Acute myocardial infarction intracoronary application of nitroglycerin and streptokinase

Author

Rentrop KP, Blanke H, Karsch KR, et al. Reference

Clin Cardiol 1979; 2: 354-363 Abstract

In five patients with acute myocardial infarction, the effects of both intracoronary nitroglycerin (NTG) and subsequent intracoronary streptokinase application were evaluated. In addition, transluminal recanalization was performed in one of these patients. Injection of NTG into the infarct-related coronary artery resulted in improved distal filling of the subtotally occluded left circumflex artery in one patient, and in transient patency of the completely occluded right coronary artery in a second patient. In a third patient patency of the totally occluded left anterior descending artery (LAD) was achieved by transluminal recanalization with a guide wire. In a fourth patient with occlusion of the LAD, there was no response to intracoronary NTG and mechanical recanalization was not attempted. Subsequent intracoronary infusion of streptokinase (1000-2000 U/min for 15-60 min) resulted in a further and long-term reduction of narrowing at the site of acute occlusion in patients I-III and in opening of the completely occluded LAD in patient IV Improvement of lumen was paralleled by alleviation of symptoms. In a fifth patient, in whom the LAD was subtotally occluded, the degree of coronary obstruction could not be changed by intracoronary application of NTG or by lysis. In this patient, symptoms and ECG changes improved with reduction of pathologically elevated blood pressure values. The findings suggest that myocar-dial infarction had been caused by thrombotic occlusion in four patients, and that spasm of the infarct vessel could have been an additional factor in two of these patients. In the fifth patient, an increase of afterload in the presence of a subtotal lesion might have caused the critical imbalance between oxygen supply and demand, resulting in cell death.

Summary

Acute myocardial infarction (AMI) is due to coronary occlusion with thrombus. Flow can be restored by passing a guidewire through the thrombus or by the use of streptokinase. Flow in a subtotally occluded vessel can be improved with nitrate therapy, whilst the effects of reduced flow can be ameliorated by reducing pathologically elevated blood pressure.

Citation Count 271

Related References

1. Davies MJ, Woolf N, Robertson WB. Pathology of acute myocardial infarction with particular reference to occlusive coronary thrombi. Br Heart J 1976; 38: 659-664.

2. Judkins MP. Selective coronary arteriography. Part 1: a percutaneous femoral technique. Radiology 1967; 89: 815.

Key message

Reperfusion therapy can be used to relieve symptoms and improve the coronary perfusion. Why it's important

Although a small paper, this summarizes all that has since followed in the field of reperfusion therapy. The role of vasospasm is assessed with the use of intracoronary nitrates. The dispersion of thrombus with streptokinase was then attempted successfully. Finally, the current fervour with which primary percutaneous coronary intervention (PPCI) is pursued clearly has its origins in the mechanical dispersion of clot with an angioplasty wire in one of the five patients discussed. This paper clearly suggests several different methods to open the artery.

Strengths

Its main strength is the foresight of the paper. This was published in 1979. Weaknesses

Only five patients were enrolled. This is not randomized controlled trial data! Relevance

This was the first report of mechanical reperfusion therapy in man. Although only a guidewire was passed, flow still improved, and symptoms and electrocardiographical (ECG) changes resolved.

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