomize
t-PA
50 mg bolus
Placebo
bolus
Immediate angiography
TIMI 3
Second bolus
of study drug
TIMI 0, 1, 2
Immediate
angioplasty
Follow-up angiogram 5-7 days, ETT 6 wk
Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.
Percent TIMI Grade
2/3 FLow
Patency of the Infarct Artery on Catheter
Laboratory Arrival (Core Laboratory)
80
61
60
34.3
28
TIMI 2
TIMI 3
40
20
19
33
15
0
Placebo
t-PA
*All comparisons P<0.001.
Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.
Technical Results of PTCA:
Core Laboratory Results
94.6 92.8
100
Placebo
t-PA
86.7
79 76.6
% of Patients
80
60
40
15.6 16.2
20
0
P=NS
TIMI 0,1
TIMI 0, 1
TIMI 0, 1
TIMI 2
TIMI 2, 3
TIMI 3
TIMI 2
TIMI 3
Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.
82.8
Convalescent LV Function By Patency
Group: Global Ejection Fraction
TIMI 3 on cath lab arrival
TIMI 3 on cath lab arrival
Never had TIMI 3
% Convalescent LVEF
P=0.004
80
62.4
57.9
60
40
20
0
Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.
54.7
PACT: Adverse Events
Adverse Event
t-PA Placebo P Value
Major bleeding
12.9%
13.5%
0.84
Stroke (any)
0.7%
0.7%
0.99
Intracranial hemorrhage
0.3%
0.3%
0.99
Emergency revascularization
7.3%
7.2%
0.98
Hospital death
3.6%
3.0%
0.64
30-day death
3.6%
3.3%
0.81
Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.
Summary: Pharmacologic/Mechanical
Combination Therapy
• Safe: no increase in ICH, CABG, reocclusion,
or repeat PTCA
• Mounting evidence of better clinical outcomes
• May have special value in decreasing time
delay to revascularization associated with PTCA
• Outcomes best if artery open before PTCA