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Identification and Management of Patients with Failed Thrombolysis after Acute Myocardial Infarction

Lorne E. Goldman, MD; and Mark J. Eisenberg, MD, MPH
[+] Article and Author Information

From Jewish General Hospital and McGill University, Montreal, Quebec, Canada.


Grant Support: Dr. Eisenberg is a Research Scholar of the Heart and Stroke Foundation of Canada.

Requests for Single Reprints: Mark J. Eisenberg, MD, MPH, Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Côte-Ste-Catherine Road, Suite A-118, Montreal, Quebec H3T 1E2, Canada; e-mail, marke@epid.jgh.mcgill.ca.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Dr. Goldman: Division of Cardiology, Jewish General Hospital/McGill University, 3755 Côte-Ste-Catherine Road, Room E-206, Montreal, Quebec H3T 1E2, Canada.

Dr. Eisenberg: Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Côte-Ste-Catherine Road, Suite A-118, Montreal, Quebec H3T 1E2, Canada.


Ann Intern Med. 2000;132(7):556-565. doi:10.7326/0003-4819-132-7-200004040-00008
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Clinical outcome after thrombolytic therapy for acute myocardial infarction is strongly associated with patency of the infarct-related artery (14). Unfortunately, thrombolytic therapy fails to achieve patency of the infarct-related artery in 15% to 50% of patients (1, 57). Percutaneous transluminal coronary angioplasty (PTCA) of persistently occluded infarct-related arteries (rescue PTCA) may improve outcome in patients with failed thrombolysis after acute myocardial infarction (8). This article reviews the current literature on the identification and management of patients with failed thrombolysis. Particular attention is paid to the noninvasive identification of reperfusion as well as the evidence for and against the use of rescue PTCA. Potential advances in the management of patients with failed thrombolysis are also reviewed.

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Figure.
Approach to the patient with failed thrombolysis.MIPTCA(30)(30)(59, 60)(27, 30)TIMICABG(23)(57)

Symptoms and electrocardiographic signs are poorly diagnostic of coronary artery patency and lead to an underestimate of the proportion of patients whose vessels have reperfused. Biochemical markers may increase the ability to identify failed thrombolysis but are not yet ready for routine clinical use. Patients with acute myocardial infarction ( ) and suspected failed thrombolysis should be considered for immediate angiography and possible rescue percutaneous transluminal coronary angioplasty ( ). Factors to be considered include hemodynamic instability, presence of severe congestive heart failure, size and location of the myocardial infarction, and timing of presentation. Only two randomized clinical trials have directly examined the use of rescue PTCA. The following footnotes indicate the evidence in support of aspects of the figure. *Data from the Randomized Evaluation of Salvage Angioplasty with Combined Utilization of Endpoints (RESCUE) trial suggest that patients with anterior myocardial infarction and failed thrombolysis may benefit from rescue PTCA . †Patients in the RESCUE trial were randomly assigned within 8 hours of chest pain onset . ‡If access to a cardiac catheterization laboratory is not possible, repeated thrombolysis should be considered . §To date, two randomized trials suggest clinical benefit of PTCA of infarct-related arteries with Thrombolysis in Myocardial Infarction ( ) 0 or 1 flow. ‖Few data are available concerning the possible benefits of immediate PTCA of infarct-related arteries with TIMI 2 flow. The ongoing RESCUE II trial will help answer this question. ¶The Thrombolysis and Angioplasty in Myocardial Infarction 1 trial suggests that clinical outcomes do not improve with immediate compared with delayed PTCA after successful thrombolysis. There was a trend toward a higher rate of emergency coronary artery bypass grafting ( ) precipitated by acute vessel occlusion in patients undergoing immediate PTCA . **For patients with acute transmural myocardial infarction, DeWood and colleagues found that early emergency CABG (within 6 hours of symptom onset) improved short- and long-term mortality compared with late surgery (performed more than 6 hours after symptom onset). However, this study was performed in the prethrombolytic era, and the additional bleeding risks posed by full-dose thrombolytics suggest that this therapy should be reserved for selected groups of high-risk patients. GP = glycoprotein; IABP = intra-aortic balloon counterpulsation.

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