Detecting failed thrombolysis in the accident and emergency department

The primary objective in managing a patient with ST segment elevation myocardial infarction (STEMI) is to establish reperfusion in the infarct-related artery and to maintain it. Two approaches to coronary reperfusion are used in the UK - primary angioplasty and intravenous thrombolysis. Primary angioplasty is the gold standard approach to managing STEMI, but in the UK (due to financial, resource and personnel limitations) this is not the first-line treatment. Thrombolytic therapy remains the most widely used approach and the benefits of such an approach are irrefutable; thrombolysis saves lives, reduces infarct size and limits left ventricular dysfunction. However, data from the thrombolytic trials also suggest that 30-40% of patients fail to reperfuse with standard thrombolytic therapy. Similar data demonstrates that patients who do not sustain adequate perfusion in the infarct-related artery have a poor prognosis and increased mortality rates. As long as thrombolysis remains the standard therapy for STEMI, it is important that patients in whom the treatment has been unsuccessful are swiftly recognised and appropriate interventions instituted. The criteria to assess successful reperfusion of the infarct-related artery need to be simple to apply, easy to interpret and non-invasive. This article will discuss the most useful criteria to make such a diagnosis and suggest approaches to enable recognition of 'failed thrombolysis' in the accident and emergency department. The current views on managing failed thrombolysis will conclude the article.