Perceived contraindications to thrombolytic treatment in acute myocardial infarction. A survey at a teaching hospital.

OBJECTIVE: To examine the use of thrombolytic treatment in acute myocardial infarction when faced with perceived contraindications to treatment and to explore the justification for withholding treatment in such clinical situations. METHODS: Interview survey of all doctors responsible administering thrombolysis to patients with acute myocardial infarction at a teaching hospital in the UK from March to May 1997. RESULTS: 20 doctors were interviewed and asked whether they would give or withhold thrombolysis in a series of 19 clinical situations. These included patients presenting with both an acute myocardial infarction and one of the following associated conditions: a confirmed gastrointestinal haemorrhage, a suspected gastrointestinal haemorrhage, a peptic ulcer, an abdominal aortic aneurysm, a recent cerebrovascular accident, a known intracranial aneurysm, a known intracranial tumour, a recent dental extraction, recent surgery, severe hypertension, proliferative diabetic retinopathy, a history of bleeding diathesis, coma, recent cardiopulmonary resuscitation, pregnancy, menstruation, and a recent central venous puncture. In all but one of the clinical situations (definite current gastrointestinal haemorrhage) there was wide variation in response as to what constitutes a contraindication to thrombolytic treatment. Overall, a substantial proportion of doctors (35%-95%) would withhold treatment on account of any one of these clinical histories. CONCLUSION: Clinicians may be withholding thrombolysis in acute myocardial infarction on account of perceived contraindications for which there is little or no evidence of increased haemorrhagic risk. An effective treatment for acute myocardial infarction is probably being underused.     

Optimal thrombolytic strategies for acute myocardial infarction--bolus administration

Optimal strategies for thrombolysis in myocardial infarction (TIMI) are still being sought because the TIMI 3 flow rates achievable using standard regimens average approximately 60%. Double bolus administration of recombinant tissue plasminogen activator (tPA) is a novel approach with potential for earlier patency combined with ease of administration. We reviewed total patency rates, TIMI 3 patency rates, mortality, stroke and intracranial haemorrhage rates in the major trials of accelerated infusion tPA/bolus tPA/reteplase in acute myocardial infarction. A direct comparison was performed with results of two recent trials of double bolus (two 50 mg boli, 30 min apart) vs. accelerated infusion tPA: the Double Bolus Lytic Efficacy Trial (DBLE), an angiographic study, and the COBALT Trial, a mortality study. The DBLE trial showed equivalent patency rates for accelerated infusion and double bolus administration of tPA. Reviewing other angiographic trials, total patency and TIMI 3 patency rates achievable with double bolus tPA were comparable to those with accelerated infusion tPA or bolus reteplase administration. The COBALT study demonstrated a 30-day mortality of 7.53% in patients treated with accelerated infusion tPA compared with 7.98% for double bolus tPA treated patients. The small excess in mortality with double bolus treatment was confined to the elderly; in those < or = 75 years, mortality rates were 5.6% and 5.7%, for double bolus and accelerated infusion, respectively, and rates for death or non-fatal stroke were 6.35% and 6.3%, respectively. Comparison with other trials demonstrated mortality, stroke and intracranial haemorrhage rates with double bolus treatment similar to those associated with either accelerated infusion tPA or bolus reteplase treatment. Double bolus administration of tPA to patients with acute myocardial infarction is associated with total patency, TIMI 3 patency, mortality, stroke and intracranial haemorrhage rates similar to those associated with either accelerated infusion of tPA or bolus reteplase.     

Thrombolysis for acute myocardial infarction in Australasia 1999

Objective: To describe revascularization practice for acute myocardial infarction in a sample of Australasian hospitals during 1999. Design: Survey for the 1999 calendar year. Setting: Hospitals with Australasian College for Emergency Medicine‐accredited emergency departments in Australia and New Zealand. Participants: Forty‐eight hospitals of 80 surveyed (60%), comprising 15 tertiary and 33 non‐tertiary hospitals. Main outcome measures: Time from arrival in emergency department to initiation of thrombolytic therapy, site of therapy, agent used, mortality and intracranial haemorrhage rates. Results: Approximately 30% of patients with acute myocardial infarction had revascularization therapy. Sixty‐two per cent of patients receiving thrombolytics were given this treatment in the emergency department, the remainder in the coronary care unit. Overall median door‐to‐needle times were 35.0 min emergency department versus 48.3 min coronary care unit. Streptokinase was used for 58.3% of thrombolysis. In‐hospital mortality of thrombolysed patients was 6.7% in the emergency department versus 4.3% in the coronary care unit with intracranial haemorrhage rates of 0.8% emergency department and 0.7% coronary care unit. Conclusions: Overall times to thrombolysis and outcome rates in this sample were within internationally reported figures. Emergency department times were shorter than in coronary care unit.     

Australian and New Zealand 1997 thrombolysis audit

Objectives : To describe patterns of revascularization techniques in acute myocardial infarction in Australasia, particularly time to thrombolysis, site of delivery, patient demographics, revascularization rates and outcomes. Methods : Seventy‐four Australasian emergency departments were surveyed. Data from 1997 were obtained on number of acute myocardial infarction patients, age, gender, time to revascularization, intracranial haemorrhage rate, mortality, location and rate of revascularization and angioplasty. Grouped data were analysed. Results : Thirty‐three hospitals responded (44.6%). Many others could not supply data. Of 2930 acute myocardial infarction patients, 29% received thrombolysis and 5% angioplasty. Tertiary hospitals thrombolysed more in coronary care units (24.2% versus 8.8%), while non‐tertiary hospitals used emergency departments more (16.2% versus 5.9%). Average emergency department door‐to‐needle time was 49.4 min (median 38.6) versus 63.9 min (median 66.8) in coronary care units. More patients had streptokinase than tissue‐type plasminogen activator. Inferior myocardial infarction accounted for 58% of cases. Primary angioplasty commenced on average 61.5 min (median 69.2) after arrival. Conclusions : Australasian revascularization procedure rates, times, mortality and intracranial haemorrhage rates are similar to internationally published values. Thrombolysis starts sooner if given in emergency departments. Hospitals thrombolysing patients in coronary care units should consider emergency department thrombolysis if median times are greater than 50 min.     

New developments and perspectives of intensive neurology]

In the last few years considerable advances have been made in the diagnosis and treatment of cerebrovascular diseases, neurotrauma, and infections or inflammatory diseases of the CNS. Although thrombolysis of medial cerebral artery infarction and craniotomy with dural replacement plastic in space-occupying medial cerebral artery infarction only concern a minority of "patients with acute cerebral infarction", these treatment strategies have now been accepted as justifiable methods in the acute management of vascular ischaemic cerebral events. In addition to invasive and non-invasive monitoring of intracranial pressure and perfusion pressure in acute craniocerebral injuries, the therapeutic possibilities include treatment with calcium antagonists in traumatic subarachnoid haemorrhage and early recognition of space-occupying hemorrhagic brain contusions, in particular those mainly concerning the frontal portion of the brain. In the last few years, remarkable progress has also been made in understanding the pathophysiology of intracranial processes in bacterial meningitis. In addition to consecutive monitoring and management strategies, it is now possible to make prognostic statements and to propose adjuvant treatment strategies based on pathophysiological variables. In the therapeutic management of most severe intensive neurological disorders (spontaneous subarachnoid haemorrhage, craniocerebral trauma, dexamethasone in bacterial meningitis, etc.), a series of carefully conducted prospective randomised double-blind studies are currently under way. Hence, further significant advancements in the understanding of pathophysiology, in diagnostic and prognostic measurements and, in particular, the application of causal and adjuvant treatment strategies, are anticipated in the near and nearest future.     

急性心肌梗死后心肌内出血

在急性心肌梗死患者中, 通过经皮冠状动脉介入治疗进行血管重建能够有效降低死亡率。然而, 即使成功开通了心外膜血管, 仍有相当比例的急性心肌梗死患者发展为慢性心力衰竭。研究发现, 冠状动脉微血管阻塞引起的"无复流"现象及随后出现的心肌内出血是参与此过程的重要因素。了解心肌内出血在"无复流"现象和心肌损伤中的作用, 对制定新的急性心肌梗死治疗策略至关重要。本文将对心肌内出血的病理生理学、影像学、临床意义和治疗策略等最新进展进行综述。     

Bleeding intracranial aneurysm? Pituitary apoplexy!

Pituitary apoplexy describes the clinical syndrome characterised by headache, visual impairment and ophthalmoplegia caused by sudden enlargement of a pituitary adenoma. This is usually due to extensive tumour infarction or haemorrhage. Pituitary apoplexy is rare, mimics spontaneous intracranial bleeding, and thus may be easily mistaken for acute subarachnoid haemorrhage. Urgent surgical intervention and hormone replacement therapy are required.     

An unusual case of infective endocarditis presenting as acute myocardial infarction

A 39-year-old Zimbabwean man presented with a 1 week history of fever, general malaise and acute-onset chest pain. He had a urethral stricture, which had been managed with an indwelling supra-pubic catheter. The electrocardiography on admission showed inferior ST-T segments elevation. His chest pain and electrocardiography changes resolved subsequent to thrombolysis, and he remained haemodynamically stable. The 12-h troponin I was increased at 10.5 microg/l (NR <0.04 microg/l). Echocardiography confirmed severe mitral regurgitation and a flail anterior mitral valve leaflet with an independently oscillating mobile vegetation. Enterococci faecalis were grown on blood cultures. A diagnosis of enterococci infective endocarditis with concomitant acute myocardial infarction due to possible septic emboli was made. Despite the successful outcome from thrombolysis in the setting of acute myocardial infarction with infective endocarditis, the case highlights the current lack of definitive data on the optimal acute management of such an unusual clinical scenario. Although there is serious concern that thrombolytic treatment for myocardial infarction in the setting of infective endocarditis may be associated with higher risk of cerebral haemorrhage, there is little documented evidence supporting the safety of primary percutaneous coronary intervention with these patients.     

Thrombolytic therapy in acute myocardial infarction.

Multiple clinical trials have demonstrated that thrombolytic treatment early in the course of acute myocardial infarction significantly reduces mortality. Patients under 75 years of age who have had chest pain for no longer than six hours and who demonstrate ST-segment elevation on electrocardiogram are the best candidates for this therapy. Recent studies suggest that there is little difference in effectiveness among streptokinase, alteplase and anistreplase. However, streptokinase is 10 times less expensive than the other agents and causes fewer intracranial bleeds, the major serious adverse effect of thrombolytic therapy. An advantage of anistreplase is that it can be given in a five-minute bolus injection, compared with a one-hour infusion for streptokinase and a three-hour infusion for alteplase. Thrombolytic therapy is contraindicated in patients with known pregnancy, active internal bleeding, uncontrolled hypertension, aortic dissection, intracranial neoplasm or a history of hemorrhagic stroke. Heparin should be administered with both alteplase and streptokinase. Aspirin, beta blockers, nitrates and lidocaine are useful adjunctive therapies in the setting of an acute myocardial infarction.     

Intraventricular streptokinase infusion in acute post-haemorrhagic hydrocephalus

Neonatal post-haemorrhagic hydrocephalus is a clinical condition with a high mortality and long-term morbidity. Its clinical management is difficult and not well standardized. We describe the case of a term baby suffering from acute intracranial hypertension caused by an intraventricular and thalamic haemorrhage. In this case, the external ventricular drain inserted to control intracranial pressure was ineffective because of repeated obstructions due to blood clots. Continuous intraventricular infusion of streptokinase of 20 000 U/day allowed quick lysis of the clots, drainage of the cerebrospinal fluid and relief from the coma. Although it did not prevent a permanent ventriculoperitoneal shunt, we obtained reabsorption of the intraventricular haemorrhage without rebleeding complications. We suggest the use of low-dose fibrinolytic infusion through an external drain for the treatment of acute intracranial hypertension following intraventricular haemorrhage in term infants. Received: 8 April 1997 Accepted: 16 December 1997     

Case of the month: A case of airway obstruction following tenecteplase administration

The value of thrombolysis in the treatment of acute myocardial infarction is well established. Haemorrhage into subcutaneous tissues is fortunately a rare complication of fibrinolytic administration. However, if as a result of trauma a haematoma develops within the neck following thrombolysis, it can lead to rapid airway compromise. This is the first reported case of tenecteplase administration leading to subcutaneous haemorrhage and consequent airway compromise. It is also the first reported case where the antecedent trauma was a jaw thrust.     

Examination of the effect of histodil prophylaxis in infarction patients with inhibited haemostasis

The initiation of anticoagulants and drugs with platelet aggregation inhibiting properties is justified for the treatment of myocardial infarction in a great number of conditions. The well-known complications of this therapy are gastro-intestinal haemorrhage and the concomitant discomfort. In the period from 1983 to 1986 Histodil was given as adjuvant to therapy for infarction patients with ulcer, gastro-intestinal haemorrhage, hyperacidity or other epigastric burn-pain syndrome in history. The patients treated at our department between 1979-82 had not received Histodil for this purpose. According to the retrospective examinations the preventive effect of Histodil prophylaxis was 100%. Therefore the drug may be recommended to myocardial infarction patients in whom the inhibition of haemostasis means an increased risk of gastro-intestinal alteration.     

Myocardial Infarction and Stroke as the Presenting Symptoms of Acute Myeloid Leukemia

Background: Hyperleukocytosis in acute leukemia is associated with lymphadenopathy, hepatosplenomegaly, disseminated intravascular coagulation, and central nervous system complications. Patients with hyperleukocytosis have lower complete remission rates and have a higher mortality rate, primarily from intracranial hemorrhage. Objectives: To present the potential complications from extreme leukocytosis. Case Report: A 76-year-old man presented to the Emergency Department with chest pain, right-sided weakness, and decreased responsiveness. He was diagnosed with both an acute stroke and myocardial infarction due to extreme leukocytosis from acute myeloid leukemia. Each of these complications by itself would be an unusual manifestation of hyperleukocytosis. To the best of the author's knowledge, this represents the first reported case of these two complications simultaneously from extreme leukocytosis. Conclusions: Patients with acute leukemia may present with hyperleukocytosis, which may result in decreased tissue perfusion. Ischemia occurring in the heart can lead to an acute myocardial infarction, whereas ischemia in the brain can lead to a stroke. These events may, on occasion, be the initial presentation of leukemia. Rapid identification and treatment of the hyperleukocytosis may prevent these complications.     

心肌梗塞与血液流变学指标关系的研究

本文对20例急性心肌梗塞患者（急性期及恢复期）和16例陈旧性心肌梗塞患者进行纤维蛋白原、血液流变学指标测定，并与正常组进行对照。发现三组的全血比粘度（低切变率、高切变率）及纤维蛋白原均较正常组明显增高，经统计学处理有显著差异，且随着病情的好转呈降低趋势。认为此检查对心肌梗塞的诊断、指导治疗及判定预后有一定的价值。     

Myocardial salvage: pharmacologic treatment

We have attempted to review the role of pharmacologic agents in the treatment of patients with acute myocardial infarction for the purposes of limiting infarct size. At this time, the beta-blocking agents and nitroglycerin have been the most extensively studied in clinical trials and should be part of our overall pharmacologic approach to patients with acute myocardial infarction. Treatment, however, needs to be individualized, depending on the resources available within one's hospital and community. The early treatment of patients with acute myocardial infarction is undergoing a revolution. Whereas a decade ago we were satisfied with simply monitoring patients for malignant arrhythmias, now we are aggressively attempting to limit infarct size and reperfuse myocardium. In all these proposed treatments for myocardial salvage, time is a crucial element. Therefore, emergency physicians and paramedics become a vital link to begin appropriate treatment leading to myocardial salvage and reperfusion. We must begin to think of all patients with symptoms of acute myocardial infarction as candidates for aggressive attempts at myocardial salvage. These attempts will only take place with well-coordinated, multidiscipline efforts involving cardiologists, cardiothoracic surgeons, emergency physicians, paramedics, and critical care teams. Our challenge over the next few years will be to develop efficient systems so that all patients with acute myocardial infarction can receive optimal care.     

Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

The rupture of an atherosclerotic plaque in an epicardial coronary artery with subsequent occlusive coronary thrombosis has been established as the decisive event in the pathogenesis of an acute coronary syndrome, which encompasses the clinical entities of unstable angina, non-ST- and ST-elevation myocardial infarction. This article focuses on contemporary treatment strategies for patients with acute ST-elevation myocardial infarction and reviews the role of pharmacologic thrombolysis and mechanical reperfusion by percutaneous transluminal approaches. Statements of the latest guidelines for the treatment of ST-elevation myocardial infarction are included, as well as some recently distributed information not covered by the guideline publications. Finally, some future perspectives for the treatment of acute ST-elevation myocardial infarction are outlined.     

Compartment syndrome after thrombolysis for acute myocardial infarction

The use of various forms of thrombolytic treatment in acute myocardial infarction has been widespread for many years and their potential to cause haemorrhagic complications well recognised. Haemorrhagic sequaelae are usually minor and consist of oozing from venepuncture or cannula sites or minor haemorrhage from mucosal membranes. The potential for more serious bleeding complications is acknowledged, but is fortunately less common. Isolated cases of compartment syndrome have been reported in the past, but these usually follow some degree of local trauma. The case is reported of a patient who developed atraumatic compartment syndrome of the thigh after single dose thrombolysis.     

Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

The rupture of an atherosclerotic plaque in an epicardial coronary artery with subsequent occlusive coronary thrombosis has been established as the decisive event in the pathogenesis of an acute coronary syndrome, which encompasses the clinical entities of unstable angina, non-ST- and ST-elevation myocardial infarction. This article focuses on contemporary treatment strategies for patients with acute ST-elevation myocardial infarction and reviews the role of pharmacologic thrombolysis and mechanical reperfusion by percutaneous transluminal approaches. Statements of the latest guidelines for the treatment of ST-elevation myocardial infarction are included, as well as some recently distributed information not covered by the guideline publications. Finally, some future perspectives for the treatment of acute ST-elevation myocardial infarction are outlined.     

Knowledge of symptom clusters among adults at risk for acute myocardial infarction

BACKGROUND: Individuals need to recognize acute myocardial infarction symptoms in order to seek treatment promptly. Previous acute myocardial infarction symptom studies asked subjects to identify single symptoms from a list. However, people think about illnesses or respond to symptoms by considering groups or clusters of symptoms. OBJECTIVE: To use Q methodology to identify the cluster of symptoms that individuals at high risk for acute myocardial infarction and their significant others believe to be associated with acute myocardial infarction. METHODS: A Q sort instrument that represented a range of symptoms was developed after analysis of 140 interviews with acute myocardial infarction survivors. Individuals with known coronary artery disease or their significant others (n = 63) sorted the resulting 49 statements describing acute myocardial infarction into "most expected" and "least expected" categories. By-person factor analysis was used. RESULTS: Four factors were identified that described different presentations of acute myocardial infarction symptoms. Respondents loaded on the following factors: Factor 1 (traditional symptoms), Factor 2 (symptoms possibly related to gastrointestinal disorders), Factor 3 (nonspecific symptoms), and Factor 4 (a variation on traditional symptoms). This four-factor solution accounted for 36% of the total variance. CONCLUSIONS: The Q methodology showed that people with known coronary artery disease and their significant others had varied expectations of acute myocardial infarction symptoms. New and various strategies need to be developed to help patients accurately identify acute myocardial infarction symptoms.     

The acute myocardial infarction

Cardiovascular death is the number one cause of death in the United States, with a rate that is more than double that for cancer. Over half of these cardiovascular deaths are due to acute myocardial infarction. Management of the patient with acute myocardial infarction during and after hospitalization is discussed with an emphasis on primary and secondary prevention, patient autonomy and decision making. There is also a review of the directions that treatment of acute myocardial infarction will take in the future.