New developments in medical-surgical treatment of acute myocardial infarction.

Selective intracoronary thrombolysis with streptokinase was successful in 72 of 84 (86%) patients admitted to the hospital with definitive signs of acute transmural myocardial infarction due to complete occlusion of either the left anterior descending coronary artery, the right coronary artery, or the circumflex artery. The average time between onset of acute symptoms and medically induced reperfusion was 241 +/- 90 minutes (SD). Reperfusion resulted in prompt relief of pain, regression of cardiogenic shock, and normalization of electrocardiograms. Follow-up treatment was either medical or surgical. The 32 medically treated patients had a high reocclusion rate, with 6 fatal (19%) and 9 nonfatal (28%) reinfarctions. In order to the reduce the risk of reinfarction, additional simultaneous transluminal balloon angioplasty was done in a recent series of patients with stenoses accessible to this technique. The best early and long-term results were achieved in 17 patients who underwent coronary artery bypass grafting within three days after successful thrombolysis. There was no operative mortality, and subsequent bleeding has not been a problem. It is concluded that early operation is the treatment of choice in all patients suitable for such intervention who have undergone successful intracoronary thrombolysis within 4 hours after onset of acute myocardial infarction. Late coronary bypass operation should be reserved for symptomatic patients who have definitive signs of infarction in spite of successful thrombolysis.