The outcome of patients with acute myocardial infarction ineligible for thrombolytic therapy. Israeli Thrombolytic Survey Group (original) (raw)
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Journal of the American College of Cardiology, 1991
This . study sought to determine whether clinical variables can he used Ia identify patients at high risk of recurrent sponlaneoas myocardial ischemia or hemodynamic compromise during the 151 4 days after intravenous thrombolycis for oswte myocardial infarction . Of 288 patients randomly assigned to a conservative pusnhrombulysis strategy, 54 (19%) required m4ent cardiac catheterization within 24 h; 75 126%I underwent urgent eardlae catheterization within 4 days of admission. Of the clinical varia . bles examined by multiple logistic regression analysis, only patient age and anterior wall myocardial infarction correlated with the need for urgent cardiac catheterization (p = 0.016 and p = 0.017, respeclively) . Compared with recombinant tissue-type plas . minogen activator or urokinase monotherapy, crombmattoo deer . spy with these agents was associated with a lower need far acute intervention during the let 24 h after admission, but Ihedifference did not reach statistical significance 114% for ex nbination therapy vs. 21% for each agent alone, p = 0 .30) .
American Journal of Cardiology, 1992
Six-year follow-up was conducted in a consecutive series of 192 patients receiving thrombolytic therapy for acute myocardial infarction (AM) with STsegment elevation. Cardiac catheterization was performed within a day, and patients with an open infarct artery routinely had early revascularizatlon: 66 (67%) underwent coronary bypass surgery and 16 (12%) coronary angioplasty. With this treatment strategy, 6-year cardiac mortality was 14.5% 6% (12 patlents) in hospital and 9% (16 patients) for survivors of hospitalization.
Circulation, 1991
Recent trials of myocardial reperfusion using single-agent thrombolytic therapy and sequential cardiac catheterization have supported a conservative approach to the patient with acute myocardial infarction. To evaluate combination thrombolytic therapy and the role of a previously untested strategy for the aggressive use of cardiac catheterization, we performed a multicenter clinical trial with a 3 x 2 factorial design in which 575 patients were randomly allocated to one of three drug regimens--tissue-type plasminogen activator (t-PA) (n = 191), urokinase (n = 190), or both (n = 194) - and one of two catheterization strategies--immediate catheterization with angioplasty for failed thrombolysis (n = 287) or deferred predischarge catheterization on days 5-10 (n = 288). Patients with contraindications to thrombolytic therapy, cardiogenic shock, or age of more than 75 years were excluded. Global left ventricular ejection fraction was well preserved and almost identical at predischarge ca...
Efficacy of Rescue Thrombolysis in Patients with Acute Myocardial Infarction: Preliminary Findings
Cardiovascular Drugs and Therapy, 2000
Thrombolysis reduces mortality in patients with acute myocardial infarction (AMI) who are hospitalized within 6 hours from the onset of symptoms. AMIs involving a small area of myocardium show a lower mortality in comparison with AMI involving a large area. The present study was aimed at evaluating the safety and efficacy of rescue thrombolysis in patients with large AMI who had failed thrombolysis. Ninety patients (69 males and 21 females), mean age 56.7 ± 9 years, hospitalized for suspected AMI within 4 hours from the onset of symptoms, suitable for thrombolysis (First episode), and showing pain and persistent ST segment elevation 120 minutes after starting thrombolysis, were randomized (double-blind) into two groups. Group A (45 patients: 10 Females and 35 males) received an additional thrombolytic treatment (rTPA 50 mg), 10 mg as bolus plus 40 mg in 60 minutes. Group B (45 patients: 11 Females and 34 males) received placebo. Positive noninvasive markers were defined as follows: (1) resolution of chest pain, (2) ≥ 50% reduction in ST segment elevation, (3) double marker of creatine kinase (CK) and CK-MB activity 2 hours after the start of thrombolysis, and (4) occurrence of reperfusion arrhythmias within the First 120 minutes of thrombolytic therapy. Blood pressure, heart rate, and ECG were continuously monitored. An echocardiogram was carried out at entry, and before discharge, to control ejection fraction and segmentary kinetics. Adverse events such as death, re-AMI, recurrent angina, incidence of major and minor bleeding, and emergency CABG/PTCA were checked. The groups were similar in terms of age, sex, diabetes, smoking habits, hypertension, and adjuvant therapy (beta-blockers). No significant difference was observed between the two groups regarding the time elapsed from the onset of symptoms to thrombolysis and AMI localization. Thirty-five patients (77.7%) showed reperfusion (10–50 minutes) after commencement of additional rTPA. Of the patients receiving placebo, 12 (26.6%) showed reperfusion within 35–85 minutes. Group A showed an earlier and lower CK and CK-MB peak than the control group, (respectively p = 0.0001–0.009 and 0.002). Mortality (17.7%, 16 patients) was higher in group B than in the additional rTPA group, i.e. 28.8% (3 patients) in group A) versus 6.6% (13 patients) in Group B (p = 0.041). Seven patients from group A showed nonfatal re-AMI. Angina was observed in 18 patients (40%) from group A and 3 (6.6%) from group B, (p = 0.006). Ten of these patients underwent urgent PTCA (9 from group A and 1 from group B), and 3 from group A underwent urgent CABG. Minor bleeding was higher in group A than in group B (44.4% versus 15.5%, p = 0.047). Major bleeding was observed in group A (nonfatal stroke). At predischarge the echocardiogram ejection fraction was higher in group A than in group B (46 ± 8% versus 38 ± 7%, p = 0.0001). Our data suggest that an additional dose of thrombolytic drug in patients with unsuccessful thrombolysis is feasible and also that the bleeding increase is an acceptable risk in comparison with the advantages obtained in reducing AMI extension. Rescue thrombolysis can allow a gain in time to perform mechanical revascularization in patients admitted to hospital without an interventionist cardiology laboratory or in those who have to be referred to another hospital for urgent CABG.
The American Journal of Cardiology, 1993
Despite the proven benefits of thrombolytic therapy in acute myocardial infarction, concern for its complications, especially in patients misdiagnosed with myocardial infarction, has led to hesitancy in its use. Historical, clinical and electrocardiographic criteria were developed for enrolling patients with suspected acute myocardial infarction into thrombolytic trials by noncardiovascular specialists. The incidence of misdiagnosis of myocardial infarction and the clinical outcomes when these criteria were used were evaluated for 1,387 consecutive patients given thrombolytic therapy. Twenty-five community hospitals and 7 interventional centers were the sites of enrollment. Most patients (63%) were enrolled from community hospitals. Criteria for thrombolytic therapy included: symptoms of acute myocardial infarction < 6 hours but > 20 minutes, and not relieved by nitroglycerin; and ST-segment elevation > or = 1 mm in 2 contiguous leads or ST-segment depression of posterior myocardial infarction. Exclusion criteria reflecting increased risk of bleeding were used. A final diagnosis of myocardial infarction was based on creatinine kinase-MB, electrocardiographic and ventriculographic evaluation. Acute myocardial infarction was misdiagnosed in 20 patients (1.4%; 95% confidence interval 0.8-2.0%). These patients were demographically similar to those with acute myocardial infarction. All misdiagnosed patients survived; no significant adverse events occurred. Thus, in several clinical settings, a simple algorithm with specific criteria was used for diagnosing acute myocardial infarction and administering thrombolytic therapy. The inclusion criteria used in this study led to a low rate of misdiagnosis.
Objective: To compare the incidence of early in-hospital recurrent ischemia and/or reinfarction (fatal or nonfatal) in patients receiving thrombolytic therapy for ST segment myocardial infarction (STEMI) and those who did not receive thrombolysis, and to assess the clinical risk factors for reischemia and /or reinfarction in both groups. Methods: 285 consecutive patients presenting with STEMI were enrolled, and divided into two groups, whether refused primary percutaneous coronary intervention (PCI) and being eligible candidates for thrombolytic therapy in the first group, and those who were not the candidate to thrombolytic therapy in the second group. Eighteen clinical variables were assessed to identify the predictors of early in-hospital (pre-discharge) reischemia and/or reinfarction in both groups. Results: Thrombolytic therapy was given to 159 patients, while 126 (44.2%) patients were treated conservatively. Re-ischemia was diagnosed in 30 patients (19 in thrombolytic versus 11 in non thrombolytic candidates), while reinfarction was diagnosed in twelve patients (8 in thrombolytic versus 4 in non thrombolytic candidates). Five of the reinfarction events were fatal. The episodes occurred within 4.71±3.6 days in thrombolytic cases versus 5.85±2.5 days in the non thrombolytic cases (P=0.263). Anti-thrombotic and anti-ischemic medications were used equally in both groups (P=0.002 and P>0.05 respectively). However there was a significant higher rate of Beta-blockers usage among thrombolytic candidates than non thrombolytic candidates (P=0.002). Thrombolytic candidates were relatively younger than non thrombolytic candidates (P=0.001). Conclusion: Despite of conventional medical treatment including thrombolytic, anti-thrombotic and anti-ischemic therapy some survivors of MI were subjected to re-ischemia and/or reinfarction events during early in-hospital follow up. The incidence is slightly higher in patients who received thrombolytic therapy compared to those who did not, but statistically not significant.