Optimal utilization of thrombolytic therapy for acute myocardial infarction: concepts and controversies

Department of Medicine, University of Kentucky Medical Center, Lexington 40536-0084.

Timely administration of thrombolytic therapy decreases myocardial infarct size, lessens the incidence of congestive heart failure and improves survival. However, available data suggest that only 10% of patients with acute infarction in the United States receive thrombolytic drugs. Given the benefits of thrombolytic therapy, all patients with myocardial infarction would likely be treated were it not for associated risks. Several groups exist in which the risk/benefit ratio of thrombolytic therapy continues to be controversial, including those with inferior infarction, absence of ST segment elevation or presentation greater than 6 h from symptom onset, elderly patients and those with hypertension. Three recent thrombolytic trials reported a reduction in mortality that was entirely independent of infarct location. Pooled data from trials involving 12,000 patients with inferior infarction have demonstrated a reduction in mortality rate (6.8% versus 8.7%, p less than 0.0001). Furthermore, improvement in regional and global left ventricular function occurred after reperfusion therapy of inferior infarction. Pooled data indicate that patients treated between 6 and 24 h after symptom onset have a lower mortality rate than do those who receive placebo (11.1% versus 13.1%, p less than 0.001). Improved survival occurs after thrombolytic therapy in patients with ST segment elevation or left bundle branch block, but not in those with isolated ST depression or a normal electrocardiogram. Age should not be considered an absolute contraindication because the lifesaving potential of thrombolytic therapy in the elderly may be two to three times that of the overall group of patients with myocardial infarction. Finally, recent studies demonstrated that patients who present with hypotension or hypertension or who have undergone cardiopulmonary resuscitation may also benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

This article has been cited by other articles:

				S. Gravely-Witte, C. Y. Jurgens, H. Tamim, and S. L. Grace Length of delay in seeking medical care by patients with heart failure symptoms and the role of symptom-related factors: a narrative review Eur J Heart Fail, October 1, 2010; 12(10): 1122 - 1129. [Abstract] [Full Text] [PDF]

				M. W Savage and K. S Channer Improving the management of acute myocardial infarction BMJ, November 23, 2002; 325(7374): 1185 - 1186. [Full Text] [PDF]

				F. Gao, T. A. Christopher, B. L. Lopez, E. Friedman, G. Cai, and X. L. Ma Mechanism of decreased adenosine protection in reperfusion injury of aging rats Am J Physiol Heart Circ Physiol, July 1, 2000; 279(1): H329 - H338. [Abstract] [Full Text] [PDF]

				R. J. Goldberg, J. H. Gurwitz, and J. M. Gore Duration of, and Temporal Trends (1994-1997) in, Prehospital Delay in Patients With Acute Myocardial Infarction: The Second National Registry of Myocardial Infarction Arch Intern Med, October 11, 1999; 159(18): 2141 - 2147. [Abstract] [Full Text] [PDF]

				M. Lescoe-Long and M. J. Long Defining the Utility of Clinically Acceptable Variations in Evidence-based Practice Guidelines for Evaluation of Quality Improvement Activities Eval Health Prof, September 1, 1999; 22(3): 298 - 324. [Abstract] [PDF]

				M. Tani, Y. Honma, M. Takayama, H. Hasegawa, K. Shinmura, Y. Ebihara, and K. Tamaki Loss of protection by hypoxic preconditioning in aging Fischer 344 rat hearts related to myocardial glycogen content and Na+ imbalance Cardiovasc Res, March 1, 1999; 41(3): 594 - 602. [Abstract] [Full Text] [PDF]

				U. Zeymer, K.-L. Neuhaus, K. Wegscheider, U. Tebbe, P. Molhoek, R. Schroder, and for the HIT-4 Trial Group Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement J. Am. Coll. Cardiol., October 1, 1998; 32(4): 876 - 881. [Abstract] [Full Text] [PDF]

				N. R. Harris and K. W. Langlois Age-dependent responses of the mesenteric vasculature to ischemia-reperfusion Am J Physiol Heart Circ Physiol, May 1, 1998; 274(5): H1509 - H1515. [Abstract] [Full Text] [PDF]

				A. Melgarejo-Moreno, J. Galcera-Tomas, A. Garcia-Alberola, M. Valdes-Chavarri, F. J. Castillo-Soria, E. Mira-Sanchez, J. Gil-Sanchez, and J. Allegue-Gallego Incidence, Clinical Characteristics, and Prognostic Significance of Right Bundle-Branch Block in Acute Myocardial Infarction : A Study in the Thrombolytic Era Circulation, August 19, 1997; 96(4): 1139 - 1144. [Abstract] [Full Text]

				M. Tani, Y. Suganuma, H. Hasegawa, K. Shinmura, Y. Hayashi, X.-d. Guo, and Y. Nakamura Changes in Ischemic Tolerance and Effects of Ischemic Preconditioning in Middle-aged Rat Hearts Circulation, June 3, 1997; 95(11): 2559 - 2566. [Abstract] [Full Text]

				S. Gottlieb, U. Goldbourt, V. Boyko, G. Barbash, L. Mandelzweig, H. Reicher-Reiss, S. Stern, and S. Behar Improved Outcome of Elderly Patients (>=75 Years of Age) With Acute Myocardial Infarction From 1981-1983 to 1992-1994 in Israel Circulation, January 21, 1997; 95(2): 342 - 350. [Abstract] [Full Text]

				J. M. Gore, C. B. Granger, M. L. Simoons, M. A. Sloan, W. D. Weaver, H. D. White, G. I. Barbash, F. Van de Werf, P. E. Aylward, E. J. Topol, et al. Stroke After Thrombolysis : Mortality and Functional Outcomes in the GUSTO-I Trial Circulation, November 15, 1995; 92(10): 2811 - 2818. [Abstract] [Full Text]

				M. Verstraete Thrombolytic treatment BMJ, September 2, 1995; 311(7005): 582 - 583. [Full Text]

				E. T. Hasche, C. Fernandes, S. B. Freedman, and R. W. Jeremy Relation Between Ischemia Time, Infarct Size, and Left Ventricular Function in Humans Circulation, August 15, 1995; 92(4): 710 - 719. [Abstract] [Full Text]

				A. M. Fendrick, P. M. Ridker, and B. S. Bloom Improved Health Benefits of Increased Use of Thrombolytic Therapy Arch Intern Med, July 25, 1994; 154(14): 1605 - 1609. [Abstract] [PDF]

				A. S. Midgette, J. B. Wong, J. R. Beshansky, A. Porath, C. Fleming, and S. G. Pauker Cost - Effectiueness of Streptokinase for Acute Myocardial Infarction: A Combined Meta-analysis and Decision Analysis of the Effects of Infarct Location and of Likelihood of Infarction Med Decis Making, April 1, 1994; 14(2): 108 - 117. [Abstract] [PDF]

				C F M Weston, W J Penny, and D G Julian Guidelines for the early management of patients with myocardial infarction BMJ, March 19, 1994; 308(6931): 767 - 771. [Full Text]

				C. L. Pashos, J. P. Newhouse, and B. J. McNeil Temporal Changes in the Care and Outcomes of Elderly Patients With Acute Myocardial Infarction, 1987 Through 1990 JAMA, October 20, 1993; 270(15): 1832 - 1836. [Abstract] [PDF]

				A. J. Doorey, E. L. Michelson, and E. J. Topol Thrombolytic Therapy of Acute Myocardial Infarction: Keeping the Unfulfilled Promises JAMA, December 2, 1992; 268(21): 3108 - 3114. [Abstract] [PDF]

				D. R. Cragg, H. Z. Friedman, J. D. Bonema, I. A. Jaiyesimi, R. G. Ramos, G. C. Timmis, W. W. O'Neill, and T. L. Schreiber Outcome of Patients with Acute Myocardial Infarction Who Are Ineligible for Thrombolytic Therapy Ann Intern Med, August 1, 1991; 115(3): 173 - 177. [Abstract] [PDF]

				M. A. Pfeffer, L. A. Moye, E. Braunwald, L. Basta, E. J. Brown Jr, T. E. Cuddy, G. R. Dagenais, G. C. Flaker, E. M. Geltman, B. J. Gersh, et al. Selection Bias in the Use of Thrombolytic Therapy in Acute Myocardial Infarction JAMA, July 24, 1991; 266(4): 528 - 532. [Abstract] [PDF]

				J. H. Gurwitz, R. J. Goldberg, and J. M. Gore Coronary Thrombolysis for the Elderly? JAMA, April 3, 1991; 265(13): 1720 - 1723. [Abstract] [PDF]

				J. W. Kennedy Expanding the Use of Thrombolytic Therapy for Acute Myocardial Infarction Ann Intern Med, December 15, 1990; 113(12): 907 - 908. [Abstract] [PDF]

				R. C. Schlant Thrombolytic Therapy of Patients With Acute Myocardial Infarction JAMA, August 8, 1990; 264(6): 738 - 739. [Abstract] [PDF]