Diagnosis of Diagnosis of acute MIacute MI

Pharmacologic Pharmacologic therapy*therapy*

Immediate Immediate angiographyangiography

PTCAPTCA

Other RxOther Rx

*Antithrombin agents, antiplatelet agents, and fibrinolytic agents.

““Prejunctive” TherapyPrejunctive” 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

Plasminogen-Activator AngioplastyPlasminogen-Activator AngioplastyCompatibility Trial (PACT)Compatibility Trial (PACT)

Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

Eligible acute infarct patientsn=606ASA, IV heparin

t-PA50 mg bolus

Placebobolus

Immediate angiography

TIMI 3 TIMI 0, 1, 2

Second bolusof study drug

Immediateangioplasty

Follow-up angiogram 5-7 days, ETT 6 wk

Randomize

1519

33

28

0

20

40

60

80

Perc

ent T

IMI G

rade

2/

3 FL

ow

Placebo t-PA

TIMI 2TIMI 3

34.3

61

*All comparisons P<0.001.Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

Patency of the Infarct Artery on Catheter Patency of the Infarct Artery on Catheter Laboratory Arrival (Core Laboratory) Laboratory Arrival (Core Laboratory)

94.6 92.8

79 76.6

15.6 16.2

86.7 82.8

0

20

40

60

80

100

TIMI 0,1 TIMI 0, 1 TIMI 0, 1 TIMI 2

Placebo t-PA

Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.P=NS TIMI 2, 3 TIMI 3 TIMI 2 TIMI 3

Technical Results of PTCA: Technical Results of PTCA: Core Laboratory ResultsCore Laboratory Results

% o

f Pat

ient

s

62.4 57.9 54.7

0

20

40

60

80

TIMI 3 on cath lab arrival TIMI 3 on cath lab arrival Never had TIMI 3

Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962.

% C

onva

lesc

ent L

VEF

Convalescent LV Function By Patency Convalescent LV Function By Patency Group: Global Ejection FractionGroup: Global Ejection Fraction

P=0.004

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.

PACT: PACT: AdverseAdverse Events Events

Summary: Pharmacologic/Mechanical Summary: Pharmacologic/Mechanical Combination TherapyCombination 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