Limitations of thrombolytic therapy for acute myocardial infarction complicated by congestive heart failure and cardiogenic shock

Department of Internal Medicine, University of Michigan, Ann Arbor.

As many as one quarter of patients treated with thrombolytic therapy present with congestive heart failure or cardiogenic shock. Although thrombolytic therapy has been shown to limit infarct size, preserve left ventricular ejection fraction and decrease mortality in most subgroups of patients, no apparent benefit has been demonstrated in patients with clinical left ventricular dysfunction. The lack of correlation between ejection fraction and other measurements of left ventricular dysfunction such as exercise time, cardiac output, filling pressures, activation of the neurohumoral system and regional perfusion bed abnormalities may partly explain this paradox. Alternatively, lower perfusion rates, higher reocclusion rates, associated mechanical complications or completed infarction may explain these findings. Preliminary data indicate that emergency coronary angioplasty or bypass graft surgery improves survival in selected patients with cardiogenic shock. Because these findings suggest that restoration of infarct artery patency is especially important in patients with clinical left ventricular dysfunction, additional studies are needed in these patients to investigate the potential benefit that new thrombolytic strategies, inotropic or vasodilator agents or intraaortic balloon counterpulsation might offer by augmenting coronary blood flow and improving reperfusion rates. Currently, acute mechanical revascularization should be considered for patients who present with congestive heart failure associated with hypotension or tachycardia and for patients with cardiogenic shock.

This article has been cited by other articles:

				I. George and M. C. Oz Myocardial Revascularization after Acute Myocardial Infarction Card. Surg. Adult, January 1, 2008; 3(2008): 669 - 696. [Full Text]

				H. C. Wijeysundera, R. Vijayaraghavan, B. K. Nallamothu, J. M. Foody, H. M. Krumholz, C. O. Phillips, A. Kashani, J. J. You, J. V. Tu, and D. T. Ko Rescue Angioplasty or Repeat Fibrinolysis After Failed Fibrinolytic Therapy for ST-Segment Myocardial Infarction: A Meta-Analysis of Randomized Trials J. Am. Coll. Cardiol., January 30, 2007; 49(4): 422 - 430. [Abstract] [Full Text] [PDF]

				C. S. Duvernoy and E. R. Bates Management of Cardiogenic Shock Attributable to Acute Myocardial Infarction in the Reperfusion Era J Intensive Care Med, July 1, 2005; 20(4): 188 - 198. [Abstract] [PDF]

				J. G. Webb, A. M. Lowe, T. A. Sanborn, H. D. White, L. A. Sleeper, R. G. Carere, C. E. Buller, S. C. Wong, J. Boland, V. Dzavik, et al. Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1380 - 1386. [Abstract] [Full Text] [PDF]

				D. C. Lee, W. Ting, and M. C. Oz Myocardial Revascularization after Acute Myocardial Infarction Card. Surg. Adult, January 1, 2003; 2(2003): 639 - 658. [Full Text]

				A. H. Wu, L. Parsons, N. R. Every, and E. R. Bates Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: A report from the Second National Registry of Myocardial Infarction (NRMI-2) J. Am. Coll. Cardiol., October 16, 2002; 40(8): 1389 - 1394. [Abstract] [Full Text] [PDF]

				J. G. Webb, L. A. Sleeper, C. E. Buller, J. Boland, A. Palazzo, E. Buller, H. D. White, J. S. Hochman, and for the SHOCK Investigators Implications of the timing of onset of cardiogenic shock after acute myocardial infarction: a report from the SHOCK Trial Registry J. Am. Coll. Cardiol., September 1, 2000; 36(3_Suppl_A): 1084 - 1090. [Abstract] [Full Text] [PDF]

				D. Hasdai, R. M. Califf, T. D. Thompson, J. S. Hochman, E. M. Ohman, M. Pfisterer, E. R. Bates, A. Vahanian, P. W. Armstrong, D. A. Criger, et al. Predictors of cardiogenic shock after thrombolytic therapy for acute myocardial infarction J. Am. Coll. Cardiol., January 1, 2000; 35(1): 136 - 143. [Abstract] [Full Text] [PDF]

				R. Collins, R. Peto, C. Baigent, and P. Sleight Aspirin, Heparin, and Fibrinolytic Therapy in Suspected Acute Myocardial Infarction N. Engl. J. Med., March 20, 1997; 336(12): 847 - 860. [Full Text] [PDF]

				J. Kellett and J. Clarke Comparison of "Accelerated" Tissue Plasminogen Activator with Streptokinase for Treatment of Suspected Myocardial Infarction Med Decis Making, October 1, 1995; 15(4): 297 - 310. [Abstract] [PDF]