Medline ® Abstracts for References 6-8
of 'Predictors of coronary artery reocclusion following fibrinolysis (thrombolysis)'
Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials.
Hudson MP, Granger CB, Topol EJ, Pieper KS, Armstrong PW, Barbash GI, Guerci AD, Vahanian A, Califf RM, Ohman EM
BACKGROUND: Trials report a 2% to 6% incidence of reinfarction after fibrinolysis for acute myocardial infarction (MI). We combined the Global Utilization of Streptokinase and Tissue plasminogen activator (alteplase) for Occluded coronary arteries (GUSTO I) and Global Use of Strategies To Open occluded coronary arteries (GUSTO III) populations to better define frequency, timing, and clinical predictors of in-hospital reinfarction.
METHODS AND RESULTS: In 55 911 patients with ST-segment elevation myocardial infarction (MI) who were receiving fibrinolysis, we compared baseline characteristics and mortality rate by reinfarction incidence and developed multivariable logistic regression models to predict in-hospital reinfarction and composite of death or reinfarction. Reinfarction occurred in 2258 patients (4.3%) a median of 3.8 days after fibrinolysis; rates did not differ between GUSTO I (4.0%) and GUSTO III (4.2%) or by fibrinolytic assignment (streptokinase, 4.1%; alteplase, 4.3%; reteplase, 4.5%; combined streptokinase and alteplase, 4.4%; P=0.55). Advanced age, shorter timeto fibrinolysis, non-US enrollment, nonsmoking status, prior MI or angina, female sex, anterior MI, and lower systolic blood pressure were associated significantly with reinfarction. Patients with reinfarction had higher mortality at 30 days (11.3% versus 3.5% without reinfarction; odds ratio, 3.5; P<0.001) and from 30 days to 1 year (4.7% versus 3.2%; hazard ratio, 1.5; P<0.001). Significant multivariate predictors of in-hospital death or reinfarction included age, Killip class, systolic and diastolic blood pressures, heart rate, anterior MI, smoking status, prior MI, sex, and country of enrollment (all P<0.001).
CONCLUSIONS: Reinfarction occurs infrequently after fibrinolysis but confers increased risk of 30-day and 1-year mortality. Some predictors of reinfarction differ from known predictors of death after MI. Improved treatment and prevention strategies for reinfarction deserve study.
Duke Clinical Research Institute, Durham, NC, USA. firstname.lastname@example.org
Admission clinical and electrocardiographic characteristics predicting an increased risk for early reinfarction after thrombolytic therapy.
Birnbaum Y, Herz I, Sclarovsky S, Zlotikamien B, Chetrit A, Olmer L, Barbash GI
Am Heart J. 1998;135(5 Pt 1):805.
BACKGROUND: This study assessed the ability of clinical and electrocardiographic variables routinely obtained on admission to identify patients with acute myocardial infarction treated with thrombolytic therapy at risk of early reinfarction.
METHODS AND RESULTS: The study included 2602 patients who received thrombolytic therapy for acute myocardial infarction. Baseline demographic variables and admission clinical and electrocardiographic variables were compared between patients with and without reinfarction. Multivariable logistic regression technique was used and included recurrent infarction as the dependent variable, and baseline demographic, clinical, and electrocardiographic variables as independent variables. History of hypertension (odds ratio [OR]1.52, 95% confidence interval [CI]1.00 to 2.31) and diabetes mellitus (OR 1.59, 95% CI 1.00 to 2.53) were associated with a higher risk, and current smoking was associated with a lower risk (OR [no versus yes]1.64, 95% CI 1.05 to 2.58) of early hospital reinfarction. Distortion of the terminal portion of the QRS complex (OR 1.86, 95% CI 1.20 to 2.87) and absence of abnormal Q waves on admission (OR 1.54, 95% CI 0.98 to 2.43) were associated with increased risk of early reinfarction.
CONCLUSIONS: A simple electrocardiographic sign is a reliable predictor of early reinfarction among patients who receive thrombolytic therapy for acute myocardial infarction.
Beilinson Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah-Tiqua, Israel.
Reocclusion following successful thrombolysis. Emerging concepts.
Thrombolytic therapy, through the restoration of coronary arterial blood flow and myocardial perfusion significantly improves outcome among patients with acute myocardial infarction. Despite its widely appreciated benefits, however, thrombolysis removes only a small portion of existing thrombus at the site of atheromatous plaque rupture. Further, thrombogenic substrate is frequently exposed and may even be generated to the extent that rethrombosis occurs, causing recurrent ischemia, reinfarction, and coronary reocclusion. The mechanisms underlying this important event are discussed.
Division of Cardiovascular Medicine, University of Massachusetts Medical Center, Worcester 01655.