SeminarFailed coronary thrombolysis
Section snippets
Suboptimal results using current thrombolytic regimes
The efficacy of reperfusion can be assessed at several stages during the process of infarction, from restoration of flow at angiography to measures of cellular reperfusion. Recent data suggest that there is significant room for improvement in our current therapeutic approach where thrombolytics are administered with little regard as to whether they have actually produced the desired effect.
Pathogenesis of failed thrombolysis
Thrombolysis fails because of mechanisms operating at the site of the original obstruction and, secondarily, mechanisms downstream in the microvascular network.
Non-invasive detection of failed thrombolysis
The gold standard for the diagnosis of failed reperfusion is a combination of coronary angiography and myocardial contrast imaging but this is impracticable for routine clinical use. The search for a reliable non-invasive marker has generated a lot of data but few clear answers.
Management of failed thrombolysis
There are three options for the management of failed thrombolysis—namely, rescue angioplasty, an intra-aortic balloon pump, or repeat thrombolysis. There are theoretical reasons to support the use of platelet antagonists but the place of these drugs in the context of failed thrombolysis is unproven.
Conclusion
Failure of ST segment resolution after thrombolysis defines a high risk group of patients following a myocardial infarction. A post-thrombolytic ECG is already performed on most patients and probably deserves more attention than it receives. Whilst the ECG is neither very sensitive nor specific for the diagnosis of reperfusion its convenience makes it the diagnostic tool of choice, particularly when taken in conjunction with the presence of continuing pain. We need more trials to define fresh
References (64)
- et al.
Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction
Am J Cardiol
(1996) - et al.
Extent of early ST segment elevation resolution: a simple but strong predictor of outcome in patients with acute myocardial infarction
J Am Coll Cardiol
(1994) - et al.
A simple electrocardiographic predictor of the outcome of patients with acute myocardial infarction treated with a thrombolytic agent: a Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2)-derived analysis
J Am Coll Cardiol
(1994) - et al.
What do we do when thrombolysis fails?: a United Kingdom survey
Int J Cardiol
(1997) - et al.
Zwolle myocardial infarction study group: clinical value of 12-lead electrocardiogram after successful reperfusion therapy for acute myocardial infarction
Lancet
(1997) - et al.
Serial thrombolysis-related changes after thrombolytic therapy with TPA in patients with acute myocardial infarction
Thromb Res
(1990) - et al.
Systemic lytic state is not a predictor of coronary reperfusion in acute myocardial infarction
Int J Cardiol
(1996) - et al.
Usefulness of fibrinogenolytic and procoagulant markers during thrombolytic therapy in predicting clinical outcomes in acute myocardial infarction: thrombolysis in myocardial infarction
Am J Cardiol
(1996) - et al.
Lack of influence of pretreatment antistreptokinase antibody on efficacy in a multicenter patency comparison of intravenous streptokinase and anistreplase in acute myocardial infarction
Am Heart J
(1992) - et al.
Necropsy evaluation in seven patients with evolving acute myocardial infarction treated with thrombolytic therapy
Am J Cardiol
(1984)