Spontaneous splenic rupture complicating thrombolytic therapy in acute myocardial infarction

A 64-year-old woman with the diagnosis of acute anterior infarction was treated with streptokinase, i.v. heparin, and aspirin. After 20 hours of hospitalization she developed hypotension and a fall in hematocrit level with acute onset of severe abdominal pain. After genitourinary and gastrointestinal bleeding, pulmonary embolism and reinfarction had been ruled out, however, abdominal ultrasonography revealed intraabdominal hemorrhage and the patient was given three units of blood transfusion. Abdominal laparotomy and laparoscopy were not performed as the patient's clinical status stabilized on the 3rd day and hemodynamics did not deteriorate thereafter. Abdominal computerized tomography in the second week revealed a splenic rupture.     

Diffuse pulmonary hemorrhage complicating thrombolytic therapy for acute myocardial infarction

Diffuse pulmonary hemorrhage has rarely been reported as a complication of thrombolytic therapy. Recently, two patients who developed this complication were observed at our institution. This diagnosis should be considered in any post-thrombolytic patient with respiratory distress, diffuse pulmonary infiltrates, and an otherwise unexplained fall in hemoglobin.     

东菱克栓酶冠状动脉溶栓治疗急性心肌梗塞的临床研究

报告6例发病时间在4～10小时内的急性心肌梗塞患者，采用冠状动脉狭窄口堵塞近端注入东菱克栓酶（DF－521）20～30BU（Batroxobinunit简称BU，是Batroxobin的酶活性量的表示单位。37℃以下，标准人～枸椽酸血浆0．3ml中加入Batroxobin溶液0．1ml，19．0±0．2秒发生凝固时其酶活性为2BU）。进行溶栓治疗，60～90分钟后重复冠状动脉造影。结果全部有效，4例闭塞管腔再通（TIMI达Ⅲ级）2例大部分再通（TIMI达Ⅱ级），从而限制了梗塞发展且无出血及其它并发症，效果显著，值得进一步研究推广。     

Clinical benefits of thrombolytic therapy in acute myocardial infarction.

The value of coronary artery reperfusion resulting from pharmacologically induced fibrinolysis in patients with evolving myocardial infarction has been rigorously evaluated. Improved left ventricular function and even more impressive improvements in survival rates have been demonstrated consistently in controlled studies. Benefit is related to the restoration of myocardial blood flow. Maximal benefit is achieved with early and sustained restoration of coronary artery patency. Benefits observed during initial hospitalization are sustained for at least 1 year in the majority of patients, even without subsequent mechanical revascularization. To date, analysis of subgroups has not identified a population of patients with evolving infarction that should routinely be excluded from consideration for thrombolysis. As with many potent pharmacologic agents, activators of the fibrinolytic system are associated with a degree of risk whenever they are administered to a patient. Therefore, patients must be assessed carefully prior to initiating treatment, especially for potential bleeding hazards, and appropriate follow-up evaluation and concomitant therapy needs to be planned. However, given the overwhelming body of data now available regarding its benefits and relative safety, thrombolysis should be considered as conventional therapy for patients with acute evolving myocardial infarction (AMI).     

A cost-effectiveness model of thrombolytic therapy for acute myocardial infarction

OBJECTIVE: To assess the short- and long-term costs and clinical and quality of life outcomes with the use of streptokinase (SK) vs tissue plasminogen activator (tPA) for acute myocardial infarction (MI). DESIGN: A decision analysis model. PATIENTS: Patients with acute MI who were candidates for thrombolytic therapy and who presented within six hours of symptom onset. MEASUREMENTS: 30-day and one-year mortality, impacts of disabling and nondisabling stroke, reinfarction, hemorrhage, hypotension, anaphylazis, and long-term medical costs. RESULTS: Using 30-day mortality data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial, the baseline analysis yielded an incremental cost—effectiveness for tPA of $30,300 per additional quality-adjusted life year (QALY) gained, compared with SK. Using one-year mortality data from the GUSTO trial, the analysis yielded an incremental cost—effectiveness for tPA of $27,400 per additional QALY, compared with SK. The incremental cost—effectiveness of tPA over SK was sensitive to the difference in mortality seen with the two agents, exceeding $100,000 per QALY, for a relative survival advantage of approximately one-third that seen in the GUSTO trial. The incremental cost per QALY of tPA remained under $60,000 if the survival benefit was half that seen in the GUSTO trial. The cost—effectiveness of tPA declined with a shorter projected life expectancy following MI and for inferior (vs anterior) wall infarction. The analysis was modestly sensitive to the costs of the thrombolytic agents. CONCLUSIONS: In spite of its higher cost relative to SK, tPA is a cost-effective therapy for MI under a wide range of assumptions regarding clinical outcomes and costs. Presented in part at the Congress of the European Society of Cardiology, August 29–September 2, 1993, Nice, France. Supported by a research grant from Kabi Pharmacia. Dr. Kalish is the recipient of a Merck/American Federation for Aging Research Fellowship in Clinical Geriatric Pharmacology. Dr. Gurwitz is the recipient of a Clinical Investigator Award (K08 AG00510) from the National Institute on Aging, Bethesda, Maryland.     

急性心肌梗死的药物溶栓治疗进展

早期溶栓治疗 (ｔｈｒｏｍｂｏｌｙｔｉｃｔｈｅｒａｐｙ ,ＴＴ)可获得梗塞相关动脉 (ＩＲＡ)早期开放 ,有效缩小心肌梗死面积 ,保护左室功能 ,降低病死率 ,因而成为急性心肌梗死(ＡＭＩ)的常规疗法之一。然而 ,目前最佳的溶栓方案仅能使 5 4%的ＡＭＩ获得充分再灌注 ,溶栓后血管再闭塞率为 8 0 %～13 5 % ,出血并发症仍存在 ,尤其颅内出血为 0 3 %～ 1%。如何提高溶栓疗效、降低副反应仍是当前倍受关注的课题。现将这方面的一些进展综述如下。1　溶栓适应证在扩大　　溶栓病例选择在 1996年中华心血管病杂志编委会制定的参考方案基础上有…     

Stroke complicating percutaneous coronary intervention in patients with acute myocardial infarction.

BACKGROUND: Stroke associated with percutaneous coronary intervention (PCI) is a tragic complication. Despite advances in the practice of PCI, the incidence of stroke complicating PCI has not changed over the decades. The objective of the present study was to evaluate incidence and correlates of stroke occurring in patients with myocardial infarction (MI) undergoing PCI. METHODS AND RESULTS: Stroke was defined as the presence of any new focal neurological deficit lasting > or =24 h that occurred anytime during or after PCI until discharge. In 2,281 consecutive patients with PCIs for non-ST-elevation MI, or ST-elevation MI (STEMI), 20 strokes were identified (0.88%). Strokes were ischemic in 95%. On multivariate analyses, ejection fraction < or =30% (odds ratio =4.3, p=0.003) was the only independent predictor for stroke. In patients who developed stroke within 24 h of PCI, PCI of vein grafts was more frequent, and use of glycoprotein IIb/IIIa inhibitor was less frequent. Those patients tended to present late in the course of MI. Stroke found more than 24 h after PCI was related to diabetes, higher serum creatinine, lower ejection fraction, anterior wall STEMI and emergency use of intra-aortic balloon pumps. CONCLUSIONS: Low ejection fraction was the only independent predictor for stroke, but risk factors for periprocedural stroke are different from those of stroke occurring more than 24 h after PCI. Upstream use of glycoprotein IIb/IIIa inhibitor might decrease the risk of periprocedural stroke.     

溶栓疗法在初发急性心肌梗死中的应用

目的 :调查初发急性心肌梗死 （AMI）溶栓疗法的应用现状及近期疗效。方法 :总结我院 1996 - 0 1～ 1999- 0 8期间所有确诊初发 AMI患者的临床资料 ,发病超过 2 4h入院、外院转来、心内膜下心梗、再梗患者除外。结果 :2 0 2例初发 AMI患者中 ,148例 （73.3% ）符合溶栓适应证 ,132例 （6 5 .3% ）应用溶栓疗法 ,36例 （2 4.3% ）未溶栓 （16例 ）或溶栓药物剂量不足 （2 0例 ）。 70例未溶栓患者中 ,发病—入院 >12 h、符合适应证而未予溶栓、溶栓禁忌、入院心电图不能确诊 AMI的比例分别为 6 0 .0 % ,2 2 .8% ,8.6 %和 8.6 %。溶栓组住院期间病死率显著低于未溶栓组（6 .1% vs15 .7% ,P<0 .0 5 ） ,其中再通组病死率显著低于未通组 （2 .3% vs2 0 .8% ,P<0 .0 1）。结论 :尽管溶栓疗法改善了 AMI的近期预后 ,但合理应用溶栓疗法的比例仍有待提高 ,患者入院过迟、溶栓治疗不积极是溶栓疗法应用偏低的主要原因。     

Clinical controversies surrounding thrombolytic therapy in acute myocardial infarction

The treatment of acute myocardial infarction has changed tremendously in the past decade because thrombolytic therapy has become the treatment of choice for the patient with acute myocardial infarction. Although many issues have been resolved, several controversial issues remain unresolved. This article addresses thrombolytic agents in terms of their superiority in achieving infarct vessel patency and mortality reduction as well as the role of thrombolysis in patients who present with chest pain of greater than 6 hours' duration, who are elderly, and who have an inferior infarction.     

Coronary angiography after thrombolytic therapy for acute myocardial infarction

PURPOSE: To review the status of emergency, urgent, routine, and selective angiography after intravenous thrombolytic therapy. DATA SOURCES: Relevant English-language articles published from January 1985 to July 1990 were identified through MEDLINE. STUDY SELECTION: For emergency angiography, four major randomized studies were reviewed and data from nine studies that incorporated rescue coronary angioplasty were pooled for meta-analysis. For urgent angiography, two controlled trials were reviewed. Comparisons of routine and selective angiography were done using data from two dedicated, large-scale, controlled trials and the ancillary findings of four other studies of reperfusion that incorporated angiography. DATA EXTRACTION: The review emphasizes the findings from multicenter, randomized, controlled trials. DATA SYNTHESIS: Emergency coronary angiography is done primarily in preparation for primary or rescue angioplasty; the value of rescue angioplasty has yet to be assessed in a randomized trial, but technical success and reocclusion improve significantly after therapy with nonspecific plasminogen activators compared with relatively specific agents (success rate, 86% compared with 75%, respectively; P = 0.03; reocclusion rate, 10.9% compared with 26.8%, respectively; P less than 0.001). Urgent coronary angiography has value for treating recurrent ischemia, but patients who develop this complication after thrombolysis are likely to have a suboptimal outcome despite aggressive care. Studies support the use of either selective or routine angiography in uncomplicated patients after thrombolytic therapy; either approach is acceptable, but the former is more practical and may prove to be cost effective. CONCLUSIONS: Optimal follow-up for patients with evolving myocardial infarction who receive thrombolysis may incorporate coronary angiography at various stages. Although our ability to noninvasively detect reperfusion, reocclusion, or viable but ischemic myocardium is limited at present, available data may assist in selecting a catheterization strategy.     

Combined thrombolytic therapy and coronary angioplasty for acute myocardial infarction

From September, 1983, to August, 1984, combined thrombolytic therapy and percutaneous transluminal coronary angioplasty was used to treat 22 cases of acute myocardial infarction. Initial coronary angiograms showed total obstruction in 13 and severe stenosis in 9. Intracoronary infusion of urokinase reopened 7 of 13 totally occluded lesions but left a residual severe stenosis. Coronary angioplasty opened all of the remaining totally obstructed lesions and decreased the stenosis in 14 of 16 stenosed lesions. These procedures were performed 0.5 to 24 hours after the onset of chest pain. Lesions were not successfully dilated in two patients, because of arterial dissection in one and rethrombus formation in the other. One patient died from progressive hypotension beginning during the procedure, despite technically successful coronary angioplasty. Eighteen of the 20 successfully dilated lesions were patent at repeat angiography performed 1 to 3 weeks later. One successfully dilated lesion occluded 8 days after the procedure and was redilated by a larger sized balloon.     

Systemic embolization following thrombolytic therapy for acute myocardial infarction

We describe a patient with acute inferior myocardial infarction who developed a "saddle" aortic embolus during streptokinase infusion. Three months previously, this patient had sustained an anterior infarction, and an apical aneurysm was found. This patient's embolus had most probably originated from a left ventricular mural thrombus that had been dislodged by streptokinase. As fibrinolytic treatment is gaining wide acceptance, physicians should be aware of this rare, but possible, complication.     

Spontaneous hemarthrosis following thrombolytic therapy for acute myocardial infarction

We describe a 45-year-old man who developed a spontaneous hemarthrosis of his right knee following thrombolytic therapy with streptokinase and rtPA for acute myocardial infarction. Surprisingly, despite the wide use of thrombolytic therapy, only four cases of spontaneous hemarthrosis following thrombolysis have been previously reported. Prompt aspiration of the joint, after stopping anticoagulant therapy, and splinting will provide early diagnosis and may prevent further damage to the joint.     

Management of patients after thrombolytic therapy for acute myocardial infarction

The coronary artery thrombus that causes acute myocardial infarction can be lysed, and reperfusion can be achieved, in the first few hours after infarction. However, the infarct vessel will reocclude in 15-30% of patients, and this event is frequently associated with pain, reinfarction, arrhythmias, or death. The risk of reocclusion is greatest in patients with high-grade residual stenosis after thrombolysis. Percutaneous coronary angioplasty may be performed safely after thrombolytic therapy. Angioplasty effectively decreases the degree of residual stenosis, and may thereby reduce the risk of reocclusion and consequent ischemic events. However, a substantial proportion of patients with acute infarction are not suitable candidates for angioplasty. Coronary artery bypass surgery has also been safely performed within several days after thrombolytic therapy. Further studies are needed to determine which patients will benefit most from this aggressive approach to acute myocardial infarction.