1. Diagnosis of acute MI Pharmacologic therapy* Immediate angiography PTCAPTCA Other Rx *Antithrombin agents, antiplatelet agents, and fibrinolytic agents. “Prejunctive” Therapy A strategy to promote very early patency for some patients (drug responders) and very high final patency rates (assured by PTCA) for all patients

2. Plasminogen-Activator Angioplasty Compatibility Trial (PACT) Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962. Eligible acute infarct patients n=606 ASA, IV heparin t-PA 50 mg bolus Placebo bolus Immediate angiography TIMI 3 TIMI 0, 1, 2 Second bolus of study drug Immediate angioplasty Follow-up angiogram 5-7 days, ETT 6 wk Randomize

3. 34.3 61 *All comparisons P<0.001. Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962. Patency of the Infarct Artery on Catheter Laboratory Arrival (Core Laboratory)

4. Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962. P=NS TIMI 2, 3 TIMI 3 TIMI 2TIMI 3 Technical Results of PTCA: Core Laboratory Results % of Patients

5. Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962. % Convalescent LVEF Convalescent LV Function By Patency Group: Global Ejection Fraction P=0.004

6. Adverse Eventt-PAPlaceboP Value Major bleeding12.9%13.5%0.84 Stroke (any)0.7% 0.99 Intracranial hemorrhage0.3% 0.99 Emergencyrevascularization7.3%7.2%0.98 Hospital death3.6%3.0%0.64 30-day death3.6%3.3%0.81 Adapted from Ross AM, et al. J Am Coll Cardiol. 1999;34:1954-1962. PACT: Adverse Events

7. Summary: Pharmacologic/Mechanical Combination Therapy Safe: no increase in ICH, CABG, reocclusion, or repeat PTCA Mounting evidence of better clinical outcomes May have special value in decreasing time delay to revascularization associated with PTCA Outcomes best if artery open before PTCA