Fibrinolysis Group Research Articles

Coronary artery bypass grafting within the first year after treatment of large acute myocardial infarctions with angioplasty or fibrinolysis

Objectives. To calculate the incidence and analyse and outcome after coronary artery bypass grafting (CABG) within the first year after randomisation of 1 572 patients with acute myocardial infarctions with ST-segment elevation (STEMI) to either percutaneous coronary intervention (PCI) or fibrinolysis. Design. The study includes 131 patients: 108 male and 23 female with a mean age 62 years. Results. The total 30-day mortality after CABG was 4.6% (7.5% in the PCI group and 2.6% in the fibrinolysis group). The 30-day mortality was 9.8% after CABG within the first 30-days and 1.3% after CABG within 31–365 days. The patients who were operated early had a reduced EF to 43% as compared to 50% in patients who were not operated or patients having CABG after 30-days (p = 0.002). Conclusion. CABG was performed within the first year after STEMI in 10% of patients randomised to fibrinolysis and in 6.7% of patients randomised to PCI. Patients having CABG within the first 30-days after treatment of STEMI had an increased mortality of 9.8%.

Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial

The CAPTIM study randomized patients managed within 6 h of acute ST-segment elevation myocardial infarction to primary angioplasty or prehospital fibrinolysis (rt-PA), with immediate transfer to a centre with interventional facilities. It found a similar incidence of the primary endpoint of death, recurrent MI, or stroke at 30 days with both strategies. We report here the outcome in the diabetic subgroup. The relationship of diabetic status (diabetics, n=103, non-diabetics, n=731) and treatment strategy with the occurrence of the primary endpoint and of death was analysed. Compared with non-diabetics, diabetics had a higher baseline risk profile, a higher rate of the primary endpoint (14.6 vs. 5.6%; P=0.002), and a high rate of mortality (8.7 vs. 3.1%; P=0.01) at 30 days. The incidence of the primary endpoint tended to be higher in diabetics randomized to prehospital fibrinolysis compared with those randomized to primary angioplasty [21.7 vs. 8.8% (10/46 vs. 5/57); RR: 2.47 (0.91-6.74); P=0.09]. This difference was driven by the higher mortality in the fibrinolysis group [13.0 vs. 5.3% (6/46 vs. 3/57); RR: 2.47 (0.7-9.4); P=0.29]. For non-diabetics, no such trend was observed. Compared with non-diabetics, diabetics had a much higher rate of rescue angioplasty (41.4 vs. 23.5%; P=0.01) and a higher mortality after rescue angioplasty [17.4 vs. 0% (4/23 vs. 0/90); P=0.001]. These results suggest that diabetic patients presenting within 6 h of an acute myocardial infarction may derive particular benefit from a strategy of primary angioplasty. However, the small number of diabetic patients in this subgroup analysis does not allow a final conclusion and a specifically designed study is warranted.

The prognostic value of pre-discharge exercise testing after myocardial infarction treated with either primary PCI or fibrinolysis: a DANAMI-2 sub-study

To evaluate the prognostic importance of pre-discharge maximal symptom-limited exercise testing (ET) following acute myocardial infarction (AMI) in the era of aggressive reperfusion. In the DANAMI-2 (the second DANish trial in AMI) study, patients with ST-elevation AMI (STEMI) were randomized to primary angioplasty (PCI) or fibrinolysis. Of 1462 patients discharged alive, 1164 (79.6%) performed an ET. Primary endpoint was a composite of death and re-infarction. Patients randomized to fibrinolysis developed ST-depression to a greater extent than patients randomized to primary PCI (21.7 vs. 15.3%, P=0.007). Multivariable predictors of death and re-infarction included age, gender, diabetes, previous stroke, anterior AMI, randomization to fibrinolysis, and exercise capacity [risk ratio (RR) 0.82 (0.72-0.93); P<0.001]. ST-depression was predictive of the clinical outcome [RR 1.57 (1.00-2.48); P<0.05] in multivariable analysis, but stratified according to treatment groups there was a significant association between ST-depression and outcome in the fibrinolysis group [RR 1.95 (1.11-3.44); P<0.05], but not in the primary PCI group [RR 1.06 (0.47-2.36); P=ns]. However, the P-value for interaction was 0.15. Exercise testing after contemporary reperfusion therapies for STEMI confers important prognostic information. Exercise capacity is a strong prognostic predictor of death and re-infarction irrespective of treatment strategy, whereas the prognostic significance of ST-depression seems to be strongest in the fibrinolysis-treated patients.

Transfer for primary angioplasty vs. immediate thrombolysis in acute myocardial infarction: a meta-analysis

Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis.We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by intention to treat.The median delay between onset of symptoms and treatment was 130 min in the prehospital-fibrinolysis group and 190 min (time to first balloon inflation) in the primary-angioplasty group. Rescue angioplasty was done in 26% of the patients in the fibrinolysis group. The rate of the primary endpoint was 8·2% (34 patients) in the prehospital-fibrinolysis group and 6·2% (26 patients) in the primary-angioplasty group (risk difference 1·96, 95% CI−1·53 to 5·46). 16 (3·8%) patients assigned prehospital fibrinolysis and 20 (4·8%) assigned primary angioplasty died (p=0·61).A strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with early myocardial infarction.

Coronary artery bypass grafting within 30 days after treatment of acute myocardial infarctions with angioplasty or fibrinolysis – a surgical substudy of DANAMI‐2

Objective—To calculate the incidence and analyse the indications and outcome after surgical revascularization within the first 30 days after randomization of 1572 patients with acute myocardial infarction (MI) associated with ST‐segment elevation (STEMI).Design—Data regarding the patients undergoing heart surgery within the first 30 days after randomization were collected.Results—Three patients (0.2%) with acute STEMI and randomized to percutaneous coronary intervention (PCI) underwent emergent coronary artery bypass grafting (CABG). A total of 50 patients (3.2%), 30 in the PCI group and 20 in the fibrinolysis group were revascularized by surgery within the first 30 days after randomization. The most frequent indication for surgery in both groups was unstable angina pectoris, followed by left main stenosis. The incidence of postoperative complications was higher compared with the outcome after elective CABG.Conclusions—The incidence of emergency CABG in this study was low (0.2%) after treatment of acute MI with either PCI or fibrinolysis. The overall incidence within 30 days was 3.2%, however, the mortality is increased with a 30‐day mortality of 10% in this high‐risk patient group.

Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomised study

Although both prehospital fibrinolysis and primary angioplasty provide a clinical benefit over in-hospital fibrinolysis in acute myocardial infarction, they have not been directly compared. Our aim was to find out whether primary angioplasty was better than prehospital fibrinolysis. We did a randomised multicentre trial of 840 patients (of 1200 planned) who presented within 6 h of acute myocardial infarction with ST-segment elevation, initially managed by mobile emergency-care units. We assigned patients to prehospital fibrinolysis (n=419) with accelerated alteplase or primary angioplasty (n=421), and transferred all to a centre with access to emergency angioplasty. Our primary endpoint was a composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Analyses were by intention to treat. The median delay between onset of symptoms and treatment was 130 min in the prehospital-fibrinolysis group and 190 min (time to first balloon inflation) in the primary-angioplasty group. Rescue angioplasty was done in 26% of the patients in the fibrinolysis group. The rate of the primary endpoint was 8.2% (34 patients) in the prehospital-fibrinolysis group and 6.2% (26 patients) in the primary-angioplasty group (risk difference 1.96, 95% CI -1.53 to 5.46). 16 (3.8%) patients assigned prehospital fibrinolysis and 20 (4.8%) assigned primary angioplasty died (p=0.61). A strategy of primary angioplasty was not better than a strategy of prehospital fibrinolysis (with transfer to an interventional facility for possible rescue angioplasty) in patients presenting with early myocardial infarction.

Perfusion measurements of the brain: using dynamic CT for the quantitative assessment of cerebral ischemia in acute stroke

Objective: Perfusion CT has been successfully used as a functional imaging technique for the differential diagnosis of patients with hyperacute stroke. We investigated to what extent this technique can also be used for the quantitative assessment of cerebral ischemia. Methods and material: We studied linearity, spatial resolution and noise behaviour of cerebral blood flow (CBF) determination with computer simulations and phantom measurements. Statistical ROI based analysis of CBF images of a subset of 38 patients from a controlled clinical stroke study with currently more than 75 patients was done to check the power of relative cerebral blood flow (rCBF) values to predict definite infarction and ischemic penumbra. Classification was performed using follow-up CT and MR data. Results: Absolute CBF values were systematically underestimated, the degree depended on the cardiac output of the patients. Phantom measurements and simulations indicated very good linearity allowing reliable calculation of rCBF values. Infarct and penumbra areas in 19 patients receiving standard heparin therapy had mean rCBF values of 0.19 and 0.62, respectively. The corresponding values for 19 patients receiving local intraarterial fibrinolysis were 0.18 and 0.57. The difference between infarct and penumbra values was highly significant ( P<0.0001) in both groups. No penumbra area was found with an rCBF value of less than 0.20. While in the heparin group only 25% of all areas with an rCBF between 0.20 and 0.35 survived, in the fibrinolytic group 61% of these areas could be saved ( P<0.05). Conclusion: Perfusion CT is a fast and practical technique for routine clinical application. It provides substantial and important additional information for the selection of the optimal treatment strategy for patients with hyperacute stroke. Relative values of cerebral blood flow discriminate very well between areas of reversible and irreversible ischemia; an rCBF value of 0.20 appears to be a definite lower limit for brain tissue to survive an ischemic injury.

SYSTEMIC EFFECTS OF TISSUE PLASMINOGEN ACTIVATOR-ASSOCIATED FIBRINOLYSIS AND ITS RELATION TO THROMBIN GENERATION IN ORTHOTOPIC LIVER TRANSPLANTATION

Orthotopic liver transplantation is frequently associated with hyperfibrinolysis, the origin and clinical relevance of which is largely unknown. In 20 orthotopic liver transplantations, we studied the occurrence and systemic effects of hyperfibrinolysis. Severe fibrinolysis was defined to be present when the euglobulin-clot lysis time and the whole-blood-clot lysis time, as measured by thrombelastography, were shorter than 60 and 90 min, respectively, at some time during the operation. Based on these criteria, 7 patients had minimal fibrinolysis (group I), and 13 patients had severe fibrinolysis (group II). In group II a gradual increase of tissue-type plasminogen activator (t-PA) activity was seen during the anhepatic stage, followed by an "explosive" increase immediately after graft reperfusion (P = 0.0004, compared with group I), and a reduction of plasminogen activator inhibitor (PAI) activity. Plasma degradation products of fibrinogen and fibrin increased parallel to t-PA activity, and levels were significantly higher at 45 min after graft reperfusion in group II compared with group I (P less than 0.04). Thrombin-antithrombin III complexes showed an identical steady increase in both groups, indicating that increased t-PA activity was not related to thrombin formation. A combination of increased endothelial release and reduced hepatic clearance may have caused the increased t-PA activity. The t-PA-associated destruction of fibrinogen and fibrin after graft reperfusion is consistent with the clinical signs of severe oozing often seen in this period. These observations may have important clinical implications for the treatment of bleeding in patients undergoing orthotopic liver transplantation.

Fibrinolytic Activity of Middle Ear Fluid in Otitis Media with Effusion

In order to investigate the prolonged factors of otitis media with effusion, hydrolytic activities for specific substrates of plasmin and plasminogen activator (P.G.-activator) and the activity for fibrin degradation (fibrinolysis) were measured. Materials were middle ear fluids of 36 cases diagnosed as unilateral otitis media with effusion. Age of the patients were from 28 to 88 years old (mean: 61.3). Using specific substrates, determinations of P.G.-activator activity and plasmin activity were made by the method of Claeson et al. and fibrinolysis was determined by the standard fibrin plate. The results are shown below: 1) Both activities for decomposition of amide against the specific substrates of plasmin and of P.G.-activator were revealed. 2) Concerning fibrinolysis in all cases, we divided them into 3 groups; fibrinolysis (-) group of 8 cases (22.2%) which could not dissolve fibrin at all, fibrinolysis (+) group of 17 cases (47.2%) which could dissolve fibrin. Fibrinolysis (+/-) group of 11 cases (30.6%) of which the presence of fibrin dissolution was unknown. 3) The progress of fibrinolysis was observed by serial collection of middle ear fluid in the same side ear of 5 cases out of 17 cases having much activity for fibrin degradation, and lowering of fibrinolytic activity was revealed in 4 out of these 5 cases as the result. On the basis of these results, we discussed on the process of prolongation in this disease from the standpoint of the presence of fibrinolytic activity in the middle ear fluid.

Is open decortication superior to fibrinolytic therapy as a first line treatment in the management of pleural empyema?

Objective:To confirm that either Fibrinolytic therapy or open decortication which of the two is an effective First line treatment of pleural empyema.Methods:This prospective comparative study was conducted in the department of surgery Sheikh Zayed Medical College and Hospital, Rahim Yaar Khan. Seventy eight (78) patients were included in this study. There were two groups of patients; Group I (n=35) patients treated with fibrinolytic therapy, Group II (n=43) patients treated with open decortication. Data was entered and analyzed in SPSS v16. Student’s t-test was used for comparison of quantitative variables. Chi-square and Fisher’s Exact test were used for comparison of qualitative variables. P-value ≤ 0.05 was taken as significant difference.Results:There was no significant difference in base baseline characteristics of patients of Group I and II. Incidence of comorbidities was also same between the groups. Most of the patients in Group I and II were in empyema stage III. Fluid cultures was positive in 33 (94.3%) patients in group I and 39 (90.7%) patients in group II. 30 (85.7%) was successfully treated using fibrinolytic therapy but this therapy failed in five (14.3%) patients, two of these patients expired within the hospital. There was only one (2.3%) treatment failure in open decortication Group that patient expired within the hospital (p-value 0.04). Overall duration of hospitalization was significantly high in fibrinolytic group, this was 17.6± 1.95 days versus 12.09± 2.18 days in open decortication group (p-value<0.0001). There was no significant difference regarding operative mortality within the two groups.Conclusion:Open Drainage is associated with better outcomes as compared to fibrinolytic therapy when used as a First line treatment of empyema.