APRIL 1, 1985
The American Journal
CORONARY HEART DISEASE
Acute Myocardial Infarction Treated with lntracoronary
Streptokinase: A Report of the Society for
Cardiac Angiography *
J. WARD KENNEDY, MD, GOFFREDO G. GENSINI, MD, GERALD C. TIMMIS, MD,
and CHARLES MAYNARD,
The Society for Cardiac Angiography maintains a
regtstry of intracoronary streptokinase therapy
(IC-SK) in pagents with acute myocardial infarction.
Between July 1981 and August 1984,1,029 patients
were entered into the registry. The baseline and
clinical charactertstks of patients were determined,
the early results of therapy were evaluated, and
baseline characteristics of those in whom reperfu-
sion was achieved were compared with those in
whom it was not. Multivariate discriminant analysis
was used to kfentify the predictors of reperfusion and
hospital mortality. The overall rate of reperfusion
was 71.2 %. Reperfusion was positively associated
with hypotension, absence of cardtogenlc shock and
During the last 5 years there has been a striking change
in the early management of acute myocardial infarction
*l3egMtycomnlltteeforthesocletyforcerdicAnglogaphy:Goffredo
Gemini, MD,chakmen;Mahdi AWassam, MD,JosephR.Dorchak,M>,
Robart M. @aen, MD, John Hirshfeld. MD, Sarah Johnson, MD. J. Ward
Kennedy, MD, Kenneth M. Kent, MD, Stephen B. King, MD, Ronald J.
Krone, MD, Gcrdon A. Logan, MD, Michael D. Moscovich, MD, Richard
K. Myier, MD, Thomas J. Noto, MD, Sven Paulin, MD, August0 Pichard,
MD, Fred Schoonmaker, MD, Gerald C. Timmis, MD, and George W.
Vetrovec, MD. Manuscript received and accepted Janwy 7,1985.
Address for reprints: Society for Cardiac Angiography, 9500 Euclid
Avenue, Cleveland, Ohio 44106.
871
of CARDIO,LOGY@
VOLUME 55
NUMBER 8
MA
early treatment. The hospital mortality rate for all
patients was 8.2% and was higher for women and
the elderly. The hospital mortality was significantly
lower among patients in whom reperfusion was
achieved compared with those in whom it was not
(5.5% vs 14.7%, p <O.OOOl) and for several
high-risk subgroups.
Thus, coronary artery reperfusion induced by
IC-SK significantly reduces hospital mortality in
high-risk patients with acute myocardial infarction.
High-risk patients in whom reperfusion fails with
IC-SK therapy should be considered for early
coronary angioplasty or coronary artery bypass
surgery. (Am J Cardiol 1985;55:871-877)
(AMI) as a result of several important clinical and lab-
oratory investigations. During the mid-1970s there were
efforts to limit infarct size with the use of various drugs.
Although these interventions may have had a sound
physiologic basis and been of some benefit, they were
not successful in reducing the mortality rate of AMI.’
At the same time, experimental studies in animals
clearly demonstrated that coronary reperfusion after
varying periods of coronary occlusion resulted in salvage
of ischemic myocardium.2,3 In a few clinical centers,
coronary artery reperfusion using coronary artery by-
872 INFARCTION TREATED WITH STREPTOKINASE
TABLE I Variables Used in Linear Discriminant Analysis
2:
Time from onset of symptoms to hospital admission
Time from onset of pain to streptokinase therapy
History of myocardial infarction
Prior bypass surgery
History of congestive heart failure
Ongoing chest pain
Hemodynamically stable
Hypotension
Cardiogenic shock
Direct-current cardioversion
Moribund
Balloon pump
Number of diseased vessels
Location of thrombus
Reperk&on
Death in hospital
pass surgery within the first 6 hours after the onset of
AM1 resulted in unexpectedly low mortality and ap-
parent improvement in long-term survival.4*5For many
years the role of coronary artery thrombosis in the
pathogenesis of AM1 was controversial. This contro-
versy ended when early coronary arteriography in pa-
tients with AM1 almost always revealed coronary artery
thrombus.6 In this scientific climate, the initial reports
of successful thrombolysis with the use of intracoronary
streptokinase (IC-SK) in patients with AM1718were
quickly followed by a number of reports describing the
results of the new therapy.s-12 More recently, additional
reports about the results of IC/SK have been pub-
lished.l3-l6 To collect additional information about
thrombolytic therapy, the Society for Cardiac Angiog-
raphy began an intracoronary streptokinase registry.
Between July 1,1981, and August 1,1984,1,029 pa-
tients were registered by 35 laboratories. In this report,
we present the clinical and hemodynamic characteristics
of these patients, the efficacy of thrombolytic therapy
relative to coronary reperfusion, and the hospital mor-
bidity and mortality rates. There are no results from
control patients with which to compare these results.
We therefore compare the patients in whom IC-SK re-
sulted in reperfusion with those in whom the therapy
was unsuccessful. In making these comparisons, we do
not assume that patients in whom reperfusion is not
achieved have the same characteristics as an untreated
control group.
We recognize the limitations of observational, un-
controlled studies in the evaluation of new forms of
therapy. We also believe that it is difficult or impossible
to study high-risk subgroups of patients with controlled,
randomized trials. Because there may be important
differences in the risk and benefit of IC-SK therapy for
various subgroups of patients, a registry that includes
enough patients in these subgroups may contribute
important information that may not be available
from other sources. Thus, we believe that this multi-
institutional registry study will complement infor-
mation obtained from controlled trials.
Methods
This streptokinase registry is a voluntary activity of the
Society in which members report clinical, angiographic and
short-term outcome information on patients with AMI who
TABLE II Patient Enrollment in Society for Cardiac
Angiography Streptokinase Registry
Laboratory No. of Pts Enrolled
St. Vincent’s, New York, NY 120
Straub Clinic, Honolulu, HI 34
Vanderbilt University, Nashville, TN
Lancaster General, Lancaster, PA
St. Joseph’s, Syracuse, NY
Mt. Sinai, Miami, FL
St. Luke’s, New York, NY
Burgess Hospital, Kalamazoo, Ml
St. Louis University, St. Louis, MO
St. Luke’s, Denver, CO
Mercy Hospital, Charlotte, NC
Wm. Beaumont, Royal Oak, MI
Crouse Irving Hospital, Syracuse, NY
Emery University Hospital, Atlanta, GA
U.S.C. Medical Center, Los Angeles, CA
Med. COILof Virginia, Richmond, VA
Naval Hospital, San Diego, CA
St. Joseph’s, Burbank, CA
Lovelace Clinic, Albuquerque, NM
Bryan Memorial Hospital, Lincoln, NE
Toranomon, Tokyo
Bridgeport Hosp., Bridgeport, CT
13 other institutions
Total no. of pts 1,029
have been treated with IC-SK. Participating laboratories
agreed to register consecutive patients in a prospective man-
ner. Because some laboratories had acquired experience with
thrombolytic therapy before July 1981, these laboratories
wereencouragedto enter patients in a retrospectivemanner
so as to include all patients previously treated in their
laboratories.
Data collection forms were developed and distributed. They
were submitted to a central data analysis laboratory, where
the information was checked for consistency and completeness
and entered into a computer data bank. Data collected in-
cluded age,sex, prior myocardial infarction, history of con-
gestiveheart failure and prior coronaryartery bypasssurgery.
The presence or absence of chest pain immediately before
cardiac catheterization was recorded. The patient’s hemo-
dynamic status was categorized as stable, hypotensive (blood
pressure less than 90 mm Hg systolic), or cardiogenic shock.
The cardiogenic shock syndrome was not rigidly defined.
Patients in pulmonary edema but not in shock and those in
a moribund state were identified. The use of precatheteriza-
tion precordial shockfor the treatment of ventricular fibril-
lation and ventricular tachycardia and the use of intraaortic
balloon pump were also noted.
The location of AM1 based on the electrocardiographic and
angiographic findings was recorded. Each patient was classi-
fied as having either an anterior or inferior infarction. Lateral
infarctions were classified as anterior and posterior infarctions
were classified as inferior. From the coronary arteriograms,
patients were classified as having l-, 2- or 3-vessel,or left main
coronary artery disease. Disease was considered present if
there was at least 50?6diameter narrowing of a major coronary
artery.
Most patients received intracoronary nitroglycerin before
the administration of streptokinase, and the result of this
therapy, designed to detect the presence of coronary artery
spasm, was recorded. The use of a guidewire for thrombus
perforation was noted. Reperfusion after IC-SK therapy was
recorded as present or absent and not graded as partial or
complete. Evidence of reocclusion during hospitalization was
recorded.
The patient’s clinical status at the time of hospital discharge
was reported and included death, the development of Q-wave
 April
TABLE III Clinical Status Before Catheterization
Total
1,029
?ime to hosp (min) 119f201
Time to angio (min) 240 f 413
lschemic pain 95.3%
Hemodynamic status
Stable 86.4%
Hypotensive (SBP <90) 10.9%
Cardiogenic shock
Pulmonary edema ii::7 0.3
Defibrillation 7.4%
Moribund 1.9%
Balloon pump 1.3%
AMI = anterior myocardial infarction; angio = angiography; hosp = hospitalization;
myocardial infarction; NS = not significant; SBP = systolic blood pressure (mm Hg).
infarction, presence of stable or unstable angina and the use
of anticoagulant and antiplatelet agents. Patients who un-
derwent surgical revascularization or balloon dilatation of the
coronary artery after streptokinase therapy were identified.
Finally, the complications of therapy were recorded.
Becausemultiple factors determine if a vessel will reperfuse
with IC-SK, or if the patient will survive an AMI, we have
performed multivariate discriminant analysis of the predictors
of reperfusion and mortality. This analysis has been used with
3 groups of patients:
Group Z-all patients. This group includes the 1,029 pa-
tients for whom vital status was known and the 1,011patients
for whom reperfusion status was known. Group II-patients
with anterior infarcts (n = 467). Group III-patients with
inferior infarcts (n = 544).
Statistical methods: Patient characteristics were screened
univariately using the chi-square statistic for discrete variables
and the t test for continuous variables. Multivariate statistical
methods were used to identify baseline factors that are im-
portant in determining reperfusion and hospital mortality.
Stepwise linear digcriminant analysis was used to distinguish
the group that survived from the group that died and the
group in which reperfusion was achieved from the group in
which it was not. In this study, variables related to patient
cardiac history, time of treatment, clinical status before car-
diac catheterization and coronary anatomy were used to
identify the predictors of reperfusion and mortality (Table
I). Linear discriminant analysis was used to select the vari-
ables that best distinguished the 2 groups of interest.lT
The principle of linear discriminant analysis is to select the
combination of variables which most completely separatesthe
two groups. The process is carried out in a stepwise manner
so that the relative importance of each variable selected for
the model is identified. The processstops when the remaining,
unselected variables do not add significant predictive power
to the model (p >0.05). The relative importance of each
variable selected is indicated by the F statistic. Variables with
F value 14.0 (p <0.05) are included in this report.
Results
During the period July 1981 through August 1,1984,
1,029 patients were entered into the registry. Thirty-five
catheterization laboratories enrolled 1 to 208 patients
(Table II). There were 824 men and 205 women, mean
age 5’7 f 10 years. Of the 1,029 patients, 17.8% had a
history of AM1 and 3.1% had previous coronary artery
bypass surgery. The average time from onset of symp-
toms of AM1 to hospitalization was 119 f 201 minutes
1, lY83 1Ht AMtKlGAN JUUKNAL W C;AKUIULUtiY volume 33 IIS
AMI MI p Value
467 551 0.009
124f250 114 f 236 NS
241 f 273 238 f 504
96.1% 94.7% Ii:
85.4% 87.4% NS
10.6% 11.2%
5.1% 3.7% E
4.3% 1.1% 0.002
7.5% 7.4%
3.2% 0.5% 0%
1.7% 0.9% NS
IMI = inferior
and the average time from symptoms to the onset of
therapy was 240 f 413 minutes. Table III is a list of the
precatheterization status (by location of infarction) of
the patients entered into this registry. All but 5% of the
patients were having ischemic pain at the time they
went to the catheterization laboratory. Most of the pa-
tients (86.4%)were hemodynamicahy stable, 10.9%were
hypotensive and 4.4%of them were in cardiogenic shock.
Defibrillation was required before catheterization in
7.4% of patients. Only a few patients had pulmonary
edema, were moribund or were receiving intraaortic
balloon pump treatment. There were significantly more
patients with inferior than with anterior AM1 (p =
0.009). Comparison of patients with anterior infarction
to those with inferior infarction indicated few differ-
ences in baseline clinical characteristics. Remarkably,
the incidence of hypotension was similar in both groups.
Although infrequent in both groups, pulmonary edema
was more common in those with anterior AM1 than in
those with inferior AMI, 4.3% vs 1.1% (p = 0.061).
Reperfusion occurred in 71.2%of the patients (Table
IV). The rate of reperfusion was not different between
men and women or between those who were hemody-
namically stable vs those who were unstable. Reperfu-
sion was less likely if the patient was not having chest
pain (p = 0.0004), was in cardiogenic shock (p <O.OOOl),
moribund (p = O.Ol),and if the patient died (p <O.OOOl).
The 107 patients who were hypotensive but not in car-
diogenic shock had the highest rate of reperfusion-
84.8%-which was significantly greater than for patients
not in shock (p = 0.007). Reperfusion occurred in 73%
of left anterior descending vessels,75%of right coronary
arteries, and 64% of circumflex vessels.
Table V is a list of the clinical and hemodynamic
characteristics of the patients, classified by the success
of reperfusion therapy. Patients in whom reperfusion
was successful were started on therapy earlier than
those in whom it was not, 209 minutes vs 331 minutes
(p = 0.0001). In particular, reperfusion was less likely
to be successful in those who were treated more than 6
hours after onset of symptoms (58%) than in those who
were treated within 6 hours (75%, p = 0.001). The 2
groups were similar with respect to age, sex, duration
of infusion and total dose of streptokinase. Those in
whom reperfusion was successful had a somewhat
higher left ventricular end-diastolic pressure (p = 0.017)
 074 INFARCTIONTREATEDWITH STREPTOKINASE

TABLE IV Hospital Mortality

n % Reperfused Total Reperfused Not Reperfused p Value
All 1,029 71.2% 8.2% 5.5% 14.7% <0.0001
Men 624 73.3% 7.1% 5.1% 11.6% 0.001
Women 205 69.6% 12.7% 7.0% 25.8% 0.0002
Ag~;tb)
593 73.9% 3.2% 2.5% 5.2%
60-69 309 73.1% 12.0% 6.8% 25.9% <o%o 1
70-74 63.1% 18.2% 16.3% 21.4%
275 3; 65.6% 37.5% 28.6% 54.5% Fig
Stable 664 72.8% 5.1% 3.6% 6.1%
i-l;p$tsion l 107 84.8% 5.6% 4.5% 12.5% I!:
66.7% 42.1% 84.0% <0.0001
Edema’ 2 EF. 0 38.2 % 31.8% 54.5% NS
Cardioversion’
[deebrillation) 6.3% 9.3% 5.9%
4:: :t : 7 12.1% 6.4% 21.2% oYzo2
RCA 424 75:3; 4.0% 2.9% 6.8%
127 63.8% 7.9% 2.5% 17.4% o%le
gher 19 72.2% 10.5% 15.4% 0.0% iS
l Shock patients not included.
CX = left CirCUt?‘tf~eX artery; LAD = left anterior descending coronary artery; NS = not significant; RCA = right coronary artery.

TABLE V Patient Characteristics by Status of Reperfusion’

n Total Reperfusion No Reperfusion p Value

Age04 1,014 57 f 10 57f 10 57f 11
Time to treatment (min) 928 240 f 413 209 f 137 331 f 780 ON:01
Duration of infusion (min) 835 57 f 23 57 f 22 57 f 27
Total dose (1,000 IU) 862 235 f 102 234 f 103 232 f 101 Ii:
LVEDP before (mm Hg) 638 21.1 f 8.4 21.6 f 6.3 19.8 f 8.5 0.017
% to CABG 1,011 18.2% 21.1% 10.4% <0.0001
% to PTCA 1,011 7.3% 8.5% 4.3% 0.024
l Reperfusion status could not be determined for 18 patients.
CASG = COTCWINY arterv bvoass sumerv: LVEDP = left ventricutar enddiitolic pressure; NS = not significant; PTCA = percutaneous transluminat
coronary angioplasty. - -’

and were more likely to have subsequent coronary ar-
tery bypass surgery (21.1% vs 10.4%, p <O.OOOl) or
percutaneous transluminal coronary angioplasty (8.5%
vs 4.3%, p = 0.024). The residual stenosis in those who
reperfused was 85.6 f 14.0%.Nitroglycerin was infused
in 77.6%of patients and resulted in at least some degree
of reperfusion in 8.5%. In 177 patients a guidewire was
used in an effort to perforate the thrombus. This pro-
cedure was successful in 54.2% of the cases.There was
clinical or angiographic evidence of reocclusion during
hospitalieation in 13.0% of patients in whom strepto-
kinase t ‘erapy was initially successful.
Compl-iications of therapy: Major nonfatal com-
plications of IC-SK therapy occurred in 9.0% of the
.patients. Ventricular arrhythmias occurred in 4.9%,
hypotension requiring therapy in l.Q%, bleeding in 1.3%
and dissection of the right coronary artery in 0.5%.
Miscellaneous or undefined complications occurred
in 0.4%.
Hospital mortality: Eighty-four of the 1,029patients
died during hospitalization (8.2%). The mortality for
various patient groups and their status of reperfusion
are presented in Table IV. Men had a mortality rate of
7.1%, compared with 12.7% for women (p = 0.01).
Mortality increased progressively with increasing age
for both those with and without reperfusion (Fig. 1).
Although the mortality rate was lower among patients
in whom reperfusion was successful in each agecategory,
this difference reached statistical significance only
among patients 60 to 69 years of age. For the 309 pa-
tients between 60 and 69 years of age, the reperfusion
rate was 73.1%, and those in whom reperfusion was
successful had a mortality rate of 6.8%, whereas those
in whom reperfusion failed had a mortality of 25.9% (p
<O.OOOl). Among patients in cardiogenic shock, the
mortality rate was lower in patients in whom reperfu-
sion was successful than in those in whom it was not: Of
the 44 patients in shock for whom reperfusion status was
determined, 19 achieved reperfusion (43.2%); their
mortality rate was 42.1%,while the 25 patients in whom
reperfusion failed had a mortality rate of 84% (p =
0.0005).
Patients with left anterior descending occlusions in
whom reperfusion was achieved had a mortality of 8.4%,
while those in whom it failed had a mortality of 21.2%
(p = 0.0004). Those with right coronary artery throm-
bosis in whom reperfusion was successful had a mor-
tality rate of 2.9% and those without reperfusion had a
mortality rate of 6.8% (p = 0.13). The 127 patients with
circumflex occlusions had a hospital mortality of
2.5% with reperfusion and 17.4% without reperfusion
(p = 0.008).
Multivariate analysis: Linear discriminant analysis
of factors related to reperfusion and hospital mortality
was performed for 3 groups of patients. The variables
considered as potential predictors of reperfusion and
hospital mortality are listed in Table I. For each variable
that enters the predictive model, the F statistic is an
 April 1.1985 THE AMERICAN JOURNAL OF GARUIOLwtiY volume 33 (115

indication of its relative importance (Table VI). Group TABLE VI Results of Linear Discriminant Analysis
I includes all 789 patients for whom all of the 18 vari- Group I-All Patients
ables used in the analysis were available. In group I, Mortality (n = 789) Reperfusion (n = 789)
shock, age, location of infarction and history of infarc-
tion are related to hospital mortality; and ongoing Variable F at Entry Variable F at Entry
chest pain, shock, hypotension, time to angiography Shock 186.7 Ongoing Pain 13.9
and history of congestive heart failure are related to Age 112.9 Shock 13.0
Location of MI 82.5 Hypotension 10.8
reperfusion. History of MI 64.7 Time to 9.5
Group II includes patients with anterior AMI. In this Angiography
group only shock and age, and shock and time to angi- History of CHF 8.8
ography are related to hospital mortality and reperfu- Group II-Anterior Ml
sion, respectively. Group III includes the patients with Mortality (n = 358) Reperfusion (n = 358)
inferior AMI. In these patients, shock is not related to Variable F at Entry Variable F at Entry
mortality or reperfusion as it is in groups I and II, and Shock 165.5 Shock 14.7
the F values for the predictors of mortality are much Age 103.6 Time to 9.9
lower than those in groups I and II. Angiography
Group Ill-Inferior MI
Discussion Mortality (n = 431) Reperfusion (n = 431)
Limitations of the registry: In this report, using Variable F at Entry Variable F at Entry
data from a registry, we have attempted to define the
efficacy of IC-SK for the treatment of patients with Balloon Pump 23.7 Ongoing Pain 8.9
History of MI 19.7 Balloon Pump 7.2
AMI. The large number of patients (1,029) permits the Age 15.5 Hypotension 6.6
analysis of various important subgroups of patients. CHF = congestive heart failure; Ml = myocardial infarction.
The registry has limitations: (1) It contains no un-
treated, control patients with which to compare the
results achieved in treated patients. (2) Patients were
not followed up beyond hospital discharge. (3) Incom- factor in reperfusion is the time from the onset of chest
plete data collection reduces the numbers of patients pain to the onset of therapy; in fact, there was a mean
available for multivariate analysis of hospital mortality difference of 88 minutes between those in whom re-
and reperfusion. perfusion was achieved and those in whom it was not.
The efficacy of IC-SK therapy must finally be de- Others have observed a relation between time and re-
termined from the results of large randomized trials. perfusion.18 The left ventricular end-diastolic pressure
Randomized trials, however, are restricted to popula- measured before streptokinase infusion was also related
tions in whom randomization is acceptable to both pa- to reperfusion in that the group of patients in whom
tients and physicians. This makes the inclusion of reperfusion failed had a slightly lower pressure. How-
high-risk patients, as those in shock, difficult if not ever, the relation between left ventricular end-diastolic
impossible. pressure and reperfusion is weak, and we cannot explain
Determinants of reperfusion: We have examined it in physiologic terms. There is also a much lower
the information available in this registry to determine likelihood of reperfusion in patients in cardiogenic
the factors that influence the likelihood of coronary shock. This may be a result of the early death of some
artery reperfusion. Univariately, the most important of these patients before streptokinase infusion could be

60
55
50
t 4s
Ll
2 40
I
P-NS

76
G 3s

r
za
FIGURE 1. Relation of age, reperfusion and mortality z 30
rate. NR = not reperfused; NS = not significant: R = 2 Bs
reperfused.
z 20
z 15
10
5

R
P-NS

20-59
NR R
60-60
NR

AGE
1111 R
70+
NR
 876 INFARCTION TREATED WITH STREPTOKINASE
successful, but the data do not allow us to evaluate this
hypothesis.
The presence of ongoing chest pain is also related to
reperfusion in that reperfusion is more likely in patients
with continuing pain. This variable probably interacts
with time to angiography, because in the multivariate
analysis only ongoing pain enters the model.
Finally, reperfusion was more likely to be successful
in hypotensive patients who were not in shock (84.8%,
p = 0.007) than in other patients in this study. Patients
in cardiogenic shock were the least likely to achieve
reperfusion (43.2%). The reason for improved reperfu-
sion in hypotensive patients is not clear. Hypotensive
patients who were not in shock were treated earlier (187
f 96 minutes) than okher patients who were not in shock
(244 f 436 minutes), but this difference was not sta-
tistically significant (p = 0.20).
Reperfusion and mortality: Overall, reperfusion is
associated with a marked reduction in hospital mor-
tality (5.5% vs 14.7%) for the entire population of pa-
tients. This reduction in mortality is greater for women
(7% ~~25.8%)than for men (5.1%vs 11.6%),but it is also
significantly related to the patient’s age. The decrease
in mortality is greatest for those in the 60- to 69-year age
group. In classifying patients as stable, hypotensive or
in cardiogenic shock, it becomes clear that those who
benefit most from coronary artery reperfusion have the
most impaired hemodynamic state. On the other hand,
those in whom reperfusion is not achieved do not appear
to have been injured from therapy, because they have
a hospital mortality rate similar to patients receiving
conventional therapy.igJO Reperfusion is least likely to
occur in patients who are in shock. Occasionally, this
may be a result of early death of the patient before
streptokinase therapy has had time to be effective, or
it may be a result of interruption of therapy by acute
deterioration of the patient’s hemodynamic status or
by superimposed ventricular arrhythmias. The absence
of information with respect to these factors does not
permit an analysis of their roles in explaining the re-
duced likelihood of reperfusion in patients in shock.
We also attempted to assessthe impact of pulmonary
edema and direct-current cardioversion on hospital
mortality. Both of these clinical events are frequently
associatedwith cardiogenic shock. Since there is interest
in the importance of pulmonary edema and cardiac
arrhythmias requiring direct-current cardioversion in
patients without shock, these patients have been ana-
lyzed separately. Only 25 patients in our study had
pulmonary edema, and the mortality is high in both
reperfused and nonreperfused patients (31.8%vs 54.5%,
difference not significant). In the 72 patients who re-
quired cardioversion, the mortality tended to be higher
among patients in whom reperfusion was achieved than
among those in whom it was not (9.3% vs 5.9%, differ-
ence not significant).
Others have reported a reduction in hospital mor-
tality in patients receiving E-SK therapy. In a registry
of 224 patients, Weinstein21 reported a hospital mor-
tality of 4.5% in 176 patients in whom reperfusion was
achieved and an 18%mortality in 48 patients in whom
it was not. There was 14.6%mortality in a group of 178
patients who received conventional coronary care.
Timmis et a122reported a 4.7% mortality in 84 patients
who received IC-SK and an 11.8% mortality in a con-
secutively enrolled group of patients who received
conventional therapy.
Coronary anatomy and mortality: The location of
the occluded vessel resulting in AMI, or what is often
referred to as the “infarct vessel,” is an important de-
terminant of mortality. Because the highest mortality
rate is present in patients with left anterior descending
coronary artery thrombosis, it is not surprising that the
benefits of reperfusion are greatest in this group (8.4%
vs 21.2%). For patients with right coronary artery oc-
clusions, mortality in the patients in whom reperfusion
was not achieved is 2.3 times higher than that in the
patients in whom it was, but this difference is not sta-
tistically significant. Finally, patients with circumflex
occlusions in whom reperfusion was not achieved had
a 7 times higher mortality compared with those in whom
it was (2.5% vs 17.4%). This very large difference in
hospital mortality in this subgroup is unexpected, and
the reasons for it are not clear.
Finally, we are encouraged by the relatively low in-
cidence of serious complications in these patients. The
complications in this study are similar in type and fre-
quency to those that occurred in a large randomized
study13 and lower than those reported from another
registry.21 In the randomized trial, serious arrhythmia
was the most frequent complication, as in this study,
and had a similar incidence in treatment and control
patients. Bleeding, which occurred in only 1.3%,was less
often reported in this registry. Death is not included as
a procedural complication in this report because of the
difficulty in determining whether death was a result of
AMI, the catheterization and angiographic procedure,
streptokinase therapy or reperfusion.
In conclusion, this study provides additional infor-
mation about the efficacy of coronary reperfusion in
patients with AMI. Reperfusion was accomplished in
71.2% of 1,029 patients, and when it occurred it was
associated with a low mortality rate. The patients who
have the greatest benefit from reperfusion included
those at increased risk, including women, patients with
cardiogenic shock and those with left anterior de-
scending and circumflex coronary artery thrombosis.
Although the mortality is reduced in all age groups with
coronary reperfusion, this difference is only significant
in those patients between ages 60 and 69 years. By
multivariate analysis of baseline clinical and hemody-
namic variables, we have shown that although hospital
mortality is related to the severity of the patient’s
condition before treatment, success of reperfusion is
only weakly related to baseline variables, and the
presence of hypotension is unexpectedly a predictor of
successful reperfusion.
Most randomized studies, clinical reports from single
institutions and multi-institutional registry studies
indicate that reperfusion is associated with low hospital
mortality for patients with AMI. This large registry
study confirms these findings and further identifies
 April 1.1965 THE AMERICAN JOURNAL OF CARDIOLOGY Volume 55 877

subgroups of patients who are most likely to benefit 9. Rentrop P, Blanke H, Karsch KR, Kaiser H, Kiisterlng H, Leftz K. Selective
intracoronary thrombolysis in acute myocardial infarction and unstable
from coronary reperfusion. angina pectoris. Circulation 1981;63:307-317.
Intracoronary thrombolytic therapy is cumbersome IO. Ganz W, Buchblnder N, Marcus H, Mondkar A, Maddahl J, Charuzl Y,
O’Connor L, Shell W, Fishbein MC, Kass R, Miyamoto A, Swan HJC. In-
and difficult to apply early in the course of AMI. tracoronary thrombolysis in evolving myocardial infarction. Am Heart J
1981;101:4-13.
High-dose, short-term intravenous infusion of strep- 11. Mathey Do, Kuck KH, Tllsner V, Krebber HJ, Bleffeld W. Nonsurgical
tokinase or new thrombolytic agents such as tissue-type coronary artery recanaiization in acute transmural myocardial infarction.
Circulation 1981;63:489-497.
plasminogen activator may soon provide an intravenous 12. Reduto LA, Freund GC, Gaeta JM, Smelling RW, Lewfs B, Gould KL.
alternative to IC-SK therapy.23-27 The results of this Coronary artery reperfusion in acute myocardii infarction: beneficiii effects
of intracoronary streptokinase of left ventiicufar safvage and performance.
trial indicate reperfusion is associated with a large re- Am Heart J 1981;102:1168-1177.
duction in overall hospital mortality from AMI, while 13. Kennedy JW, Rltchle JL, Davis KB, Fritz JK. Western Washington ran-
domized triii of intracoronary streptokinase in acute myocardlai infarction.
those in whom reperfusion fails do not benefit. Early N Engl J Med 1983;309:1477-1481.
14. Anderson JL, Marshall HW, Bray BE, Lutz J, Frederick Pf?, Yanowltz FG,
recognition of failure to reperfuse and alternate therapy Datz FL. Kfausner SC. Haaan AD. A randomized trial of lntracoronarv
with percutaneous transluminal coronary angioplasty streptokcnase in the tredtmeit
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of acute myocardial infarction. N Engl J ti
or revascularization surgery may be the best course for 15. KhaJa F, Walton JA Jr, Brymer JF, Lo E, Osf I., O’Nefll WW, Coffer
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