Influence of Heparin Therapy on Percutaneous Transluminal Coronary Angioplasty Outcome in Patients with Coronary Arterial Thrombus Mary Ann Lukas Laskey, MD, Ezra Deutsch, MD, John W. Hirshfeld, Jr., MD, William G. Kussmaul, MD, Elliot Barnathan, MD, and Warren K. Laskey, MD

The clinical and angiographii outcome of 18 patients with coronary thrombus undergoing percutaneous transluminal coronary angioplasty without antecedent heparin therapy was compared to that of a group of 35 patients receiving preprocedural heparin therapy. The former group had a significant reduction in angiographic success (61 vs 64%, p 7 days) (%) Antiplatelet therapy (%) Intravenous nitroglycerin (%)

Group A

Group B

26/9

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(532946) 14W) 30 (85) 3 (8) 33 (94)

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16(46)

8W 13 (72) 0 17 (94)

9 (50)

identified patients were reviewed for data regarding demographics, clinical presentation, in-hospital management, concomitant medications (including intravenous heparin and antiplatelet agents) and clinical outcome. PTCA outcome was assessedfor angiographic success (defined as a final stenosis1.5 X control) within 24 hours of the PTCA. All PTCA procedureswere performed in a standardized fashion by the samegroup of 4 staff angiographers over the time interval of this study. The frequency distribution of individual angiographers was unchanged over the time interval of the study and was similar for both groups of patients. As seenin Figure 1, the uncomplicated angiographic successrate for the 35 patients in group A (94%) was significantly higher than for the 18 patients in group B (61%). One patient in group B had an unsuccessfuloutcome due to failure of the balloon-guidewire unit to cross the lesion. Residual nonocclusive thrombus was present in 6 patients in group A (17%) and 4 patients in group B (22%). This difference was not statistically significant. Total vesselocclusion occurred in the catheterization laboratory in 2 patients in group A and 6 patients in p co5

100

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n q

Heparln No Hepam

80

Heparin FmJRE2chmpkte(tlrombotk)vesselocclurSonaceumd

~lraclucntlyhthenonhepariwpdreatedgroup(6of18 patienb)6wintJtehephnbdgroup(2of26pa6ents). 180

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 65

No Heparin

group B (Figure 2). Intracoronary streptokinase was given to both patients in group A (1 having received prior streptokinase therapy) and was successful in achieving reperfusion in 1. In group B (none received prior streptokinase) 2 patients received streptokinase with reperfusion achievedin 1. Despite attempts to reestablish flow using repeateddilatation, 4 of the 6 patients in group B had unresolved vessel closure resulting in ongoing myocardial ischemia and were taken emergently to the operating room. One patient in each group with unresolved occlusion was managed conservatively due to the absenceof clinical or hemodynamic deterioration. Thus, in group A unresolvedocclusion occurred with a frequency of 3% in contrast to 28% in group B (p 300 seconds)was documented in all 8 patients with vesselocclusion. In group A 5 PTCA procedureswere performed immediately after the diagnostic catheterization with a successfulresult in 3 patients and acute closure in 2. In group B 10 PTCA procedureswere performed immediately after the diagnostic study with successachievedin 7 patients and acute closure in 3. Thus, in this clinical setting, ad hoc PTCA carried a significantly lower success rate compared to the entire study population (ad hoc 67%, total population 85%, p