Management of failed fibrinolysis (thrombolysis) or threatened reocclusion in acute ST elevation myocardial infarction
- C Michael Gibson, MS, MD
C Michael Gibson, MS, MD
- Professor of Medicine
- Harvard Medical School
- J Brent Muhlestein, MD
J Brent Muhlestein, MD
- Professor of Medicine
- University of Utah
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Coronary reperfusion with fibrinolysis or primary percutaneous coronary intervention (PCI) substantially improves survival in patients with an acute ST elevation (Q wave) myocardial infarction compared to no reperfusion therapy. Primary PCI is preferred for most patients if it can be performed by an experienced operator with less than a 90 minute delay from presentation to the emergency department. However, fibrinolysis remains an important therapeutic modality, due in part to limited availability of primary PCI. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy" and "Primary percutaneous coronary intervention in acute ST elevation myocardial infarction: Determinants of outcome" and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy".)
The principle reason for the preference of PCI to fibrinolysis is the relatively high frequency of failure of fibrinolysis to establish reperfusion (primary failure). In addition, early reocclusion occurs in a significant number of cases. (See 'Primary failure' below and 'Threatened reocclusion' below.)
Primary failure of fibrinolysis is often manifested clinically by persistent or worsening chest pain (particularly if associated with other symptoms such as dyspnea and diaphoresis), persistent or worsening ST segment elevation, and/or hemodynamic instability or heart failure . However, these clinical factors are not sufficiently predictive in all patients. As a result, in the absence of clear indications of reperfusion, the clinician must maintain a high index of suspicion for primary failure . Additionally, in patients who undergo diagnostic angiography after fibrinolysis, both TIMI 0/1 and TIMI 2 flow are associated with increased mortality compared to those with TIMI 3 (normal) flow . (See 'Diagnosis of primary failure' below.)
These observations have provided the rationale for immediate angiography with intent to perform rescue PCI, as well as routine early elective angiography one to two days after fibrinolysis. However, angiography in the first two hours after fibrinolytic therapy, when bleeding risks are higher, is reserved for patients with overt evidence of failed fibrinolysis. The use of routine angiography after fibrinolysis is discussed separately. (See "Acute ST elevation myocardial infarction: Selecting a reperfusion strategy", section on 'Fibrinolysis followed by PCI'.)
If initial fibrinolysis fails to establish reperfusion or if threatened reocclusion occurs, further efforts to achieve reperfusion should be attempted. This topic will review the roles of angiography followed by PCI (or coronary artery bypass graft surgery if indicated) for failed fibrinolysis or threatened reocclusion and of retreatment with fibrinolytic drugs for threatened reocclusion.
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- GENERAL ISSUES
- Importance of restoration of normal flow
- Diagnosis of primary failure
- Diagnosis of threatened reocclusion
- Reinfarction in a new territory
- PRIMARY FAILURE
- Rescue PCI
- - TIMI grade 2 flow
- - Technical issues
- - Summary
- Repeat fibrinolysis
- THREATENED REOCCLUSION
- PCI for threatened reocclusion
- Repeat fibrinolytic therapy
- - Alteplase
- - Streptokinase
- - Other antithrombotic agents
- CABG AFTER FIBRINOLYSIS
- RECOMMENDATIONS OF OTHERS
- SUMMARY AND RECOMMENDATIONS