Preinfarction Angina

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Abstract
Before medical professionals consider changing their practice of administering thrombolytic agents on the basis of the presence or absence of preinfarction angina, as is suggested by Andreotti et al. (Jan. 4 issue),1 we feel obligated to comment on their study and present more recent data disputing their findings. The study involved a small number of patients (23) treated between 1987 and 1989 and used a less effective regimen of tissue plasminogen activator (t-PA) than is currently used. Nevertheless, after 90 minutes of treatment they obtained a flow of grade 3 (according to the Thrombolysis in Myocardial Infarction [TIMI] classification) in the infarct-related arteries of 86 percent of their patients with preinfarction angina and 73 percent of patients overall — levels of success not achieved in a large-scale study of myocardial infarction.2 One cannot determine whether these angiographic results affected clinical outcomes. In contrast, the first Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial (GUSTO-1) was a large, randomized, prospective study involving four thrombolytic strategies in patients with acute myocardial infarction,3 and it included an angiographic substudy.2 To determine whether preinfarction angina of either recent (seven days or less) or remote (more than seven days) onset affected angiographic and clinical outcomes, we reviewed the clinical and angiographic core laboratory results of the GUSTO study ( Table 1 ).