Preinfarction angina as a predictor of more rapid coronary thrombolysis in patients with acute myocardial infarction

Background. When a myocardial infarction is preceded by angina, the infarct tends to be smaller than when there is no preinfarction angina. Prompt re canalization of the occluded infarct-related artery is crucial in limiting the size of the infarct. We prospectively studied the relation among preinfarction unstable angina, the speed of coronary reperfusion, and the size of the infarct in patients with acute myocardial infarction receiving thrombolytic therapy. Methods. We compared 14 patients who had unstable angina during the week before myocardial infarction with 9 patients who had no preinfarction angina. Coronary arteriograms were obtained at base line and 15, 35, 55, and 90 minutes and 24 hours after the start of thrombolytic therapy, The size of the infarct was estimated on the basis of creatine kinase and creatine kinase MB levels, which were measured every 4 hours during the first 24 hours. Results. Complete reperfusion (a flow of grade 3 according to the Thrombolysis in Myocardial Infarction classification) was achieved at 35 minutes in 64 percent of the patients with preinfarction angina but in none of those without preinfarction angina (P = 0.006); at 55 minutes in 86 percent and 38 percent, respectively (P = 0.05); and at 90 minutes in 86 percent and 50 percent, respectively (P = 0.14). The mean (+/-SD) time to reperfusion was 27+/-16 minutes in the group with preinfarction angina and 48+/-17 minutes in the group without preinfarction angina (P = 0.04); the peak creatine kinase levels were 1118+/-783 and 2395+/-1615 U per liter, respectively (P = 0.03); the peak creatine kinase MB levels were 102+/-67 and 251+/-186 U per liter, respectively (P = 0.009); and the 24-hour integrated creatine kinase MB levels were 1716+/-1171 and 4267+/-3252 U . liter(-1). 24 hours, respectively (P = 0.009). The time to reperfusion was positively correlated with the indexes of infarct size (r greater than or equal to 0.53, P less than or equal to 0.02). Conclusions. In patients with acute myocardial infarction preceded by unstable angina, as compared with those without preinfarction angina, thrombolytic therapy resulted in more rapid reperfusion and smaller infarcts. Earlier myocardial reperfusion may thus account for the smaller infarct size in patients with preinfarction angina. (C) 1996, Massachusetts Medical Society.