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“Prejunctive” Therapy

“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.

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“Prejunctive” Therapy

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  1. “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.

  2. Plasminogen-Activator AngioplastyCompatibility Trial (PACT) Eligible acute infarct patients n=606 ASA, IV heparin Randomize t-PA 50 mg bolus Placebo bolus Immediate angiography TIMI3 TIMI 0, 1, 2 Second bolus of study drug Immediate angioplasty Follow-up angiogram 5-7 days, ETT 6 wk Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

  3. Patency of the Infarct Artery on Catheter Laboratory Arrival (Core Laboratory) 61 34.3 *All comparisons P<0.001. Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

  4. Technical Results of PTCA: Core Laboratory Results % of Patients TIMI 2, 3 TIMI 2 TIMI 3 TIMI 3 P=NS Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

  5. Convalescent LV Function By Patency Group: Global Ejection Fraction P=0.004 % Convalescent LVEF Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

  6. P Value PACT: Adverse Events Adverse Event t-PA Placebo 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.

  7. 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

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