Thrombolytic therapy administered to patients with complete heart block complicating acute myocardial infarction

Abstract

Background Thrombolytic therapy has frequently been withheld from patients with complete heart block lollowing acute myocardial infarction because of significant hypotension and the risk of bleeding should temporary transvenous pacing be required. We assessed the course of patients with acute myocardial infarction complicated initially by complete heart block who received thrombolytic therapy. Methods Patients had clinical and ECG evidence of acute myocardial infarction of less than 6 hours' duration, were in complete heart block when first assessed, and were suitable for thrombolytic therapy. Coronary angiography was performed during the hospital stay, and left ventricular function was assessed by radionuclide ventriculography during convalescence. Results Twenty-one patients were treated: 20 had an inferior myocardial infarction and 17 patients were first seen outside the hospital. Initial systolic blood pressure in 13 of 21 (62%) was 90 mm Hg or less. Thrombolytic therapy commenced at 154 minutes (mean) after the onset of infarction and 12 patients received prehospital thrombolysis. All patients had received intravenous atropine, and in seven 1:1 atrioventricular conduction had occurred. Of the 12 who remained in complete heart block at the time of receiving the thrombolytic agent, 10 reverted to 1:1 atrioventricular conduction and one to chronic atrial fibrillation within 2 hours. Of the two in second-degree atrioventricular block, both reverted to 1:1 atrioventricular conduction within 7 hours. Only four patients required temporary transvenous pacing (in three for complete heart block). Coronary artery patency was 79% (15 of 19), and mean global left ventricular ejection fraction was 57% ± 10%. No hemorrhagic complications occurred; only one patient with anterior myocardial infarction and cardiogenic shock died. Conclusions Thrombolytic therapy administered to patients with myocardial infarction complicated by complete heart block is safe and frequently results in resumption of normal atrioventricular conduction, thus reducing the need for pacing and improving prognosis.