Thrombolytic Therapy: A Review of Its Use in Acute Myocardial Infarction

1998 ◽  
Vol 32 (7-8) ◽  
pp. 769-784 ◽  
Author(s):  
Eric D Bizjak ◽  
Vincent F Mauro
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Clinical Trials ◽  
Thrombolytic Therapy ◽  
Thrombolytic Agent ◽  
Clinical Investigation ◽  
Survival Rates ◽  
Thrombolytic Agents ◽  
Significant Difference ◽  
To Receive

OBJECTIVE: To review the literature on the use of thrombolytic agents in the pharmacotherapeutic management of acute myocardial infarction (AMI). DATA SOURCE: English-language clinical trials, reviews, and editorials derived from MEDLINE (January 1966–September 1997) and/or cross-referencing of selected articles. STUDY SELECTION: Articles that were selected best represent the clinical trials researching the role for thrombolytics in the therapy of AMI to improve morbidity and mortality. DATA SYNTHESIS: AMI is one of the leading causes of mortality in the US. Following supportive data that the most common cause of an AMI is an intracoronary thrombus, clinical investigation has demonstrated that intravenous thrombolytic agents improve survival rates in patients who experience an AMI. Several clinical trials have been conducted to determine whether one thrombolytic agent is superior to others with respect to improving mortality. At present, only the first Global Use of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) trial has reported any statistically significant difference in mortality rate. In this trial, “front-loaded” alteplase induced a statistically significant (p < 0.001) 1% absolute reduction in 30-day and 1-year mortality compared with streptokinase. This has led to alteplase being the preferred thrombolytic at many US institutions. However, the results of GUSTO-I have been questioned by some on the basis of either study design or clinical significance. CONCLUSIONS: Thrombolytic agents have secured a place in the treatment of AMI due to their well-proven reduction in mortality rates. In general, comparative trials have demonstrated minimal differences in efficacy among these agents. Probably just as important as choosing which thrombolytic agent to use is ensuring that a patient experiencing an AMI is administered thrombolytic therapy unless a contraindication to receive such therapy exists in the patient and/or the patient is a candidate to receive an emergent intracoronary procedure. Trials also indicate that the sooner thrombolytics can be administered, the greater the benefit to the patient.

Thrombolytic Therapy in Acute Myocardial Infarction: A Review with Current Recommendations

1993 ◽  
Vol 1 (4) ◽  
pp. 145-151 ◽  
Author(s):  
Roger L. White
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Thrombolytic Therapy ◽  
Percutaneous Transluminal Coronary Angioplasty ◽  
Therapeutic Modality ◽  
Current Therapy ◽  
Advantages And Disadvantages ◽  
Thrombolytic Agents ◽  
Ideal Agent ◽  
Transluminal Coronary Angioplasty

Thrombolytic therapy has clearly become an established therapeutic modality to treat patients with acute myocardial infarction. Since there is no ideal agent at this time, we must evaluate the advantages and disadvantages of current therapy based on major clinical studies. Thrombolysis is the body's natural response to dissolving clots after they have served their purpose. Thrombolytic agents accelerate fibrinolysis by overwhelming the system. There are 4 thrombolytic agents currently available: streptokinase urokinase, anistreplase (APSAC), and rt-PA. Tissue plasminogen activator is a naturally occurring protein that can be created with genetic recombinant technology (rt-PA). It establishes higher patency rates (70–90%) than the other available thrombolytic agents. Recently published results of accelerated rt-PA infusion during acute myocardial infarction demonstrate that the infarct-related artery seems to open more quickly and provide greater blood flow. The use of intravenous heparin as adjunctive therapy along with aspirin seems to maintain patency at comparable levels to streptokinase. Not only is mortality reduced in the accelerated rt-PA group, but complications from myocardial infarction such as arrhythmia and heart failure are significantly reduced. rt-PA remains the drug of choice in the hypotensive patient and, because of potential allergy, in patients with previous exposure to streptokinase. Percutaneous transluminal coronary angioplasty is frequently needed to improve long-term patency and reduce ischemic episodes. Recent studies show that it may provide some advantage over thrombolytic therapy, because the artery can be opened faster, with higher flow rates.

scholarly journals Relationship between QT dispersion and reperfusion in the acute myocardial infarction

2003 ◽  
Vol 60 (1) ◽  
pp. 19-27 ◽  
Author(s):  
Branko Gligic ◽  
Radoslav Romanovic ◽  
Goran Radjen ◽  
Dragan Tavciovski ◽  
Predrag Djuran ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Thrombolytic Therapy ◽  
Qt Dispersion ◽  
The Other ◽  
Significant Difference ◽  
The Difference

Background. QT dispersion (QTd) represents the parameter of the expanded heterogeneity of myocard of ventricles. The aim of this study was to examine the dynamics of changes of QTd during the first 5 days of the acute myocardial infarction (AMI) in dependence to noninvasively estimated success of thrombolytic therapy. Methods. Thirty six patients with AMI were included in the study. All patients were treated with alteplaze according to rapid protocol. QTd (QTc max-QTc min) was measured immediately after the reception (0 min), after the thrombolytic therapy (90 min) and since the 2nd to the 5th day of the hospitalization. Reperfusion was estimated on the basis of electrocardiographic and biohumoral parameters. Results. In the group of 36 patients, 22 male and 11 female, both parameters of the reperfusion were not compatible in 3 patients. The other 23 patients had the reperfusion, while 10 patients did not have it. At the reception there was no significant difference of QTd between the group with reperfusion (79?34 ms) and the group without reperfusion (65?19 ms). After receiving alteplase, the average QTd in the group with reperfusion was 67?31 ms, which was not shorter in relation to the group without reperfusion (70?23 ms). Since the 2nd day of AMI, significantly smaller QTd in patients with reperfusion was not registered compared with the patients without the reperfusion (54?17 vs.73?20 ms), whereas since the 3rd day the difference became significant (46?16 vs. 87?24 ms). On the 4th day it was 43?12 vs. 78?21 ms, and on the 5th day it was 38?11 vs. 62?23 ms. On the 1st day significant difference of QTd between the groups with and without reperfusion was not registered in the group of patients with anterior AMI (0 min: 97?47 vs. 72?16; 90 min 68?47 vs. 72?20) whereas on the 2nd day it became statistically significant (51?15 vs. 74?20 on the 2nd day, 51?20 vs. 88?24 on the 3rd day, 46?10 vs. 81?19 on the 4th day and 40?8 vs. 69?22 ms on the 5th day. In the group of patients with inferolateral AMI, only on the 3rd day significant difference of QTd between the group with and the group without reperfusion was registered (43?14 vs. 69?29 ms), while in all other measuring it was not registered (0 min: 69?22 vs. 42?9; 90 min: 67?20 vs. 67?41; 55?19 vs. 60?25 on the 2nd day; 41?14 vs. 51?6 on the 4th day and 51?12 vs. 37?8 ms on the 5th day). Conclusion. Qt dispersion was of significantly shorter duration in patients with the successfully performed reperfusion in relation to the patients without the reperfusion. In patients with the anterior AMI, QTd was significantly different in patients with in relation to the patients without the reperfusion in distinction with the patients with inferolateral AMI.

Thrombolytics

1992 ◽  
Vol 3 (2) ◽  
pp. 423-434
Author(s):  
C. Lynne Ostrow
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Thrombolytic Therapy ◽  
The United States ◽  
Similar Efficacy ◽  
Left Ventricular ◽  
Bleeding Complications ◽  
Thrombolytic Agents ◽  
Suspected Acute Myocardial Infarction ◽  
Careful Assessment

Thrombolytic therapy is the most recent advance in the treatment of acute myocardial infarction. Several research trials have been conducted worldwide in the last decade that have established that thrombolytic therapy has reduced mortality 50%, reduces the size of the infarction, improves left ventricular function, and reduces the incidence and severity of congestive heart failure. The three most commonly used thrombolytic agents at this time arc streptokinase, tissue plasminogen activator, and anisoylated plasminogen-streptokinase activator complex. All three agents can be administered through a peripheral intravenous. Recent research results have reported similar efficacy on 5-week mortality of all three agents. Careful assessment of prospective patients is essential since bleeding complications arc the most serious side effect of this therapy. Nursing care of a patient undergoing thrombolytic therapy includes careful assessment of the patient for contraindications in the patient’s medical history, assessment of potential allergic and bleeding complications, and evaluation of the reperfusion markers. Patients are subsequently treated with anticoagulants, aspirin, or dipyridamole. It appears that thrombolytic therapy will become increasingly available to all patients with a diagnosis of suspected acute myocardial infarction. At present, treatment with thrombolytic agents is less available in the United States compared to Europe

Effects of EMS Transportation on Time to Diagnosis and Treatment of Acute Myocardial Infarction in the Emergency Department

1994 ◽  
Vol 9 (3) ◽  
pp. 160-163 ◽  
Author(s):  
Robert Swor ◽  
William Anderson ◽  
Raymond Jackson ◽  
Andrew Wilson
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Emergency Department ◽  
Thrombolytic Therapy ◽  
Emergency Medical Services ◽  
Diagnosis And Treatment ◽  
Medical Services ◽  
Thrombolytic Agents ◽  
Emergency Medical ◽  
Time To Diagnosis

AbstractIntroduction:Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography.Purpose:Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)?Design:Retrospective, case-control studyPopulation:The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992.Methods:Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using “Student's” t-test and Yates corrected Chi-square (X2).Results:Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 ±9.1 min. versus 20.8 ±25.3 win.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 ±31.5 min. versus 78.0 ±63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups.Conclusion:Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments.

Comparative Study Among Three Different Models for Induction of Acute Myocardial Infarction in Rats

2021 ◽  
Vol 23 (Supplement_D) ◽  
Author(s):  
Ahmed Elshaer ◽  
Ahmed Elsaeed Sobhy ◽  
Mohammed Mohsen Elalfy ◽  
Alyaa Mohammed Ghoneem ◽  
Amira Kamal Elhawary ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Survival Rates ◽  
Inflammatory Cells ◽  
Moderate Degree ◽  
Drug Induced ◽  
Surgical Methods ◽  
Significant Difference ◽  
Doxorubicin Group ◽  
Surgical Group

Abstract Aim Laboratory study of Acute Myocardial Infarction (AMI) has become of great importance for further investigations about prevention, diagnosis and treatment of the increasing number of patients worldwide. In this study, we are seeking the best experimental AMI model by comparing three methods by which AMI can be experimentally induced in rats to illuminate the most reliable model to use in further studies. Methods and Results Experimentally, AMI can be produced by either drug induced methods or surgical methods. Here, we compared two drug induced methods (isoproterenol and doxorubicin) and a surgical model to find out which method is best simulating human AMI. 50 male sprague dowley rats were put into 5 groups, each contained 10 rats as follows. Surgical group in which the proximal left anterior descending coronary artery (LADCA) was dissected and ligated. Isoproterenol group in which Isoproterenol (300 gm/kg) was injected in ten rats subcutaneously on 2 doses a day apart. Doxorubicin group in which doxorubicin (2.5 mg/kg) was given intraperitonially every other day for total cumulative dose of 15 mg/kg. Control group where rats received only 2 ml of saline intraperitonially or subcutaneously. Sham group where rats underwent a similar surgery, but without LADAC ligation. After the induction, the biochemical parameter (serum Troponin I) at 12, 24, 36, 48 and 72 hours and histopathological changes (using hematoxylin, eosin and Mallory's trichrome stains) in all groups on days 1, 7, 14 and 21 were recorded. Data were statically analyzed, and Troponin curves were designed for each group to be correlated with that of AMI in human. After 7 days, histopathological studies of the surgical group exhibited wide areas of focal fibrosis at the apex and scattered mononuclear inflammatory cells infiltration. While the isoproterenol group showed moderate degree of inflammation with multifocal areas of fibrosis and scattered mononuclear inflammatory cells. However, the doxorubicin group showed more or less normal histology of cardiomyocytes. Biochemical studies reflected a significant difference in serum Troponin levels and peak timing among the groups. The surgical and isoproterenol groups Troponin peaked around 24 hours after the intervention, with higher levels in the surgical group. However, the doxorubicin group showed lower peaks around 36 hours post intervention. Correlations with human AMI histopathology and biochemical markers show more mimicking changes in the surgical group when compared to the other models, followed by the isoproterenol group and least similar in the doxorubicin- induced group. However, the survival rate of rats in the isoproterenol group was superior, followed by the surgical group and the doxorubicin group showed the lowest survival rates. Conclusions Surgical induction of AMI in rats achieves the high similarity to AMI in human but the low survival rates jeopardize the reliability of the model. However, isoproterenol shows sufficient levels of mimicking and higher survival indicating the highest reliability in simulation. Doxorubicin based models are the least reliable.

scholarly journals Comparative assessment of the indices of the left ventricle post-infarction remodelling of the left ventricle and its dependence on the strategy of acute myocardial infarction management

2013 ◽  
Vol 20 (3) ◽  
pp. 75-78
Author(s):  
D. M. Zhidovich ◽  
L. V. Shcheglova
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Left Ventricle ◽  
Thrombolytic Therapy ◽  
Comparative Assessment ◽  
Dynamic Monitoring ◽  
Sphericity Index ◽  
Significant Difference ◽  
Group Ii ◽  
Left Ventricle Remodelling

Comparative assessment of the indices of post-infarction remodelling of the left ventricle was carried out in the patients with myocardium reperfusion (thrombolytic therapy) and without reperfusion. ECG was performed for all patients on admission to the hospital and then 3 and 6 months later. The results obtained demonstrated that after the acute period of myocardial infarction there was no difference between the parameters under control. At the same time the results of dynamic monitoring confirmed that later on the patients felt some peculiarities during the left ventricle remodelling process. Three months later there was an increase of the left ventricle sphericity index during the systoly in the patients of group II. Six months later the patients of group II showed significant difference in five indices of remodelling versus the patients on thrombolitic therapy.

scholarly journals THROMBOLYTIC THERAPY FOR ACUTE MYOCARDIAL INFARCTION AT THE PREHOSPITAL STAGE: CLINICAL GUIDELINES AND REAL PRACTICE

2021 ◽  
Vol 21 (4) ◽  
pp. 70-76
Author(s):  
V. I. Shalnev
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Clinical Trials ◽  
Thrombolytic Therapy ◽  
Clinical Guidelines ◽  
Modern Approach ◽  
Real Practice

The article highlights the modern approach to the thrombolytic therapy of acute myocardial infarction at the prehospital stage. The results of most significant clinical trials and registers in this area are discussed. Recent international and Russian clinical guidelines on thrombolytic therapy and pharmacoinvasive strategy in the treatment of acute myocardial infarction are also highlighted.

Alteplase: A Tissue Plasminogen Activator for Acute Myocardial Infarction

1988 ◽  
Vol 22 (1) ◽  
pp. 6-14 ◽  
Author(s):  
Frederick P. Zeller ◽  
Sarah A. Spinier
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Coronary Artery ◽  
Thrombolytic Therapy ◽  
Continuous Infusion ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Thrombolytic Agent ◽  
Interindividual Variation ◽  
Tissue Plasminogen

Alteplase is a human tissue plasminogen activator (t-PA) produced by recombinant DNA technology. It is a relatively fibrin-specific thrombolytic agent, used primarily to lyse coronary artery clots. It has proven effective in the treatment of acute myocardial infarction (AMI). Despite continuous reevaluation of pharmacokinetic parameters for t-PA, limited distribution and clearance data mandate administration of t-PA as a continuous infusion. Tissue plasminogen activator is eliminated primarily by hepatic metabolism with an elimination half-life of five to ten minutes. Plasma levels show great interindividual variation but correlate with infusion rate and decrease in fibrinogen level. The current recommended dose is 100 mg administered as a 10-mg iv bolus followed by a continuous infusion over three hours. However, 40-150 mg has been used in clinical trials. The compound has undergone extensive testing, comparing it with placebo and streptokinase (SK), and combining it with angioplasty and coronary artery bypass surgery. Tissue plasminogen activator is effective at opening clotted coronary arteries in approximately 70 percent of AMI patients and has been shown to be approximately twice as effective as SK in one U.S. trial. Although there is considerable evidence of efficacy with t-PA, data evaluating the influence of t-PA on mortality are limited, but suggest a reduction to five percent. Currently, thrombolytic therapy is indicated for patients experiencing a transmural AMI with onset of symptoms within three to six hours before presenting to the emergency room. Active internal bleeding or conditions predisposing to serious hemorrhage are contraindications to thrombolytic therapy. In general, there are few side effects with t-PA, the most common being bleeding localized to the catheterization site. Alteplase is approved for administration in AMI. From data generated thus far, we feel this new drug will be a valuable addition to the hospital formulary and will replace streptokinase as the intravenous thrombolytic agent of choice for treatment of AMI.

scholarly journals Delay factors on the administration of thrombolytic therapy in patients diagnosed with acute myocardial infarction in a general hospital

2008 ◽  
Vol 16 (1) ◽  
pp. 52-56 ◽  
Author(s):  
Luis Antônio Muller ◽  
Eneida Rejane Rabelo ◽  
Maria Antonieta Moraes ◽  
Karina Azzolin
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Thrombolytic Therapy ◽  
Medical Records ◽  
Medical Service ◽  
Time Of Arrival ◽  
Thrombolytic Treatment ◽  
Study Results ◽  
Significant Difference ◽  
Long Time

OBJECTIVE: To identify factors that delay the onset of thrombolysis in patients with acute myocardial infarction (AMI). METHODS: A cohort study was carried out with 146 patients, each diagnosed with AMI and subjected to thrombolytic therapy. The data was extracted from medical records between January 2002 and December 2004. RESULTS: The average age of the studied population was 57.5 ± 9 years, 64.4% were male. The average time between the onset of pain and arrival at the hospital was 254.7 ± 126.6 minutes, 28.1% used an ambulance for the trip to the hospital, the door-to-electrocardiogram time averaged 19.4 ± 7.3 minutes and the door-to-needle time was 51.1 ± 14.9 minutes. There was no significant difference between the time of arrival to the hospital and the method of transportation used (P= 0.81), and those seen by cardiologists and during the nightshift had a reduction in the door-to-needle time, respectively (P=0.014) and (P=0.034). CONCLUSIONS: Study results show that the delay in the search for medical service, and the long time taken from door-to-electrocardiogram and to reach the AMI diagnosis were the factors involved in the delay of thrombolytic treatment.

Sign in / Sign up

Export Citation Format

Share Document