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Background: Treatment of patients with acute myocardial infarction should aim to restore blood flow in the infarct-related artery as soon as possible. Thrombolytic therapy has recently been compared with direct angioplasty; however, these interventions may not be sufficient, and coronary artery bypass grafting (CABG) may be necessary., Methods: In a series of 301 patients with acute myocardial infarction, randomly assigned either to receive intravenous streptokinase (n = 149) or to undergo percutaneous transluminal coronary angioplasty (PTCA; n = 152), 31 patients (aged 61 +/- 10 years; 27 men, four women) underwent CABG within 6 weeks of acute myocardial infarction., Results: Twelve patients (nine in the PTCA group and three in the streptokinase group) underwent surgery within 48 h of the onset of symptoms. Bypass surgery was performed in the streptokinase group on failure of thrombolytic therapy (n = 2), recurrent ischemia (n = 4), or postinfarct angina (n = 9). In the PTCA group, CABG was performed for left main stenosis (n = 6), failed PTCA (n = 3), recurrent ischemia (n = 2), or postinfarct angina (n = 5). An intra-aortic balloon pump (IABP) was required in 15 patients (five streptokinase and 10 PTCA). Major complications after CABG were more common among patients who underwent surgery within 48 h than those after 48 h (eight in 12 patients versus four in 19, respectively). After 17.0 +/- 8.6 months (range 3-33 months), two patients had died; one of end-stage heart failure after 3 months, and one of a stroke after 16 months (both were in the PTCA group and one had undergone surgery within 48 h). One patient suffered a reinfarction after 11 months and one a non-fatal stroke after 1 month (both underwent CABG within 48 h). The left ventricular ejection fraction did not differ between the groups (43 +/- 15% for the 'early' group and 42 +/- 11% for the 'late' group)., Conclusion: CABG can be performed safely and effectively after initial treatment with direct angioplasty or thrombolytic therapy after acute myocardial infarction. If it is performed within 48 h of onset of symptoms, (in-hospital) morbidity is higher, without affecting mortality or left ventricular function.

Objectives: The purpose of the present study was to compare intravenous streptokinase therapy with immediate coronary angioplasty without antecedent thrombolytic therapy with regard to left ventricular function and hospital mortality and reinfarction., Background: Despite the widespread use of intravenous thrombolytic therapy and immediate percutaneous transluminal coronary angioplasty, these two strategies to treat patients with an acute myocardial infarction have only recently been compared in randomized trials. Coronary angioplasty has been shown to result in a higher patency rate of the infarct-related coronary artery, with a less severe residual stenotic lesion, compared with streptokinase therapy, but whether this more favorable coronary anatomy results in clinical benefit remains to be established., Methods: We studied 301 patients with acute myocardial infarction randomly assigned to undergo immediate coronary angioplasty without antecedent thrombolytic therapy or to receive intravenous streptokinase therapy. Before discharge left ventricular ejection fraction was measured by radionuclide scanning., Results: The in-hospital mortality rate in the streptokinase group was 7% (11 of 149 patients) compared with 2% (3 of 152 patients) in the angioplasty group (p = 0.024). In the streptokinase group recurrent myocardial infarction occurred in 15 patients (10%) versus in 2 (1%) in the angioplasty group (p < 0.001). Either death or nonfatal reinfarction occurred in 23 patients (15%) in the streptokinase group and in 5 patients (3%) in the angioplasty group (p = 0.001). Left ventricular ejection fraction was 44 +/- 11% (mean +/- SD) in the streptokinase group versus 50 +/- 11% in the angioplasty group (p < 0.001)., Conclusions: These findings indicate that immediate coronary angioplasty without antecedent thrombolytic therapy results in better left ventricular function and lower risk of death and recurrent myocardial infarction than treatment with intravenous streptokinase.

Background: Despite the widespread use of intravenous thrombolytic therapy and of immediate percutaneous transluminal coronary angioplasty for the treatment of acute myocardial infarction, randomized comparisons of the two approaches to reperfusion are lacking. We report the results of a prospective, randomized trial comparing immediate coronary angioplasty (without previous thrombolytic therapy) with intravenous streptokinase treatment., Methods: A total of 142 patients with acute myocardial infarction were randomly assigned to receive one of the two treatments. The left ventricular ejection fraction was measured by radionuclide scanning before hospital discharge. Quantitative coronary angiography was performed to assess the degree of residual stenosis in the infarct-related arteries., Results: A total of 72 patients were assigned to receive streptokinase and 70 patients to undergo immediate angioplasty. Angioplasty was technically successful in 64 of the 65 patients who underwent the procedure. Infarction recurred in nine patients assigned to receive streptokinase, but in none of those assigned to receive angioplasty (P = 0.003). Fourteen patients in the streptokinase group had unstable angina after their infarction, but only four in the angioplasty group (P = 0.02). The mean (+/- SD) left ventricular ejection fraction as measured before discharge was 45 +/- 12 percent in the streptokinase group and 51 +/- 11 percent in the angioplasty group (P = 0.004). The infarct-related artery was patent in 68 percent of the patients in the streptokinase group and 91 percent of those in the angioplasty group (P = 0.001). Quantitative coronary angiography revealed stenosis of 36 +/- 20 percent of the luminal diameter in the angioplasty group, as compared with 76 +/- 19 percent in the streptokinase group (P < 0.001)., Conclusions: Immediate angioplasty after acute myocardial infarction was associated with a higher rate of patency of the infarct-related artery, a less severe residual stenotic lesion, better left ventricular function, and less recurrent myocardial ischemia and infarction than was intravenous streptokinase.

This article describes briefly the short- and long-term results of PTCA with monorail technique. From 1988 to 1992, 2183 out of a total of more than 4000 patients have been treated with this technique. From these patients, a total of 2693 vessels were dilated. Primary success was achieved in 93% of all attempted vessels, while the overall major complication rate of 3% was acceptable in this series. Although the primary success rates were comparable between patients with stable angina (n = 1288), unstable angina (n = 720), and acute myocardial infarction (n = 175), the major complication rate of 5.1% in patients with unstable angina was about twice of that in patients with stable angina. The long-term clinical follow-up of a mean of 22 months was favorable with low mortality (2%) and infarction (6%) rates. However, an additional revascularization procedure (repeat PTCA or bypass surgery) was necessary in 19% of the patients due to restenosis. In conclusion, PTCA using the monorail technique can be performed safely and effectively in patients with either stable angina, unstable angina, or acute myocardial infarction.

2 closing remarks should be made. In the 1st place: Under optimal conditions (experienced house staff and experienced interventional cardiologists, well equipped catheterization laboratory all available on a 24 hour service) primary PTCA can be done safely with excellent results as demonstrated by Hartzler et al. and by the Zwolle study. In the 2nd place: Recent reports have demonstrated better results from a combination of thrombolytic agents and probably this is due to higher patency rates and possibly less deleterious effects on plaque morphology and ischemic myocardium. Anti platelet therapy is still a major concern because of the limited efficacy of aspirin and heparin. Specific binding of platelet membrane glycoprotein. IIB/IIIA to monoclonal antibodies (7E3 Fab) is a promising and potential new concept. Other agents may also be effective of which hirudin and angiopeptin should be mentioned. All these factors may contribute to a better treatment strategy for acute myocardial infarction.

An attempt to reposition an Integra PTCA balloon-on-a-wire failed although the whole stenosed segment could be crossed before inflation. After careful removal the device showed a grossly altered shape. Deflated balloon profiles, quite different from the initial shape, can determine the outcome both in dissections and in multilesion cases.

The level of the glycosylated haemoglobin hbA1c was measured in (1) subjects with normal renal function, (2) patients with renal failure and (3) patients on intermittent haemodialysis. In 60 subjects with normal renal function but with a varying degree of glucose tolerance, there was a significant correlation between HbA1c and fasting blood-glucose. In 20 patients with renal failure the mean value of HbA1c was 6.6 +/- 1.3% (mean +/- SD) whereas in 17 subjects with normal renal function, but with the same degree of glucose tolerance, this value was 4.7 +/- 0.9%. In 30 patients on intermittent dialysis the mean level of HbA1c was 6.3 +/- 1.5%. This level did not fall after 3 months of dialysis with a glucose-free fluid. In both groups of patients with renal failure there was no correlation between HbA1c and fasting blood-glucose. -- It is concluded that renal failure itself causes an increase in HbA1c.

The symptoms of ecthyma are described. Treatment directed against secondary bacterial infection may consist in parenteral or local administration of antibiotics. Experimental inoculation of two commercial vaccines showed that reinoculation will take within 2-3 and five months after the first vaccination. The two vaccines produced a serological response, even after reinoculation. The fact that humoral antibodies are found to be present, is not indicative of the degree of immunity. Inoculation by scarifications will introduce pathogenic virus in a herd without producing a form of immunity, the degree and length of which are known. The virus used on vaccination will spread among the herd.