Primary Thrombolysis Research Articles

Abstract 63: Basilar Artery Occlusion due to Vertebral or Basilar Dissection in the Basilar Artery International Cooperation Study (BASICS)

Introduction: Since there are few reports of patients with stroke secondary to basilar artery occlusion (BAO) due to dissection, there are scarce data on its risk factors, clinical presentation, prognosis and best treatment options. Methods: The Basilar Artery International Cooperation Study (BASICS) was a large prospective, observational registry of consecutive patients who presented with an acute symptomatic BAO. We assessed clinical, radiological and therapeutical data of patients with BAO secondary to radiologically confirmed vertebral or basilar artery dissection. Stroke severity at time of treatment was dichotomized as severe (coma, locked-in state, or tetraplegia) or mild to moderate (any deficit that was less than severe). Outcome was assessed at 1 month. Poor outcome was defined as a modified Rankin scale score of 4 or 5, or death. Patients were divided into three groups according to the treatment they received: antithrombotic treatment only (AT), which comprised antiplatelet drugs or systemic anticoagulation; primary intravenous thrombolysis (IVT), including subsequent intra-arterial thrombolysis; or intra-arterial therapy (IAT), which comprised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches. Results: In 32 (5.4%) of 592 patients with BAO, the stroke etiology was dissection. Twenty patients were men, mean age was 45.2 (± 12.7 SD) years. Fourteen patients had no vascular risk factors. Seven patients were current smokers; history of hypertension was present in 4, of dyslipidemia in 4 and other risk factors in 6 patients. Prodromal symptoms (e.g. headache, neck pain, vomiting) were present in 24 patients. History of TIA prior to BAO was recorded in 5 patients and minor stroke in 9. Twenty one patients had a progressive stroke, in 6 symptoms fluctuated and 4 presented with a maximum deficit from onset. Deficits at time of treatment were severe in 22 patients and mild to moderate in 10. Initial CT scan was normal in 9 patients, 13 had a dense basilar sign and 13 presented with early ischemic changes. In most (20) patients the BAO was in the proximal third, in 8 it was located in the distal third and in 4 in the middle third. Eleven patients were treated with only AT (3 antiplatelets, 8 anticoagulation), 9 with IVT and 12 with IA. Three patients- all treated with IA - had symptomatic hemorrhage. Overall, 18 (56%) patients had a poor outcome (AT 9 of 11, IVT 2 of 9, IA 7 of 12, p=0.03, Fisher’s exact test). Conclusions: Dissection is a rare cause of BAO that affects mainly younger patients, with few or no vascular risk factors. Patients often present with prodromal symptoms, and a progressive stroke. Initial CT changes are common and the proximal third of the basilar artery is the main localization of occlusion. As in other causes of BAO, prognosis is poor and in this registry patients treated with IVT had a lower rate of poor outcome.

Hochrisikolungenembolie

High risk pulmonary embolism commonly presents with a variety of symptoms and is an acute life-threatening event. In patients showing unclear acute circulatory distress, pulmonary embolism should be quickly ruled out by computed tomography or echocardiography. The diagnostic steps and surgical treatment of pulmonary embolism in a 25-year-old female patient suffering from acute circulatory insufficiency resulting in cardiac arrest within 11min after emergency hospital admission are reported. Due to the reasonable suspicion of acute right heart decompensation, systemic perfusion was re-established by cardiopulmonary bypass after cardiopulmonary resuscitation for 41min. Sternotomy and surgical embolectomy were performed. The patient was successfully extubated the following day and despite the long resuscitation time the outcome was excellent without any neurological deficit. Recent publications addressing the advantages of primary embolectomy versus intravenous thrombolysis in acute circulatory distress caused by pulmonary embolism are discussed. Primary surgical treatment including cardiopulmonary bypass for right ventricular relief and re-establishing of systemic perfusion is recommended for patients with pulmonary embolism undergoing cardiopulmonary resuscitation.

Emerging data and decision for optimizing STEMI management: the European perspective

Univocal management of STEMI patients in Europe is necessary to extensively implement guidelines and allow uniform standard of care and outcome. The European Society of Cardiology released recently new guidelines for the treatment of STEMI patients. These recommendations emphasize the importance of early reperfusion therapy. To achieve this goal, local networks have to be improved, to promote early in-ambulance treatment, including thrombolysis or to transfer immediately the patient to a primary PCI hospital, avoiding delay in vessel reopening. Several studies indicate that the most impactful strategy on short and long term outcomes is to privilege primary percutaneous coronary intervention vs thrombolysis, when an efficient and competent unit is available, but only if reduced door-to-balloon times are possible. Unfortunately, throughout Europe there are wide differences in primary PCI centers in terms of geographic distribution, organization and level of competence. The priority should be to obtain a more homogeneous standard of care, based on a consensus triage, efficient regional network and outcome data auditing. The TAPAS study results indicate that thrombus aspiration prior to PCI is associated with improved tissue reperfusion and lower rate of cardiac mortality at 1 year follow-up. Also, the anti-thrombotic strategy during STEMI needs to be balanced between the effectiveness on thrombus removal and the emergent risk of bleeding. The HORIZONS-AMI trial demonstrates that bleeding has a significant impact on early and long term mortality, with better outcomes with new anti-thrombin agents (bivalirudin) compared to the combination of heparin + GP IIb/IIIa inhibitor, however at the cost of some significant increase of stent thrombosis immediately following the acute intervention (first 24 hours). Trans-radial interventions during STEMI, a rapidly growing approach all over the Europe, need to be considered as a promising component of the global strategy that attempts to reduce the incidence of acute bleeding. Further, preventive therapy using evidence based medicine prescription, in-hospital as well at the time of discharge, is a gold standard to be pursued for a more favorable long-term outcome. Although a global and uniformed European strategy in STEMI is far to be obtained, and difficult to be applied in various regional frameworks, common goals based on new recommendation of the European Society of Cardiology should be pursued to try to optimize the system of care.

Paramedics at the front line of heart attack treatment

The STREAM trial for acute myocardial infarction will compare the two gold standard emergency treatments for acute myocardial infarction: primary percutaneous coronary intervention and pre-hospital thrombolysis. Bristol paramedic Andy Halliday was responsible for enrolling the first patient on the UK mainland in this landmark study.

PCI after lytic therapy: when and how?

Primary percutaneous coronary intervention (PCI) and thrombolysis are approved therapies in the treatment of ST-elevation myocardial infarction (STEMI). Many clinical trials have shown that primary PCI provides better results than thrombolysis for the STEMI treatment. However, the advantages of invasive approach over fibrinolytic therapy may be blunted by low availability of experienced centres offering 24 h/7 days primary PCI service and by delay to mechanical reperfusion due to prolonged transport. Current guidelines recommend that primary PCI should be performed by skilled professionals within less than 90 (120) min after first medical contact. In practice, these requirements prohibit a large number of STEMI patients from benefiting from primary PCI because of the lack of access to an established primary PCI centre at the site of first presentation and long anticipated interhospital transfer time. Many of them are treated with lytics and referred to angiography with subsequent PCI in different time mode. Current data support the strategy of immediate PCI after lytics than waiting for rescue PCI if lysis is non-effective. The purpose of this article is to review the current approaches to patients after fibrynolytic therapy referred for PCI for STEMI.

Abstract 5779: Quantification of Right Ventricular Dyssynchrony in Acute Pulmonary Embolism and Right Ventricular Pressure Overload Using Speckle-Tracking Strain Imaging

Acute right ventricular (RV) pressure overload can alter RV systolic synchronicity associated with RV expansion and wall motion abnormalities in patinets with acute pulmonary thrombo-embolism (APTE). Twenty patients with massive or sub-massive APTE (mean age 57 ± 18 years, estimated peak systolic pulmonary pressure 51 ± 16mmHg) had echocardiography with speckle-tracking strain imaging on admission. RV dyssynchrony was defined as the time difference from earliest to latest peak strain among 6-sites (basal septum, mid septum, apical septum, apical free wall, mid free wall, basal free wall) form apical 4-chamber view using speckle-tracking longitudinal strain imaging. All intervals were corrected for heart rate (corrected interval = measured interval/(RR interval) 1/2 ). Twenty normal subjects (Control: mean age 58 ± 10 years) were also assessed RV function and synchronicity for comparison. APTE had significantly low RV fractional area change (29 ± 10%* vs. 50 ± 7%), low global RV strain (−13 ± 4%* vs. −25 ± 3%), and large RV dyssynchorny (220 ± 103msec* vs. 78 ± 39msec) compared with Control (*p<0.05 vs. Control). After hemodynamic recovery from acute RV pressure overload by primary thrombolysis and/or anticoagulation therapy, both global RV strain and dyssynchrony were improved (−18 ± 4%† and 130 ± 53msec†, †p<0.05 vs. APTE on admission, respectively). Acute RV pressure overload induced reversible RV systolic dyssynchrony associated with RV systolic dysfunction in patients with APTE.

Abstract 2652: Primary Angioplasty And Thrombolysis For ST Elevation Myocardial Infarction Result In Similar Left Ventricular Function And Rates Of Inducible Ventricular Tachycardia.

Introduction/Hypothesis. Electrophysiological studies (EPS) predict risk of sudden death after myocardial infarction. Primary angioplasty has become the preferred method of treatment for STEMI due to improved patency rates of the infarct related artery, along with decreased rates of reinfarction and death. Despite this, intravenous thrombolysis remains the first line treatment in 30 –70% of cases worldwide. We assessed the hypothesis that the left ventricular ejection fraction (LVEF) and rates of inducible VT would be more favorable in patients treated with primary angioplasty compared to thrombolysis. Methods/Results. Consecutive patients receiving primary angioplasty (n=225) or thrombolysis (n=195) for STEMI were included. Mean LVEF assessed predominantly by gated blood heart pool scan was 47.7 ±12.1% for the primary angioplasty group and 46.3 ±13.0% for the thrombolysis group (p=0.30). The proportion of patients with LVEF less than 40% was 29.7% in the primary angioplasty group and 29.6% in the thrombolysis group (p=0.98). Patients with LVEF less than 40% underwent EPS. VT was inducible in 10% of patients who had primary angioplasty versus 11% of patients who had thrombolysis (p=0.69). Mean cycle length (CL) of inducible VT in milliseconds (ms) was 246 ± 48 for the angioplasty group and 261 ± 62 for thrombolysis group (p=0.65). Implantable cardiac defibrillators were inserted in 30 patients of which 8 (27%) had appropriate device activations. The mean time from infarction to first spontaneous activation was 387 ± 458 days. Mean CL of spontaneous VT was 314 ± 62 ms. Conclusions. In conclusion patients treated with thrombolysis or primary angioplasty for STEMI are likely to have similar resultant left ventricular function and rates of inducible ventricular tachycardia. There was a surprisingly high rate of spontaneous defibrillator activations often occurring late after myocardial infarction. Table 1: Patient and treatment characteristics for each group.

Myocardial Protection Via the Coronary Sinus Long-Term Effects of Intermittent Coronary Sinus Occlusion as an Adjunct to Reperfusion in Acute Myocardial Infarction

Recent reports on facilitated reperfusion therapy re-address interests in coronary sinus interventions (CSI). Patients in whom short time results have been reported earlier were re-evaluated, with the aim of gathering the long-term results of pressure-controlled intermittent coronary sinus occlusion (PICSO) generated in patients with acute myocardial infarction (MI) and revascularization. Thirty-four patients with ST elevated MI, in whom complete revascularization was achieved, underwent primary thrombolysis with or without PICSO. Follow-up data from these patients were collected for at least 48 months. Immediate perioperative differences were observed for time to peak creatine kinase (CK), as well as cumulative CK. In addition, the time until reperfusion was considerably less than for the control group (p=0.014). Long-term data showed significant differences in reinfarction (p=0.015), as well as in major adverse cardiovascular events, between the 2 groups (p<0.0001). These data, because of the wide interval between collection and current analysis, could have inherited historical bias. Nonetheless, they are also uniquely indicating the potential of CSI to induce not only immediate, but also clinically significant long-term, effects as an adjunct to reperfusion therapy. Therefore, CSI should be, once again, on the study agenda and be placed under contemporary and best-available scientific scrutiny.

Management cost of acute limb ischaemia.

The cost of attempting limb salvage in patients who presented with acute lower limb ischaemia was recorded prospectively for 20 months. Seventy-five patients were admitted during the study; 45 were treated primarily by radiological intervention and 18 had primary surgery. The remainder were treated conservatively. Patients who had primary surgery required fewer visits to the operating theatre than those who had primary thrombolysis, but there was no difference in the total time that the theatre or radiology suite was occupied: median 2.3 (10th centile range 1.5-5.0) h and 3.0 (2.0-5.0) h respectively. Median (range) cost of disposables for performing surgery was Pounds 82 (58-169) and for thrombolysis was Pounds 407 (252-596). When the costs of using the theatre or radiology suite were included, the costs of both treatments were similar: surgery Pounds 683 (309-1438) and lysis Pounds 861 (611-1244). Median (10th centile range) inpatient stay for surgical patients was 9 (3-18) days and for those having thrombolysis 11 (2-29) days. Median (10th centile range) costs for bed occupancy were similar in both groups: surgery Pounds 2497 (643-9115) and lysis Pounds 2189 (902-6020). Mean cost for attempting limb salvage by surgery was Pounds 3429 (1094-10065) compared with Pounds 3230 (1543-8353) for thrombolysis.

Primary angioplasty versus prehospital thrombolysis: how do the treatment costs compare?

Primary angioplasty versus prehospital thrombolysis: how do the treatment costs compare?

Health-related quality of life one month after thrombolysis or primary PCI in patients with ST-elevation infarction. A DANAMI-2 sub-study.

Objectives. To evaluate the health-related quality of life (HRQoL) following Primary percutaneous coronary intervention (PCI) or thrombolytic treatment for ST-elevation myocardial infarction (STEMI). Design. A questionnaire based study on patients randomised in the DANAMI-2 study to Primary PCI or thrombolysis for STEMI. A total of 1 351 patients (93.2% response rate) randomised in the DANAMI-2 study completed the HRQoL questionnaire one month after the infarction. Results. With respect to the primary end-points (SF-36 physical component score, angina pectoris, and dyspnoea), patients randomised to primary PCI scored better on the SF-36 physical component score (PCS) (p = 0.007), and reported significantly less angina pectoris (p = 0.010) and dyspnoea (p = 0.010). Higher scores among PCI patients were also found on the SF-36 scales physical functioning (p = 0.015), role-physical (p = 0.017), and general health (p = 0.009). Conclusion. The results in this study support the hypothesis that primary PCI is superior to thrombolysis in treating STEMI, not only in clinical outcome, but also in quality of life outcome.

Hospitalization costs of primary stenting vs. thrombolysis in acute myocardial infarction: cost analysis of the canadian stat study

Hospitalization costs of primary stenting vs. thrombolysis in acute myocardial infarction: cost analysis of the canadian stat study

P1092 Primary angioplasty versus intravenous thrombolysis with a reasonable amount of early angioplasty in acute myocardial infarction

P1092 Primary angioplasty versus intravenous thrombolysis with a reasonable amount of early angioplasty in acute myocardial infarction

In-hospital and one-year outcomes according to ST-segment resolution in high-risk patients with acute myocardial infarction treated with primary angioplasty or thrombolysis: Data from the MISTRAL study

In-hospital and one-year outcomes according to ST-segment resolution in high-risk patients with acute myocardial infarction treated with primary angioplasty or thrombolysis: Data from the MISTRAL study

Primary PCI vs. Thrombolysis at Hospitals Without On-Site Cardiac Surgery

PCI is superior to thrombolytic therapy for treating acute ST-segment-elevation MI (STEMI), but is this true at hospitals without on-site cardiac

High-risk myocardial infarction: in-hospital and one-year outcome after primary angioplasty and thrombolysis: a prospective nationwide multicenter study

High-risk myocardial infarction: in-hospital and one-year outcome after primary angioplasty and thrombolysis: a prospective nationwide multicenter study

Primary angioplasty vs. intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the maximal individual therapy in acute myocardial infarction registry and the myocardial infarction registry

Primary angioplasty vs. intravenous thrombolysis in acute myocardial infarction: can we define subgroups of patients benefiting most from primary angioplasty? Results from the pooled data of the maximal individual therapy in acute myocardial infarction registry and the myocardial infarction registry

Primary Coronary Angioplasty vs Thrombolysis for the Management of Acute Myocardial Infarction in Elderly Patients

ContextDespite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known.ObjectiveTo determine survival after primary PTCA vs thrombolysis in elderly patients.DesignThe Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files.SettingAcute care hospitals in the United States.PatientsA total of 20,683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy.Main Outcome MeasuresThirty-day and 1-year survival.ResultsA total of 80,356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08).ConclusionIn elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Outcome after catheter-directed thrombolysis of occluded prosthetic femoropopliteal bypasses. A prospective study.

To evaluate the outcome after catheter-directed thrombolysis of occluded femoropopliteal prosthetic bypasses with the distal anastomosis above the knee. Twenty-one patients were included in this prospective study. End-hole catheters, a bolus dose and continuous infusion of recombinant tissue-plasminogen activator (rt-PA) were used, with a median total dose of 10 mg (range 7-20 mg). With an intra-thrombotic position of the catheter, total or subtotal lysis was obtained in 19 of 21 patients (90%). No serious complications occurred. In 9 patients, the stenoses were successfully treated with balloon angioplasty (PTA, n=5), local thrombectomy/extension of bypass (n=3), or with a new bypass (n=1). After a median observation time of 18 months (6-24), 5 patients had open bypass. Re-occlusion occurred in all (6/6) bypasses in which no flow-limiting lesion was discovered, in all (4/4) bypasses treated twice with thrombolysis, as well as in all bypasses in which stenoses had not been adequately treated (3/3). One bypass re-occluded immediately due to poor runoff. In the present study, 19/21 infra-inguinal prosthetic bypasses were successfully treated with catheter-directed thrombolysis. However, re-occlusion often took place, especially in bypasses without flow-limiting lesions. If re-occlusion occurs in a bypass in which no stenoses were revealed during the primary thrombolysis procedure, a second catheter-directed thrombolytic treatment does not seem to be warranted. Our results confirm that treatment of flow-limiting lesions is a prerequisite for maintaining patency.

OUTCOME AFTER CATHETER-DIRECTED THROMBOLYSIS OF OCCLUDED PROSTHETIC FEMOROPOPLITEAL BYPASSES. A prospective study

To evaluate the outcome after catheter-directed thrombolysis of occluded femoropopliteal prosthetic bypasses with the distal anastomosis above the knee. Twenty-one patients were included in this prospective study. End-hole catheters, a bolus dose and continuous infusion of recombinant tissue-plasminogen activator (rt-PA) were used, with a median total dose of 10 mg (range 7-20 mg). With an intra-thrombotic position of the catheter, total or subtotal lysis was obtained in 19 of 21 patients (90%). No serious complications occurred. In 9 patients, the stenoses were successfully treated with balloon angioplasty (PTA, n=5), local thrombectomy/extension of bypass (n=3), or with a new bypass (n=1). After a median observation time of 18 months (6-24), 5 patients had open bypass. Re-occlusion occurred in all (6/6) bypasses in which no flow-limiting lesion was discovered, in all (4/4) bypasses treated twice with thrombolysis, as well as in all bypasses in which stenoses had not been adequately treated (3/3). One bypass re-occluded immediately due to poor runoff. In the present study, 19/21 infra-inguinal prosthetic bypasses were successfully treated with catheter-directed thrombolysis. However, re-occlusion often took place, especially in bypasses without flow-limiting lesions. If re-occlusion occurs in a bypass in which no stenoses were revealed during the primary thrombolysis procedure, a second catheter-directed thrombolytic treatment does not seem to be warranted. Our results confirm that treatment of flow-limiting lesions is a prerequisite for maintaining patency.