Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Fibrinolytic (thrombolytic) agents in unstable angina and acute non-ST elevation myocardial infarction

GENERAL PRINCIPLES

Unstable angina and non-ST elevation (non-Q wave) myocardial infarction (NSTEMI) are part of the continuum of acute coronary syndrome (ACS) that also includes ST elevation MI. (See "Criteria for the diagnosis of acute myocardial infarction", section on 'Third Universal Definition of MI'.)

Two observations constitute the rationale for consideration of the use of fibrinolytic agents in the treatment of unstable angina or acute NSTEMI:

  • The important role of intraarterial thrombus formation in this disorder
  • The efficacy of fibrinolysis in the management of acute ST elevation (Q wave) MI (STEMI).

In STEMI, fibrinolytic agents offer a trade-off between reduced mortality and increased incidence of intracerebral bleeding. In this setting, the net benefit is expressed as a difference between these two events. The choice of dose and the means of administration (eg, rapid bolus loading and concomitant intravenous heparin) is influenced by the need to achieve rapid reperfusion to preserve as much myocardium as possible. (See "Fibrinolytic therapy in acute ST elevation myocardial infarction: Initiation of therapy".)

There are a number of important differences in unstable angina/NSTEMI:

    

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2014. | This topic last updated: Sep 4, 2012.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb Investigators. Circulation 1998; 98:1860.
  2. Furman MI, Dauerman HL, Goldberg RJ, et al. Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective. J Am Coll Cardiol 2001; 37:1571.
  3. Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399.
  4. Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Circulation 1993; 87:38.
  5. Kerensky RA, Wade M, Deedwania P, et al. Revisiting the culprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol 2002; 39:1456.
  6. Wong GC, Morrow DA, Murphy S, et al. Elevations in troponin T and I are associated with abnormal tissue level perfusion: a TACTICS-TIMI 18 substudy. Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction. Circulation 2002; 106:202.
  7. Jang IK, Gold HK, Ziskind AA, et al. Differential sensitivity of erythrocyte-rich and platelet-rich arterial thrombi to lysis with recombinant tissue-type plasminogen activator. A possible explanation for resistance to coronary thrombolysis. Circulation 1989; 79:920.
  8. Mizuno K, Satomura K, Miyamoto A, et al. Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes. N Engl J Med 1992; 326:287.
  9. Gold HK, Johns JA, Leinbach RC, et al. A randomized, blinded, placebo-controlled trial of recombinant human tissue-type plasminogen activator in patients with unstable angina pectoris. Circulation 1987; 75:1192.
  10. Nicklas JM, Topol EJ, Kander N, et al. Randomized, double-blind, placebo-controlled trial of tissue plasminogen activator in unstable angina. J Am Coll Cardiol 1989; 13:434.
  11. Ardissino D, Barberis P, De Servi S, et al. Recombinant tissue-type plasminogen activator followed by heparin compared with heparin alone for refractory unstable angina pectoris. Am J Cardiol 1990; 66:910.
  12. Williams DO, Topol EJ, Califf RM, et al. Intravenous recombinant tissue-type plasminogen activator in patients with unstable angina pectoris. Results of a placebo-controlled, randomized trial. Circulation 1990; 82:376.
  13. Freeman MR, Langer A, Wilson RF, et al. Thrombolysis in unstable angina. Randomized double-blind trial of t-PA and placebo. Circulation 1992; 85:150.
  14. Schreiber TL, Rizik D, White C, et al. Randomized trial of thrombolysis versus heparin in unstable angina. Circulation 1992; 86:1407.
  15. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation 1994; 89:1545.
  16. Anderson HV, Cannon CP, Stone PH, et al. One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction. J Am Coll Cardiol 1995; 26:1643.
  17. Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6-24 hours after onset of acute myocardial infarction. Lancet 1993; 342:759.
  18. Langer A, Goodman SG, Topol EJ, et al. Late assessment of thrombolytic efficacy (LATE) study: prognosis in patients with non-Q wave myocardial infarction. (LATE Study Investigators). J Am Coll Cardiol 1996; 27:1327.
  19. Anderson HV. Intravenous thrombolysis in refractory unstable angina pectoris. Lancet 1995; 346:1113.
  20. Anderson J, Adams C, Antman E, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College or Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50:e1 www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).