778-5 Timing and Mechanism of Death After Direct Angioplasty for Acute Myocardial Infarction

Of 907 pts with acute myocardial infarction treated with direct angioplasty (PTCA) from 1984–93, 78 pts (86%) died within 30 days. Of the 78 pts, 35 (45%) had cardiogenic shock prior to intervention, and an additional 4 (5%) presented with acute pulmonary edema without shock. Twenty-eight pts (36%1 died on day 0, 9 (12%) on day 1, and 10 (13%) on day 2. The mechanisms of death were pump failure in 49 (63%), reinfarction in 7 (9%), rupture in 5 (6.4%), arrhythmia in 3 138), other cardiac causes in 2 (2.6%), and noncardiac causes in 12 (15%). Almost all the early deaths (27/28) were due to pump failure. Of 78 pts who died, 28 (36%) developed hemodynamic deterioration or cardiac arrest immediately after reperfusion and 13 of these died in the cath lab. Hemodynamic deterioration and cardiac arrest occurred less often when intra-aortic balloon pumping (IABP) was initiated before PTCA vs after PTCA or not at all (2/18 (11%) vs 26/60 143%), P l 0.03). Conclusion Mortality after PTCA, like thrombolytic therapy, is the highest in the first 24 hours, and this is almost always due to pump failure. Unlike thrombolytic therapy, the incidence of death from rupture and arrhythmias is relatively low. Early mortality is high partially due to the high incidence of cardiogenic shock in our population, but some of the early mortality may be related to hemodynamic deterioration occurring immediately after reperfusion. The use of IABP before PTCA in selected pts may help to prevent this post-reperfusion hemodynamic instability.