studies was reported as 40%,336%,442%,5 34%,641%7 and 13%.8A third heart soundheard by 2 physicians was present in 37% of our patients with CHF and normal systolicfunction. The prevalenceof an audible third heart soundin patients with CHF and normal systolic function was reported in other studies as 45%,341%4and 21%.6 Echocardiography, especially when combined with Doppler studies, is important in the management of patients with CHF.3,6,13Determination of LV systolic function and causative mechanismsof CHF is important in determining long-term therapy of CHF. In our population of 247 patients with CHF, valvular heart surgery was recommendedto patients with CHF on the basisof Doppler echocardiographicstudies.Digitalis was not administered to patients with normal systolic function unless atria1fibrillation waspresent.Vasodilators were administered to patients with abnormal systolic function unless severeor moderate aortic stenosis was present, and to patients with normal systolic function only if needed in addition to diuretics to treat hypertension. Data from our prospectivestudy showedthat LV ejection fraction was the most important prognostic variable for mortality in elderly patients with CHF associated with coronary artery disease.Survival rates for patients with CHF associatedwith coronary artery diseaseand normal LV ejection fraction were 78% at 1 year, 62% at 2 years, 54% at 3 years and 44% at 4 years. Survival rates for patients with CHF associatedwith coronary artery diseaseand abnormal LV ejection fraction were 53% at 1 year, 29% at 2 years, 22%at 3 years and 15%at 4 years. Cohn and Johnson8 observed that the average annual mortality in the Vasodilator Heart Failure Trial was 8% for patients with CHF and a normal LV ejection fraction and 19% for patients with CHF and an abnormal LV ejection fraction. In addition to LV ejection fraction, hypertension and age were independent variables that predicted death in

our patients with CHF associatedwith coronary artery disease.Patients with abnormal LV ejection fraction had a similar prevalenceof hypertension as patients with normal LV ejection fraction. Patients with CHF and normal LV ejection fraction were older than patients with CHF and abnormal LV ejection fraction. 1. McKee PA, Cast& WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: The Framingham Study. N Eng[J A4ed 1971;285: I441 1446. 2. Franc&a JA, Wile” M, Ziesche S, Cohn JN. Survival in men with severe chronic left ventricular failure due to either coronary heart disease or idiopathic dilated cardiomyopathy. Am J Car&l 1983;51:831-836. 3. Echeverria HH, Bilsker MS, Myerburg RJ, Kessler KM. Congestive heart failure: echocardiographic insights. Anz J Med 1983;75:750-755. 4. Dougherty AH, Naccarelli GV, Gray EL, Hicks CH, Goldstein RA. Congestive heart failure with normal systolic function. Am J Cardiol 1984;54:778-782. 5. Soufer R, Wohlgelernter D, Vita NA, Amuchestegui M, Sostman HD, Berger HJ, &ret BL. Intact systolic left ventricular function in clinical congestive heart failure. Am J Cardiol 1985;55:1032-1036. (i. Aguirre FV, Pearson AC, Lewen MK, McCluskey M, Labovitz AJ. Usefulness of Doppler echocardiography in the diagnosis of congestive heart failure. Am J Cardiol 1989;63:1098-1102. 7. Wong WF, Gold S, Fukuyama 0, Blanchettc PL. Diastolic dysfunction in elderly patients with congestive heart failure. Am J Cardiol 1989;63:1526-I 528. 8. Cohn JN, Johnson G, and Veterans Administration Cooperative Study Group. Heart failure with normal ejection fraction. The V-Hem study. Circulation 1990;81(supp1 ITI):III-48-111-53. 9. Aronow WS, Kronzon I. Correlation of prevalence and severity of valvular aortic stenosis determined by continuous-wave Doppler echocardiography with physical signs of aortic stenosis in patients aged 62 to 100 years with aortic systolic ejection murmurs. Am J Cardiol 1987;60:399-401. 10. Aronow WS, Kronzon I. Correlation of prevalence and severity of mitrai regurgitation and mitral stenosis determined by Doppler echocardiography with physical signs of mitral regurgitation and mitral stenosis in 100 patients aged 62 to 100 years with mitral an&r calcium. Am J Cardiol 1987;60:1189-I 190. il. Aronow WS, Kronzon I. Correlation of prevalence and severity of aortic regurgitation detected by pulsed Doppler echocardiography with the murmur of aortic regurgitation in elderly patients in a long-term health care facility. Am J Cwdiol 1989;63:128-129. 12. Aronow WS, Epstein S, Koenigsberg M, Schwartz KS. Usefulness of cchocardiographic abnormal left ventricular ejection fraction, paroxysmal ventricular tachycardia and complex ventricular arrhythmias in predicting new coronary events in patients over 62 years of age. Am J Cardiol 1988;61:1349-1351. 13. Kessler KM. Heart failure with normal systolic function. Update of prevalence, differential diagnosis, prognosis, and therapy. Arch Intern Med 1988; 148:2109-2111.

elayed Coronary Angioplasty Myocardial Infarction Thomas Little, MD, Kenneth Lee, MD, Diane Muktierjee, ?vlD, Mark Milner, MD, Joseph Lindsay, Jr., MU, and August0 D. Pichard, MD The role for and timing of percutaneous transluminal coronary angioplasty (PTCA) after thrombolytic therapy for acute myocardial infarction (AMI) remains controversial. Three large randomized trials1m3have demonstrated no benefit from PTCA performed within 48 hours of thrombolysis. Delayed PTCA performed after 48 hours has not beenascarefully studied. Someadvocateits useonly for patients with evidenceof recurrent ischemia.3 In patients with unstable angina and angiographically From

the Department

of Cardiology,

Washington

Hospital

Center,

Washington, DC 20010. Dr. Little’s current address: Two Rivers Cardiology, 123 South 22nd Street, Easton, Pennsylvania 18042. Manuscript received January 18, 1990; revised manuscript received and accepted July 9, 1990.

evident intracoronary thrombus, delaying PTCA until after a courseof anticoagulation and antiplatelet therapy hasimproved PTCA successand reducedthromboembolic coronary occlusion.4 Whether delaying PTCA after thrombolysis for AMI produces similar benefits is unknown. We report our experience with delayed PTCA performed after thrombolysis for AMI. Between November I986 and July 1989, 3,256 patients were entered in a PTCA database. Of these, 151 consecutivepatients who underwent PTCA of the infarct-related artery 3 to 14 days (mean 6) after thrombolysis .for AMI were identi$ed. The indication for PTCA was determined by eachpatient’s private cardiologist. Only stenoseswith >70% diameter narrowing were

THE AMERICAN

JOURNAL

OF CARDIOLOGY

NOVEMBER 15, 1990

TABLE I Distribution Success

of Coronary

Infarct-Related Arteries

Stenoses and Angioplasty

n (98)

Success (%)

LAD LC Right SVG

55 (36) 26 (17) 66(49

49 (89) 21(81) 59 (89)

4 (3)

4wQ

Total

151 (loo)

LAD = left anterior descending; SVG = saphenous vein graft.

LC = circumflex;

133 (88) Right = right

coronary

artery;

considered for PTCA. PTCA was performed using standard techniques. Aspirin and heparin were routinely administered before PTCA. Aspirin, heparin and a calcium channel blocker were routinely given after angioplasty. PTCA was considered successful if the lesion was reduced to GO% diameter narrowing without a major complication (acute vessel closure, emergency bypass surgery, AMI, death). Hospital survival was determined by a review of medical records. Among the 151 patients, I I6 (77%) were men (aged 35 to 80 years [mean 571). A similar number of patients had received streptokinase (48%) and tissue plasminogen activator (52%). Ouerall, left ventricular ejection fraction was normal (>50%) in I9 (13%), mildly impaired (40 to 50%) in 94 (62%), moderately impaired (30 to 40%) in 26 (17%) and seuerely depressed (