Predictors of coronary artery reocclusion following fibrinolysis (thrombolysis)
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- Sabina A Murphy, MPH
Sabina A Murphy, MPH
- TIMI Study Group
- Harvard Medical School
Reocclusion of the infarct-related artery following successful reperfusion with fibrinolysis in patients with ST-elevation myocardial infarction remains a major limitation. Despite adjunctive pharmacologic therapy with antiplatelet and anticoagulant therapy, early thrombotic reocclusion occurs in 5 to 10 percent of patients before hospital discharge and in up to 25 percent by three months in studies prior to the use of dual antiplatelet therapy [1-5]. Early reinfarction occurs in 3 to 5 percent [6-8]. Reocclusion is clinically silent in over 50 percent of cases.
Whether symptomatic or silent, reocclusion is associated with significant morbidity and mortality in both the short and long term. Among 810 patients evaluated by the TAMI study group, the in-hospital mortality rate was significantly higher in those with reocclusion (11 versus 4 percent with a patent coronary artery) . In a study of 20,101 patients enrolled in the TIMI trials, the increase in mortality with early reocclusion persisted at two years (19.6 versus 10.1 percent) .
Thus, percutaneous coronary intervention is often recommended even in clinically stable patients after fibrinolysis. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy", section on 'Fibrinolysis followed by PCI'.)
This topic will review the predictors of coronary artery reocclusion following fibrinolysis. The role of coronary artery patency in outcome after myocardial infarction and the general principals of the clinical use of fibrinolytic therapy are discussed elsewhere. (See "Coronary artery patency and outcome after myocardial infarction" and "Fibrinolytic therapy in acute ST elevation myocardial infarction: Initiation of therapy".)
CLINICAL PREDICTORS OF REOCCLUSION
Demographic and clinical variables have not proven very helpful in predicting which patients will develop reocclusion [1,2]. However, one large series did find that clinical predictors of reinfarction included advanced age, shorter time to fibrinolysis, nonsmoking status, prior infarction or angina, female sex, anterior infarction, and lower systolic blood pressure .
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- CLINICAL PREDICTORS OF REOCCLUSION
- ROLE OF FIBRINOLYSIS IN REOCCLUSION
- ANGIOGRAPHIC PREDICTORS OF REOCCLUSION
- Lesion ulceration
- High grade residual stenosis and reduced lumen area
- Lack of restoration of normal coronary flow
- POSSIBLE STRATEGIES TO MINIMIZE REOCCLUSION
- SUMMARY AND RECOMMENDATIONS