Selection of patients with acute myocardial infarction for thrombolytic therapy

PURPOSE: To critically review the current recommendations regarding the eligibility of patients with myocardial infarction for thrombolytic therapy. DATA IDENTIFICATION: Relevant studies published from January 1980 to January 1990 were identified through a computerized search of the English-language literature using MEDLINE and by a manual search of the bibliographies of all identified articles. STUDY SELECTION: All randomized, controlled trials of intravenous thrombolysis in acute myocardial infarction and unstable angina were reviewed. Smaller, observational studies and previous review articles were included when relevant to the discussion. DATA EXTRACTION: Key data were extracted from each article, including the proportions of patients eligible for thrombolysis, the reasons for exclusion from thrombolytic therapy, and the clinical outcomes of patients treated and of those excluded from treatment. The validity of certain exclusion criteria was examined using subgroup analysis from the large, randomized mortality trials of intravenous thrombolysis and observations from smaller, nonrandomized studies. RESULTS OF DATA SYNTHESIS: To date, relatively few patients with myocardial infarction have been considered eligible for fibrinolytic therapy. In this group, both early and late mortality have been significantly reduced. Patients excluded from thrombolysis, however, continue to have a high early mortality. The data suggest that the potential benefits of this treatment might be extended to selected high-risk subgroups. In particular, the risk-benefit ratio may favor the inclusion of otherwise healthy elderly patients; certain patients presenting more than 6 hours after the onset of symptoms; and patients with a history of controlled systolic hypertension or brief, nontraumatic cardiopulmonary resuscitation. The data do not support the use of fibrinolytic therapy as primary treatment in patients with unstable angina or suspected myocardial infarction in the absence of confirmatory electrocardiographic changes. CONCLUSIONS: The full potential of thrombolytic therapy to alter the natural history of acute myocardial infarction can only be realized through the continued evaluation of selection criteria and the identification and treatment of the greatest possible number of eligible patients.     

静脉溶栓治疗老年急性心肌梗死的临床分析

目的 探讨老年(≥75岁)急性心肌梗死患者静脉溶栓的疗效及安全性. 方法 将62例老年急性心肌梗死患者随机分为溶栓组和常规治疗组;溶栓组32例,采用尿激酶静脉溶栓加皮下注射小剂量低分子肝素钙.常规治疗组30例.除不用尿激酶及小剂量低分子肝素钙外,其余治疗均与溶栓组相同.结果 冠状动脉再通率溶栓组为65.6%(21/32),常规治疗组为16.7%(5/30),两组比较差异具有显著性(P<0.05);溶栓组病死率6.3%(2/32),而常规治疗组病死率为23.3%(7/30),两组比较具有显著差异性(P<0.05);两组无严重出血并发症,出血并发症比较差异无显著性(P>0.05). 结论 尿激酶静脉溶栓治疗老年急性心肌梗死可以提高冠状动脉再通率,降低死亡率和改善预后,是可行性治疗措施.     

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.     

急性心肌梗死者尿激酶溶栓治疗的疗效及预后观察

目的 观察急性心肌梗死(AMI)者尿激酶溶栓治疗的疗效、安全性及预后.方法 将58例随机分为溶栓组(A组)和非溶栓组(B组),在常规治疗基础上,A组进行尿激酶溶栓治疗,B组给予硝酸甘油和肝素钙等常规治疗.超声心动图在冠心病诊断与治疗中有重要价值[1].三个月后两组患者检查心脏彩超,分别检测左心室射血分数(LVEF)以及左心室舒张末期内径(LVEDd),以评估两组患者的预后.结果 两组组间的血管再通率、住院死亡率以及两组患者预后有显著差异性.结论 尿激酶溶栓时间越早,再通率越高,是一种治疗AMI安全、有效的抢救措施,将对AMI者的预后产生积极的影响.     

Risk assessment in patients with acute myocardial infarction treated with thrombolytic therapy

OBJECTIVE: Several noninvasive methods have prognostic information regarding mortality and new coronary events after an acute myocardial infarction (AMI). The practical for clinical decision-making in the immediate postmyocardial infarction (MI) period is, however, less evident. We investigated consecutive patients with AMI treated with thrombolysis to further clarify this issue. DESIGN: A total of 100 patients (27% women) aged 64 +/- 9 years (mean +/- SD) were studied. Risk assessment based on a clinical score system, myocardial perfusion scintigraphy single photon emission computed tomography (SPECT) at rest and during adenosine stress, echocardiography, radionuclide angiography, symptom-limited exercise stress test, and 24-h Holter ECG recording with ST-analysis and analysis of heart rate variability (HRV) were performed 5-8 days after hospital admission. Mortality, nonfatal reinfarction, and the need for revascularization were followed during 12 months. SETTING: A university hospital. RESULTS: A total of 6 patients died, seven had a nonfatal reinfarction, and 23 were revascularized. Inability to perform an exercise test (P = 0.004) and an ejection fraction (EF) < 40% (P = 0.002) were the only parameters separating those who died from the survivors. No method could predict a nonfatal reinfarction. Patients suffering either death or nonfatal reinfarction had a clinical risk assessment score 2 points higher (8.8 vs. 6.7, P = 0.05) than the group without such events. A positive symptom-limited exercise stress test (P = 0.027), ST-depressions on Holter ECG (P = 0.04), and reversibility on myocardial perfusion scintigraphy (P = 0.029) predicted the need for revascularization. CONCLUSION: Risk assessment based on clinical information, exercise stress testing, and an estimate of left ventricular function (e.g. via echocardiography) contribute with prognostic information in thrombolysed MI-patients. Additional noninvasive investigations such as adenosine-SPECT, analysis of HRV, and Holter-monitoring do not add to these commonly available tools in risk stratification of subjects at low to medium risk.     

Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy

OBJECTIVE: To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history. DESIGN: Retrospective chart review. SETTING: A large community-based hospital. PATIENTS: All patients with acute myocardial infarction hospitalized during a 27-month period. MEASUREMENTS: Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy. MAIN RESULTS: The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria. CONCLUSIONS: Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.     

高龄急性心肌梗死患者静脉溶栓治疗的临床观察

目的：探讨高龄（≥75岁）急性心肌梗死（AMI）患者静脉溶栓治疗的疗效和安全性。方法：将61例高龄AMI患者随机分为溶栓组和常规治疗组,溶栓组30例,在常规治疗基础上采用尿激酶（UK）静脉溶栓＋口服阿斯匹林（ASA）。常规治疗组31例,除不用UK外,其余治疗均与溶栓组相同。结果：血管再通率溶栓组为66．7％（20／30）,常规治疗组为12．9％（4／31）,两组血管再通率比较,差异有显著性（P＜0．05）。溶栓组住院4周病死率为3．3％,常规治疗组为22．6％,两组比较差异亦有显著性（P＜0．05）。溶栓组未见严重出血等并发症。结论：UK＋ASA治疗高龄AMI可以提高冠脉再通率,降低病死率和改善预后。     

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。     

Prognostic importance of previous myocardial infarction in patients receiving thrombolytic therapy for acute infarction

This study evaluated the prognostic significance of reinfarction location by considering the previous site or type of myocardial infarction (MI) among 1601 patients with a history of previous MI who took part in the International (non-Italian) tPA/STK trial and/or the Israeli GUSTO study population. These patients were accordingly divided and hospital mortality was compared by six location groups as follows: acute inferior with previous inferior (8.1% hospital mortality), acute inferior with previous anterior (12.8%), acute anterior with previous inferior (13.3%), acute anterior with previous anterior (11.1%), acute inferior with previous non-Q-wave MI (7.6%), and acute anterior with previous non-Q-wave MI (11.2%) (p = 0.17 for comparison between the six groups). Hospital mortality tended to increase among patients with an anterior reinfarction compared with those with an inferior one (12.1% vs. 9.5%, p = 0.12). Among patients with a reinfarction at a different ECG location from the previous event, mortality tended to be higher compared with patients with two MIs at the same location (13.1% vs. 9.7%, p = 0.07). Recurrent MI following a previous Q-wave MI did not cause a higher mortality compared with a previous non-Q-wave type of MI (11.5% vs. 9.5%, p = 0.24). Among patients sustaining reinfarction, overall mortality did not differ between STK- and tPA-treated patients (11.0% vs. 11.4%, p = NS). In conclusion, the current study identified trends for higher mortality rates in patients with anterior compared with inferior reinfarction, with remote compared with the same ECG location of the two infarctions but not following a previous non-Q-wave compared with Q-wave MI. However, no particular combination of successive MIs location was significantly associated with a higher risk for hospital mortality.     

院前静脉溶栓治疗急性心肌梗死的临床随机对照研究

目的　评价重组组织型纤溶酶原激活剂 (rt PA)在院前救治急性心肌梗死 (AMI)的近期临床治疗效果 ,并探讨在院前对AMI患者进行静脉溶栓治疗的安全性和可行性。方法　对所收治的AMI患者进行分组 ,均给予rt PA( 5 0mg)进行静脉溶栓治疗 ,对比两者的冠状动脉再通率以及发病至溶栓时间延迟对rt PA静脉溶栓疗效的影响。结果　从患者发病至进行溶栓治疗的时间间隔 ,院前组平均比院内组缩短 2 .2小时 [( 2 .9± 1.4)小时比 ( 5 .1± 1.1)小时 ] ,P <0 .0 5 ;院前治疗组的冠状动脉总再通率为 90 % ,明显高于院内治疗组的 61.8% (P <0 .0 5 )。结论　院前应用rt PA( 5 0mg)进行静脉溶栓治疗安全、可行。     

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.     

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.     

溶栓治疗老年人急性心肌梗死34例分析

目的观察老年人急性心肌梗死（ＡＭＩ）溶栓治疗的安全性和有效性。方法７１例７０岁以上老年ＡＭＩ患者分成溶栓组（３４例）和对照组（３７例），比较其临床结果。结果（１）梗死相关动脉（ＩＲＡ）的再通率溶栓组显著高于对照组（６１．８％及１３．５％，Ｐ＜０．０１）；（２）溶栓明显改善了老年ＡＭＩ患者的左室射血分数（６３％及５２％，Ｐ＜０．０５）；（３）溶栓显著降低了老年ＡＭＩ患者的住院病死率（３５．１％对１４．７％，Ｐ＜０．０５），降幅为２０．４％；（４）溶栓组发生出血并发症６例（皮肤淤斑４例，上消化道出血２例），无严重出血（无需输血）并发症及脑卒中发生。结论对无禁忌证的老年人ＡＭＩ进行溶栓治疗，可以增加其血管再通率、改善心功能及降低病死率。     

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…     

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.     

Comparison of primary angioplasty with conservative therapy in patients with acute myocardial infarction and contraindications for thrombolytic therapy

The benefit of primary angioplasty in patients with acute myocardial infarction (AMI) and contraindications for thrombolysis compared to a conservative regimen is still unclear. Out of 5,869 patients with AMI registered by the MITRA trial, 337 (5.7%) patients had at least one strong contraindication for thrombolytic therapy. Out of these 337 patients 46 (13.6%) were treated with primary angioplasty and 276 (86.4%) were treated conservatively. Patients treated conservatively were older (70 years vs. 60 years; P = 0.001), had a higher rate of a history with chronic heart failure (14.8% vs. 4.4%; P = 0.053), a higher heart rate at admission (86 beats/min vs. 74 beats/min; P = 0.001), and a higher prevalence of diabetes mellitus (27.1% vs. 12.8%; P = 0.056). Patients treated with primary angioplasty received more often aspirin (91.3% vs. 74.6%; P = 0.012), β-blockers (60.9% vs. 46.1%; P = 0.062), angiotensin converting enzyme (ACE) inhibitors (71.7% vs. 44%; P = 0.001), and the so-called optimal adjunctive medication (54.4% vs. 32.3%; P = 0.004). Hospital mortality was significantly lower in patients who received primary angioplasty (univariate: 2.2% vs. 24.7%; P = 0.001; multivariate: OR = 0.46; P = 0.0230). In patients with AMI and contraindications for thrombolytic therapy, primary angioplasty was associated with a significantly lower mortality compared to conservative treatment. Therefore, hospitals without the facilities to perform primary angioplasty should try to refer such patients to centers with the facilities for such a service, if this is possible in an acceptable time.Cathet. Cardiovasc. Intervent. 46:127–133, 1999. © 1999 Wiley-Liss, Inc.     

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.