Management of cardiac patients after thrombolytic therapy

Early thrombolytic therapy has significantly reduced morbidity and mortality through preservation of myocardium in patients with acute transmural myocardial infarction. Indications for emergent or early coronary angiography and possible angioplasty are generally limited to ongoing infarction and/or recurrent ischemia. Patients remaining clinically stable require risk stratification. Coronary angiography and revascularization with angioplasty or coronary bypass surgery is important for patients with exercise-induced ischemia. Patients with left ventricular dysfunction, poor or no exercise performance and/or advanced age are at higher risk for subsequent coronary events and thus warrant a more aggressive diagnostic approach.     

Tissue plasminogen activator administration and nursing considerations

Intravenous thrombolytic therapy is rapidly gaining acceptance in the care of acute myocardial infarction (AMI) patients. There are several thrombolytic agents in use; however, this article will focus on tissue type plasminogen activator (t-PA). A thorough understanding of the benefits and risks associated with thrombolytic administration will be critical in the successful utilization of this form of therapy. Recent data show that infarct size is linked to mortality. In the 1980s, therapy for acute myocardial infarction patients is directed at salvaging myocardium and limiting infarct size. Prior to this, therapy consisted mainly of supportive care that resulted only in minor effects on the patients prognosis. Intracoronary thrombus has recently been recognized as the cause in most cases of acute myocardial infarction. Thrombolytic therapy represents a method of dissolving a thrombus and reestablishing blood flow to the previously occluded coronary artery. Early reperfusion of ischemic myocardial tissue can limit the amount of damage caused by evolving myocardial infarction. Intervention with thrombolytic therapy in the early hours of acute myocardial infarctions has been associated with reduction in the infarct size, improvement in left ventricular function and reduction in mortality. Nursing plays a critical role in ensuring the successful use of thrombolytic therapy by early identification of appropriate patients and accurate administration of the thrombolytic agent.     

Acute myocardial infarction. Management after discharge from the coronary care unit

Although interventional techniques have changed the management of acute phases of myocardial infarction, they have not altered the need for evaluating long-term risk factors. As many as 60% of patients with multiple risk factors die within one year after discharge from the hospital, and these patients often need coronary angiography and interventional therapy to improve their prognosis. Patients who have had thrombolytic therapy and subsequently manifest recurrent myocardial ischemia need coronary angiography as a prelude to angiography or surgery. The long-term outlook for the myocardial infarction patient may be improved by modification of such risk factors as smoking, hypertension, and hypercholesterolemia.     

重组尿激酶原溶栓治疗急性心肌梗死疗效观察

目的 观察尿激酶原(Pro-uk)溶栓治疗急性心肌梗死(AMI)的疗效及安全性.方法 随机选择2004.05-2005.05间于内蒙古医学院第一附属医院住院的68例发病6 h内的AMI患者,分为Pro-uk组(n=43)和尿激酶(UK)组(n=25).其中Pro-uk 50 mg组22例、Pro-uk 60 mg组21例.在溶栓90 min时进行选择性冠状动脉造影,评价梗死相关动脉开通情况,评价早期心脏事件发生率、出血并发症以及不良反应发生率.结果 ①Pm-uk组总的梗死相关动脉再通率(TIMl2级+TIMl3级)为76.7%,明显高于UK组52.2%(P=0.041).②Pro-uk组轻度出血并发症显著低于UK组(P=0.029);两组均无颅内出血等严重并发症发生.③早期心脏事件发生率以及不良反应发生率两组差异均无统汁学意义.结论 Pro-uk静脉溶栓治疗AMI安全有效.     

Experiences with early fibrinolysis in coronary infarct at an acute care hospital. Second report of experiences with 200 patients 1980 to 1985

Over the past two decades patients with acute myocardial infarction have been treated with intravenous streptokinase therapy at the hospital in Geldern. Based on experiences in the first study from 1970 to 1979, the second study emphasized instruction on early thrombolytic therapy. Informations were given to general practitioners and to patients at risk for acute myocardial infarction. In the study from 1980 to 1985 the percentage of patients with acute myocardial infarction being treated with thrombolytic agents within two hours after the acute event was 69%. Patients with a duration of ischemia of less than two hours had a significantly decreased in-hospital mortality compared to patients who received therapy more than two hours after onset of symptoms. We conclude that intensified information and instruction of physicians and of patients at risk for myocardial infarction enables early thrombolytic therapy and results in reduced in-hospital mortality of acute myocardial infarction.     

急性心肌梗死静脉溶栓的护理体会

目的探讨急性心肌梗死静脉溶栓治疗中护理的作用。方法对35例急性心肌梗死行尿激酶溶栓治疗的患者进行护理和观察。结果 35例患者中,27例冠状动脉再通,再通率77%。结论在溶栓治疗中正确有效的护理是溶栓治疗成功的重要环节。     

New Accelerated rt-PA Strategy Has Sufficient Advantage over Older Streptokinase Strategies that It should Be the Trhombolytic Strategy of Choice in Anterior and Large Infarctions

The major goal of myocardial reperfusion therapy is to restore normal coronary blood flow as quickly as possible and to maintain coronary patency in the highest number of patients with acute myocardial infarction. Recent studies support the hypothesis that more rapid and complete restoration of coronary flow through the infarct-related artery results in improved ventricular performance and lower mortality. Accelerated tissue plasminogen activator therapy appears to produce the most favorable effects compared to other lytic strategies, particularly in patients with anterior and large myocardial infarctions. However, the finding in GUSTO II trial, that even with the best strategy only 54% of patients had TIMI grade 3 flow, suggests that further improvement in the treatment of acute myocardial infarction may be possible in the future. The effectiveness of thrombolytic therapy may be enhanced by earlier identification of evolving myocardial infarction and reduced time delays in the initiation of thrombolytic therapy, bolus thrombolytic therapy, new thrombolytic agents, or more potent adjunctive antithrombotic strategies.     

早期尿激酶静脉溶栓治疗急性心肌梗死25例临床观察

目的探讨早期尿激酶静脉溶栓治疗急性心肌梗死(AMI)的临床疗效及安全性。方法对25例AMI患者采用早期使用尿激酶栓治疗静脉再通溶栓治疗,并与25例AMI患者的常规治疗作对照。观察溶栓治疗患者的再通情况。结果尿激酶观察组与对照组的冠脉再通率分别为68.0%和16.0%,两组再通率差异有统计学意义(P<0.05);发病3 h内溶栓再通率(81.8%)明显高于3～6 h溶栓组、6～12 h内溶栓再通率(60.0%、25.0%),差异具有显著性(P<0.05)。结论早期尿激酶溶栓治疗可提高AMI患者冠脉再通率,降低病死率。     

Initiation of thrombolytic therapy for patients with acute myocardial infarction by emergency physicians: The Hong Kong experience

Abstract Objectives: To compare door-to-needle time and complications for eligible acute myocardial infarction patients receiving thrombolytic therapy in the emergency department and in the coronary care unit. Methods: A prospective study was performed involving all patients with acute myocardial infarction who received thrombolytic therapy either in the emergency department or the coronary care unit during the period January 1995 to March 1996. Patients’ time interval between registration in ED and receiving thrombolytic therapy (door-to-needle time) was the main audit parameter. Other emergency department information collected included inappropriate administration of thrombolytic therapy and the occurrence and management of complications of thrombolytic therapy. Results: In the United Christian Hospital, Hong Kong, 148 patients with acute myocardial infarction received thrombolysis. Sixty-eight cases (group A) received thrombolysis in the emergency department and 80 cases underwent thrombolysis in the coronary care unit. The 80 cases in the coronary care unit included 47 cases (group B) whose diagnosis of acute myocardial infarction and eligibility for thrombolysis were established in the emergency department, and 33 cases (group C) in which there were difficulties in diagnosis or exclusion of contraindications for thrombolysis. The mean door-to-needle times were 31.3 min in group A (95% CI, 27.6–35.1), 54 min in group B (95% CI, 47.8–60.2) and 171.8 min in group C (95% CI, 121.8–211.8). Inappropriate use of thrombolysis in the emergency department occurred in 2.9% of all cases. The most common complication of thrombolysis in the emergency department was hypotension (4.4%). All cases were successfully managed in the emergency department. There was one case of anaphylaxis during streptokinase infusion that required resuscitation in the emergency department. There were no deaths of patients receiving thrombolysis in the emergency department. Conclusion The initial experience of a regional hospital in Hong Kong supports the view that initiation of thrombolytic therapy in the emergency department can achieve a more favourable door-to-needle time without compromising the care of acute myocardial infarction patients.     

早期再灌注对急性心肌梗死伴室壁瘤形成的阻抑效应和心功能改善作用的超声心动图观察

目的　超声心动图观察早期再灌注对急性心肌梗死伴室壁瘤形成的阻抑效应和心脏收缩功能改善作用。方法　发病 12h以内急性前壁心肌梗死伴室壁瘤形成患者 98例,随机分为经皮腔内冠状动脉成形术(PCI)组(36例)、溶栓组(31)例和常规药物治疗组(31例),三组患者均在治疗后 2周、12周、24周分别行超声心动图测量左室收缩末期容积(LVESV)、左室舒张末期容积 (LVEDV),并以体表面积校正为左室收缩末期容积指数(LVESVI)、左室舒张末期容积指数(LVEDVI),同时测左室射血分数 (LVEF)、局部室壁运动指数 (RWMI)、左室质量(LVM),后者与体表面积相除得到左室质量指数(LVMI),评价LVESVI、LVEDVI和心室收缩功能改善状况。结果　治疗后 2周,PCI组和溶栓组各参数优于药物治疗组,治疗后 12周,PCI组LVESVI、LVEDVI低于溶栓组(均P<0. 05),溶栓组各参数优于药物治疗组(均P<0. 05)。PCI组和溶栓组各参数自身前后比较明显改善(均P<0. 05),LVEF较 2周时显著增高(P<0. 05)。治疗后 24周,PCI组LVEDVI、LVESVI仍低于溶栓组(P<0. 05),PCI组和溶栓组各参数均优于药物治疗组 (均P<0. 05),PCI组LVESVI、LVEDVI、RWMI较 2周、12周均减小(均P<0. 05),LVEF较 2周、12周显著增高(均P<0. 05);溶栓组各时段比较与PCI组大致相同。结论　超声心动图     

Takotsubo or stress cardiomyopathy: role of nuclear cardiology using 123I-MIBG

Takotsubo cardiomyopathy, also known as broken heart syndrome or stress cardiomyopathy, is a very interesting syndrome of acute transient left ventricular dysfunction, usually following significant emotional stress. It was first described in Japan nearly two decades ago and many aspects of its pathogenesis still remain poorly understood. The incidence of out-of-hospital sudden death related to Takotsubo is currently unknown. Excess catecholamines following stress seem to trigger Takotsubo and play an important role. The clinical presentation resembles acute myocardial infarction, including chest tightness and/or dyspnea, ECG changes and elevated cardiac enzymes. However, in contrast to a typical acute myocardial infarction, no significant coronary lesions or thrombi are found on coronary angiography. Differentiating Takotsubo from acute myocardial infarction is important to avoid the unnecessary risks of thrombolytic therapy. Typically, left ventriculography shows marked abnormalities with akinesia in the mid-distal anterior wall and apex (occasionally involving other heart regions), giving a balloon shape to the left ventricle. The name Takotsubo originates from the shape of the left ventricle, which resembles a Japanese octopus-trapping pot. Hospital mortality is low but death can be caused by severe acute heart failure and/or ventricular arrhythmias. Typically, a stressful life event is reported preceding the acute symptoms. Takotsubo is most common in menopausal women although young individuals, including men, can also be affected. The autonomic nervous system has a defined role in the process. In this article, we will review the role of imaging the heart using ¹²³I-meta-iodobenzylguanidine, a radioactive marker allowing mapping of the autonomic nervous system of the heart, in cases of suspected Takotsubo.     

依诺肝素辅助瑞替普酶静脉溶栓治疗急性心肌梗死的临床研究

目的：探讨瑞替普酶静脉溶栓辅助应用依诺肝素替代普通肝素抗凝治疗急性心肌梗死（AMI）的安全性与有效性。方法：86例AMI患者在瑞替普酶静脉溶栓时随机分为依诺肝素组（45例）和静脉普通肝素组（41例）,2周后行冠状动脉造影及冠脉介入治疗（PCI）。观察临床再通率、血管开通率、急性期并发症、出血及不良反应发生率。结果：依诺肝素组与普通肝素组临床再通率、血管开通率比较差异无统计学意义（P〉0．05）。两组急性期并发症发生率比较差异无统计学意义（P〉0．05）。依诺肝素组出血并发症低于静脉普通肝素组,两组比较差异有统计学意义（P〈0．05）。结论：瑞替普酶并依诺肝素用于AMI再灌注治疗是安全有效的。     

A Rare Cause of Myocardial Infarction: Acute Inferoposterior Myocardial Infarction After Successful Intravenous Thrombolytic Treatment of Mechanical Mitral Prosthetic Valve Thrombosis

Prosthetic valve thrombosis is a rare and dreaded complication of patients with mechanical valves, particularly those in the mitral position. A 45-year-old female with status post prosthetic mitral valve replacement was admitted to the hospital with acute pulmonary edema. Echocardiography showed mitral valve thrombosis which was treated with tissue plasminogen activator (t-PA). During t-PA infusion she developed acute inferoposterior myocardial infarction. Coronary angiography showed normal coronary arteries. Presented case had acute inferoposterior myocardial infarction secondary to coronary emboli after the successful thrombolytic treatment of prosthetic mitral valve thrombosis.     

Intracoronary thrombolytic therapy of myocardial infarction

The results of intracoronary thrombolytic therapy with avelysine given to 21 patients with acute myocardial infarction are described. Intracoronary thrombolysis was performed on the average 5 h and 30 min after myocardial infarction onset. Recanalization of the coronary artery was attained in 16 patients, with no lethal outcomes. One patient died out of the 5, in whom attempts to recanalize the artery ended in failure. Recanalization of the coronary arteries led to improvement of left ventricle function and appreciably accelerated the time-course of the enzymatic shifts (KPK and LDH) in blood of myocardial infarction patients. After successful recanalization of the coronary artery the disease in myocardial infarction patients took a far milder course as compared to those who did receive intracoronary thrombolytic therapy.     

Gender differences in acute coronary events.

The most frequent cause of death among women in the United States is coronary heart disease, which claims 200,000 lives a year. The prognosis with either medical or surgical therapy is worse in females than in males. The following significant gender differences have been observed and reported: (1) the rate of early death following acute myocardial infarction is greater in women, (2) the difference between sexes remains whether or not thrombolytic therapy is used, and (3) the hospital mortality rate following coronary angioplasty, atherectomy, or bypass surgery is greater in females. The reasons for these gender differences are not clearly understood. Nevertheless, awareness of the higher morbidity and mortality in women dictates the need for early detection and more aggressive therapy of the risk factors. However, diabetes mellitus and essential hypertension are 2 well-established major risk factors for coronary disease and stroke that are more prevalent in the female gender. These 2 risk factors are cumulative and require more intensive and aggressive therapy to prevent acute vascular events, and therefore early detection is mandatory.     

The initial electrocardiogram in patients seen by a mobile coronary care unit

The advent of thrombolytic therapy for patients with suspected acute myocardial infarction has highlighted the importance of the initial electrocardiogram (ECG) in decision making. Thus we analysed the initial ECGs of 94 consecutive cases with suspected myocardial infarction who were seen within six hours after the onset of chest pain by a mobile coronary care unit. The study included 91 patients (three patients admitted twice) (61 male), aged 27-83 years (mean 60.5). Median time from onset of chest pain to arrival of the mobile coronary care unit was 75 minutes (range 15-345), and mean mobile coronary care unit response time was 12.3 +/- 7 (SD) minutes (range 5-45). The majority of cases (65 of 94, 69.1 per cent) were seen within two hours of the onset of symptoms. A final diagnosis of myocardial infarction was made in 48 of 94 (51.1 per cent) cases; 38 had unstable angina and eight other diagnoses. Of the 48 with myocardial infarction the initial ECG showed ST segment elevation in 37, ST depression and or T wave inversion in six, Q waves only in three and left bundle branch block in two. No patient with an initially normal ECG had a myocardial infarction. Thrombolytic therapy was given out of hospital to 33 of 38 patients with ST segment elevation. In seven patients with ST elevation (median delay time to intensive care 60 minutes), rapid resolution of ST segment elevation occurred following thrombolytic therapy and there was no significant elevation of cardiac enzymes, suggesting that the infarct had been aborted.(ABSTRACT TRUNCATED AT 250 WORDS)     

Redefining the coronary care unit: an observational study of patients admitted to hospital in England and Wales in 2003

BACKGROUND: Coronary care units were developed in the 1960s as specially equipped and staffed areas where patients with acute myocardial infarction could be monitored and offered rapid resuscitation from life-threatening arrhythmias. Awareness of the morbidity and mortality of the wider spectrum of acute coronary ischaemia was unrecognized at that time. AIM: To examine the relative frequencies with which thrombolytic treatment and resuscitation from cardiac arrest are provided for patients with myocardial infarction in cardiac care units (CCUs), emergency departments (EDs) and other medical wards. DESIGN: Observational study. METHODS: We analysed records from the National Audit of Myocardial Infarction Project (MINAP) for 61 688 patients admitted to 230 acute hospitals in England and Wales during 2003, and who received a final diagnosis of myocardial infarction, for locations of initiation of thrombolytic therapy and of first cardiac arrest within hospital. RESULTS: Overall, 84% of 27 881 patients with ST-segment-elevation infarction, but only 42% of 30 382 patients with non-ST-elevation infarction, were admitted to a CCU. Of those receiving thrombolytic treatment for ST-elevation infarction, 68.3% of 21 595 did so in the ED. Within the first 4 h after arrival, the majority of episodes of cardiac arrest occurred in the ED: 709 (57%) vs. 488 (39%) in CCU, and 49 (4%) in medical wards. DISCUSSION: The traditional role of the CCU in providing early resuscitation and thrombolytic treatment for patients with ST elevation infarction has largely been devolved to the ED. The role of the CCU should be re-evaluated, and the service re-designed to provide specialist care for all presentations of acute coronary syndrome.     

Percutaneous transluminal coronary angioplasty in patients over 75 years old with acute myocardial infarct or unstable angina pectoris

Both increasing frequency and technical improvements of percutaneous transluminal coronary angioplasty (PTCA) have focussed attention on possible applications of PTCA in elderly patients with coronary artery disease. From January 1986 to June 1989, among 1872 patients treated with PTCA in our hospital, 42 patients (2.3%) were 75 or more years old. Of these patients, 14 presented with unstable angina, 28 patients suffered from acute myocardial infarction. PTCA was performed on stenoses of left anterior descending artery (43%), circumflex coronary artery (18%), and right coronary artery (39%), respectively. In patients with unstable angina, PTCA in 81% could reduce diameter stenoses of culprit lesions to 50% or less. 43% of patients with acute myocardial infarction had received previous thrombolytic therapy with streptokinase or urokinase applied either systemically or intracoronarily. On cardiac catheterization, 39% of patients presenting with acute myocardial infarction showed total occlusion of the infarct-related vessel. In 75% of patients with acute myocardial infarction, after PTCA, patency of the infarct-related artery (diameter stenoses 50% or less) was observed. In-hospital mortality of patients with acute myocardial infarction subjected to PTCA was 10%, two patients dying in prolonged cardiogenic shock, one in septic shock. In 20% of cases, coronary dissection was observed after PTCA. Non-Q-wave infarction developed in one patient. Three patients had a peripheral vascular complication, and in one patient a transient ischemic attack was observed. No severe catheter-related complications occurred after thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect on collagen metabolism of thrombolytic therapy with tissue-plasminogen activator. A randomized, placebo-controlled study

Abstract. This paper assesses alterations in collagen metabolism following thrombolytic therapy of acute myocardial infarction with tissue-plasminogen activator. Sequential serum measurements of the amino-terminal propeptide of type III procollagen (S-PIIINP) and the carboxyterminal propeptide of type I collagen (S-PICP) in patients suspected of acute myocardial infarction randomized to tissue-plasminogen activator or placebo were used. S-PIIINP increased at 3h in patients with acute myocardial infarction treated with tissue-plasminogen activator ( P < 0.05). S-PIIINP was higher in patients treated with tissue-plasminogen activator compared with placebo-treated patients at 3 and 6 h ( P < 0.05). S-PICP decreased independently of therapy and diagnosis. Tissue-plasminogen activator, therefore, induces breakdown of collagen, some of which is located in the wall of atheromatous arteries. Vascular patency following thrombolytic therapy may partly be mediated by breakdown of thrombogenic collagen in the vessel wall. The findings may suggest a role for S-PIIINP as a non-invasive indicator of the risk of reocclusion.     

Anticoagulant and thrombolytic agents in acute coronary syndrome

The term acute coronary syndrome (ACS) pertains to the instable and life-threatening forms of a clinically manifest coronary artery disease with biochemical and/or electrocardiographic evidence od myocyte cell death. In detail, it includes the unstable angina pectoris, the non-ST segment elevation myocardial infarction (NSTEMI) the ST segment elevation myocardial infarction (STEMI) and as well the sudden cardiac death. As early reperfusion of ischaemic myocardium is the most effective way for limiting infarct size by restoring the balance between myocardial oxygen supply and demand, it is the most important therapeutic goal to achieve early and complete antegrade flow in the occluded or restricted vessel, related with a reduction of short and longtime complications as heart failure and severe arrhythmias. It is generally accepted, that the primary percutaneous coronary intervention (PCI) is the method of choice in acute myocardial infarction (STEMI) to restore TIMI-3 blood flow in occluded coronary arteries, if this can be performed within two hours of symptom onset and by a highly specialized team. Since this requirements are only met in 20% of hospitals caring for patients with STEMI in Germany, the therapy with thrombolytic and anticoagulant agents plays still an important role. Apart from a rapid and effective prehospital primary care, it depends furthermore on a differentiated anticoagulatory and antithrombotic therapy during coronary intervention to get optimal results.