Outcome Of Thrombolysis Research Articles

Predicting mortality using prognostic scores and electrocardiographic parameters in ST-elevation myocardial infarction patients undergoing thrombolysis

Background: The short- and long-term outcomes of thrombolysis has been predicted by various scores and models based on the electrocardiogram. This study aimed to compare various mortality predictors in ST-elevation myocardial infarction (STEMI) patients undergoing thrombolysis. Methods: A prospective, case-control, single-center study was performed at MGM Hospital, Warangal, India, between November 2019 and November 2021. A total of 100 STEMI patients were enrolled, out of which 50 were controls (patients who survived after seven days of thrombolysis) and 50 were cases (patients who died after seven days of thrombolysis). Aldrich score, TIMI risk index (TRI), Sclarovsky-Birnbaum Ischemia Grading (SB-IG) algorithm, presence of Q waves, total ST-segment deviation, and the number of leads with ST-segment elevation (STE) in anterior wall MI (AWMI) were calculated. Results: The mean age of the case group was 55.3 ± 11.6 years, and that of the control group was 55.5 ± 10.1 years. Males comprised 46.0% and 66.0% of the case and control groups. The c-statistic of TRI was found to be the highest (c = 0.68; P = 0.001), followed by the SB-IG algorithm (c = 0.58; P = 0.021), the sum of R waves in AWMI (c = 0.5; P = 0.019), the number of leads with STE in AWMI (c = 0.47; P = 0.778), total ST-segment deviation (c = 0.47; P = 0.552), Aldrich score for AWMI (c = 0.43; P = 0.590), presence of Q waves (c = 0.40; P = 0.676), and Aldrich score for inferior wall MI (c = 0.32; P = 0.071). Conclusion: TRI and SB-IG algorithms had moderate accuracy in predicting seven-day mortality in STEMI patients undergoing thrombolysis. Other scores and parameters viz. Aldrich score, presence of Q waves, total ST-segment deviation, and the number of leads with STE in AWMI had very poor accuracy in predicting in-hospital outcomes. More extensive studies with longer durations are required to validate our findings.

Prior statin use and intravenous thrombolysis in acute ischemic stroke: a meta-analysis of cohort studies

Background: There is uncertainty whether prior statin use (PSU) influences the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). Therefore, we conducted a systematic meta-analysis of published clinical trials to evaluate whether statin use combined with IVT therapy may be useful and safe. Methods: Electronic databases were searched for clinical trials that involved outcomes between PSU and nonstatin use (NSU) among stroke patients treated with IVT. Functional outcome measures were 3-month favorable outcome (modified Rankin scale [mRS] 0–2) and 3-month excellent outcome (mRS 0–1). Adverse outcome measures were 3-month all-cause mortality, intracranial hemorrhage (ICH) and symptomatic ICH (sICH). Data were extracted and used to calculate odds ratios (ORs) with 95% confidence intervals (CIs) by Review Manager 5.4 software. Results: Eleven studies, totaling 13,745 patients (2,957 for PSU and 10,788 for NSU), met the inclusion criteria. Compared with NSU, PSU was associated with excellent outcome (OR=0.78; 95% CI, 0.70–0.88; p<0.0001), ICH (OR=1.26; 95% CI, 1.07–1.47; p=0.005) and sICH (ORNINDS=1.32; 95% CI, 1.06–1.64; p=0.01), whereas favorable outcome (OR=1.08; 95% CI, 0.86–1.35; p=0.50) and mortality (OR=1.11; 95% CI, 0.97–1.27; p=0.15) showed no significant difference between PSU and NSU. However, after combining the available multivariable data, associations with neither excellent outcomes (adjusted OR=0.92; 95% CI, 0.79–1.07; p=0.28) nor adverse outcomes (ICH: adjusted OR=1.11; 95% CI, 0.96–1.29; p=0.16; sICH: adjusted ORNINDS=1.21; 95% CI, 0.95–1.56; p=0.13) was found. Conclusions: PSU might neither positively nor negatively affect the outcomes of AIS patients treated by IVT.

Short-term outcomes of intra-arterial catheter-directed thrombolysis for acute limb ischemia: a single-center experience

Short-term outcomes of intra-arterial catheter-directed thrombolysis for acute limb ischemia: a single-center experience

FACTORS INFLUENCING THE OUTCOME OF THROMBOLYSIS IN ACUTE MYOCARDIAL INFARCTION

Coronary heart disease (CHD) is a worldwide health epidemic. It has been defined as “impairment of heart function due to inadequate blood flow to heart compared to its needs caused by obstructive changes in the coronary circulation to the heart”(1). It is the cause of 25-30% of deaths in most of the industrialized countries. In India also it is a major public health problem. It is aptly called by WHO as the 'modern epidemic'. The increasing incidence of coronary heart disease may be a reflection of increased longevity, adoption of high fat diet based on meats decreased exercise, modern lifestyle, made possible by increasing affluence.The present study is to ascertain the factors influencing outcome of thrombolysis in acute MI and concludes that Gender and Pre infarction not influence the success rate of thrombolysis, Better success rate has been seen in those consuming alcohol and smokers had a lesser success rate than non smokers but statistically not significant. Hypertensives did not show any difference with non hypertensives in the success rate. Diabetics did not differ much from non diabetics with respect to the success rate of thrombolysis. Inferior wall myocardial infarction had a better success rate than anterior wall myocardial infarctions. Those who are having short window period had a better success rate after thrombolysis. Shorter the window period higher the success rate.

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity.

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

Efficacy and safety outcomes of ultrasound assisted thrombolysis versus standard catheter direct thrombolysis in patients with submassive or massive pulmonary embolism: an updated meta-analysis

Abstract Background The use of catheter-based thrombolysis in comparison to systemic thrombolytics has emerged as a potentially lifesaving therapy for patients with sub massive or massive pulmonary embolism (PE). The addition of ultrasound waves to accelerate lytic dispersion in ultrasound assisted thrombolysis (USAT) has been proposed to improve outcomes as compared to standard catheter-directed thrombolysis (SCDT). These two modalities have been compared in small studies, but larger population data on the outcomes of these therapies is still lacking. Purpose To assess the efficacy and safety of USAT versus SCDT in patients with submassive or massive pulmonary embolism. Methods A review of electronic databases (PubMed, Scopus, Embase, and Cochrane) was performed using keywords USAT, SCDT and PE and studies were included if efficacy and safety outcomes were compared between the two types of therapies. Efficacy outcomes that were evaluated included the reduction in right ventricle/left ventricle ratio (RV/LV ratio), pulmonary artery systolic pressure (PASP) and Miller score. Safety outcomes that were evaluated included major bleeding, mortality and length of ICU stay. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for continuous variables. Risk ratio (RR) and 95% CI were reported for dichotomous variables using the random effects model in comprehensive meta-analysis and RevMan 5.4.1 softwares. Results Six studies with a total of 381 patients (USAT n=204; SCDT n=177) were included. No statistical difference in efficacy outcomes of USAT over SCDT was noted in the degree of RV/LV ratio reduction (SMD: −0.507; CI: −1.386–0.373; p>0.05; I2=92%), PASP reduction (SMD: 0.037; CI: −0.404–0.478; p>0.05; I2=59%), or Miller score reduction (SMD: 0.303; CI: −0.481– 1.087; p>0.05; I2=82%). Safety outcomes were also not statistically different with similar rates of major bleeding (RR: 1.44; CI: 0.54–3.85; p>0.05; I2=4%), mortality (RR: 1.46; CI: 0.35–6.05; p>0.05; I2=0%) and length of ICU stay (SMD: −0.01; CI: −0.29–0.27; p>0.05; I2=31%) in both treatment groups. Conclusion Our data suggest that despite the technological advancement of USAT, there is no additional benefit over SCDT in terms of efficacy and safety. Further studies are warranted for both procedures investigating financial and clinical outcomes in real world practice. Funding Acknowledgement Type of funding sources: None.

Systemic thrombolytic therapy in treatment of acute limb ischemia

Background and aim Owing to the increased risk of morbidity and mortality, the treatment of acute limb ischemia (ALI) is challenging. The authors aimed to investigate the outcomes of thrombolysis in the treatment of ALI and limb salvage. Patients and methods A retrospective observational study was conducted to revise the data of 49 patients who underwent catheter-direct thrombolysis for ALI. A total of 33 cases were at lower limb and 16 cases were at upper limb. The assessed outcomes were primary and secondary patency, survival, amputation-free survival, and conversion to surgery. Results The patients were classified according to the Rutherford classification into class I (52%), class IIa (38%), class IIb (8%), and class III (2%). The primary patency was present in 34% of the patients after the first year and 22% after the second year. On the contrary, 28% of the patients were subjected to conversion to open surgery, 8% were subjected to reintervention, and 6% were subjected to amputation within the first month. The mortality rate within 1 month was 6%. The worst primary and secondary patency rates were seen in the prosthetic grafts in addition to vein bypasses, whereas the native artery was the most successful one regarding the primary patency, secondary patency, and amputation-free survival (P<0.05 for each). Conclusion The thrombolysis of vein bypass and prosthetic grafts did not show technical success as that seen with native artery. Additional treatment at the time of thrombolysis was shown to be associated with better outcomes.

Alteplase for Stroke With Unknown Onset Time in Chronic Kidney Disease: A Pooled Analysis of Individual Participant Data.

Although chronic kidney disease (CKD) is associated with worse stroke outcomes, data regarding the influence of CKD on intravenous thrombolysis outcomes are scarce. We sought to assess the efficacy and safety of intravenous thrombolysis for acute ischemic stroke with unknown onset time in patients with CKD. Patients with an acute stroke of unknown onset time from the EOS trials (Evaluation of Unknown Onset Stroke Thrombolysis) collaboration were evaluated using an individual patient-level database of randomized controlled trials comparing intravenous thrombolysis with placebo/standard treatment. CKD was defined as baseline estimated glomerular filtration rate of <60 ml/min/1.73m2 Mixed-effect logistic-regression analysis was performed to evaluate treatment effects. A favorable outcome was defined as a modified Rankin Scale score of 0 to 1 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage at 22 to 36 hours and 90-day mortality. Baseline data on renal function were available for 688 of 843 patients. Of these, CKD was present in 146 (21%), including 69 of 351 patients receiving alteplase and 77 of 337 patients receiving placebo/standard treatment. Overall, treatment with alteplase was associated with higher odds of favorable outcome, and CKD did not modify the treatment effect (Pinteraction=0.834). A favorable outcome was observed in 31 of 69 (46%) patients with CKD in the alteplase group and in 28 of 77 (36%) patients with CKD in the control group (adjusted odds ratio, 1.19 [95% CI, 0.55-2.58]). Among patients with CKD, symptomatic intracranial hemorrhage occurred in 2 patients (3%) in the alteplase group but in none of the controls (P=0.133). At 90 days, death was reported in 3 patients (4%) in the alteplase group compared with 2 patients (3%) in the controls (P=0.539). The present analysis indicates that the benefit of alteplase does not differ between stroke patients with unknown onset time with and without CKD, although the statistical power was lacking to confirm the efficacy in subgroups. This study only applies to mild-to-moderate or predialysis CKD.

Effect of drug use in the treatment of acute ischemic stroke: A scoping review.

Background: Drugs of abuse have been associated with ischemic stroke; however, the clinical presentation, outcomes, and treatment data in this population are limited. The overall safety and efficacy of thrombolytic therapy and thrombectomy in these patients remain unclear. This scoping review summarizes published complications and clinical outcomes in patients with recent abuse of cocaine, methamphetamine (MA), cannabis, decongestant, opioids, alcohol, and 3,4-methylenedioxymethamphetamine (MDMA) presenting with acute ischemic stroke.Methods: We conducted a scoping review of the primary literature that assessed outcomes data of thrombolytic therapy or thrombectomy in drug users with acute ischemic stroke. We searched PubMed, Ovid Medline, and Web of Science. Demographic and stroke characteristics, treatment, complications, and clinical outcomes at last follow-up were collected and summarized.Results: We identified 51 studies in this review. Drugs of abuse of interest were cocaine (14 studies), MDMA (one study), MA (eight studies), cannabis (23 studies), alcohol (two studies), decongestants (one study), and opioids (two studies). Clinical presentation and stroke presentation were most commonly described features. Thrombectomy outcomes were reported for four patients total (two studies), all with history of cocaine use. Thrombolysis treatment and outcomes were reported for 8851 patients (five studies) with history of cocaine, alcohol, or cannabis. Both treatments were pursued in three patients (three studies). Treatment complications included intracerebral hemorrhage, vasospasm, and cerebral edema.Conclusion: Evidence for thrombolytic and thrombectomy treatment in drug users remains limited. Controlled studies are needed to examine complication profile and outcomes following thrombolytic and thrombectomy treatment in this population.

Patterns and outcomes of stroke thrombolysis in a tertiary care hospital in North East India

Introduction: Intravenous thrombolysis with alteplase (tissue plasminogen activator -tPA) has been approved as the standard of care for the treatment of acute ischemic stroke (AIS) since 1995. Although there have been sporadic reports of hyperacute stroke thrombolysis coming from North-East India, a well-structured study from this resource poor area is lacking in this regard. Objective:To study the efficacy and safety of intravenous thrombolysis with tPA in AIS. Materials and methods: All patients of acute Ischemic stroke who were thrombolysed using the 4.5 hour window period, between Dec 2017 to April 2021 were enrolled and studied. We analyzed differences in age, gender, time from onset to start IVT, door to needle time (DNT), pretreatment NIHSS score, postoperative NIHSS score, and so on. They were followed up for a period of 3 months for the determination of outcome. The death rate at 90 days and incidence of SICH were used for assessment of safety. Results:A total of 30 patients were thrombolysed. 37% of patients were thrombolysed during the covid-19 pandemic. Hypertension was the most common risk factor. The mean Door to needle(DTN) time was 74.1 minutes with the shortest being 25 minutes. The mean NIHSS score at the point of hospitalization was 12.42 and after 24 hours was 9.27. In 57.69% of patients, the primary outcome (≥4 increment in NIHSS score) was achieved. 14.8% of patients suffered from adverse outcomes (death and SICH). Conclusion: This study re-affirms the safety and efficacy of IV tPA for hyperacute stroke thrombolysis in our set-up.

Safety and outcomes of thrombolytic therapy in patients with pulmonary embolism and thrombocytopenia: A systematic review.

Thrombolysis is an established therapeutic modality for patients with high-risk (and some selected intermediate-risk) pulmonary embolism (PE) with hemodynamic instability. Physicians sometimes experience cases where both a high-risk PE and thrombocytopenia coexist. Although thrombocytopenia of < 100 × 103/mm3 is considered a contraindication in patients with ischemic stroke, the safety and outcomes of thrombolysis in patients with acute PE and thrombocytopenia are unknown. This systemic review aimed to pool data on the safety and outcomes of thrombolysis use in patients with PE and platelet count less than 150 × 103/mm3. Patients’ demographics, clinical characteristics, management, type of thrombolytic therapy, and outcomes were extracted and analyzed. Of 283 articles identified through the systematic search, 11 case reports fulfilled the inclusion criteria. The mean age of the patients was 52.27 years, and 54.5% were women. The median platelet level before thrombolysis was 65.50 × 103/mm3. Before thrombolysis was initiated, the lowest and highest platelet levels were 29 × 103/mm3 and 105 × 103/mm3, respectively. Alteplase was used in 10 patients and urokinase in one patient. One patient who had a massive PE died of aspiration pneumonia. Interestingly, no thrombocytopenia-related complications were reported. This systematic review highlights the potential benefits and safety of thrombolysis in patients with acute PE in the context of thrombocytopenia. Nevertheless, data available in the literature concerning this topic are scarce and limited to case reports. More extensive studies on the use of thrombolysis in patients with PE and thrombocytopenia are desperately needed.Systematic review registration: The protocol has been registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42021286415.

Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital

IntroductionSome guidelines had recommended “thrombolysis first” in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre. MethodsThis single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays. Results and discussionWe analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02–4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic. ConclusionSTEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.

Predictors of Clinical Outcomes of Pharmacomechanical Catheter-Directed Thrombolysis for Acute Iliofemoral Deep Vein Thrombosis: Analysis of a Multicenter Randomized Trial

PurposeTo identify the baseline patient characteristics that predict who will benefit from pharmacomechanical catheter-directed thrombolysis (PCDT) of acute iliofemoral deep vein thrombosis (DVT). Materials and MethodsIn the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) multicenter randomized trial, 381 patients with acute iliofemoral DVT underwent PCDT and anticoagulation or anticoagulation alone. The correlations between baseline factors and venous clinical outcomes were evaluated over 24 months using post hoc regression analyses. Interaction terms were examined to evaluate for differential effects by treatment arm. ResultsPatients with clinically severe DVT (higher baseline Villalta score) experienced greater effects of PCDT in improving 24-month venous outcomes, including moderate or severe postthrombotic syndrome (PTS) (odds ratios [ORs] and 95% confidence intervals [CIs] per unit increase in the baseline Villalta scores were as follows: for PCDT, OR, 1.08 [95% CI, 1.01–1.15]; for control, OR, 1.20 [95% CI, 1.12–1.29]; Pinteraction = .03), PTS severity (between-arm differences in the Villalta [Pinteraction = .004] and Venous Clinical Severity Scale [VCSS] [Pinteraction = .002)] scores), and quality of life (between-arm difference in the Venous Insufficiency Epidemiological and Economic Study Quality of Life score; Pinteraction = .025). Patients with previous DVT had greater effects of PCDT on 24-month PTS severity than those in patients without previous DVT (mean [95% CI] between-arm difference in the Villalta score, 4.2 [1.56–6.84] vs 0.9 [−0.44 to 2.26], Pinteraction = .03; mean [95% CI] between-arm difference in the VCSS score, 2.6 [0.94–4.21] vs 0.3 [−0.58 to 1.14], Pinteraction = .02). The effects of PCDT on some but not all outcomes were greater in patients presenting with left-sided DVT (Villalta PTS severity, Pinteraction = .04; venous ulcer, Pinteraction = .0499) or a noncompressible popliteal vein (PTS, Pinteraction = .02). The effects of PCDT did not vary by sex, race, ethnicity, body mass index, symptom duration, hypertension, diabetes, or hypercholesterolemia. ConclusionsIn patients with acute iliofemoral DVT, greater presenting clinical severity (higher baseline Villalta score) and a history of previous DVT predict enhanced benefits from PCDT.

Meta-Analysis Comparing Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism

The optimal therapy for submassive pulmonary embolism (sPE), defined by right ventricular dysfunction without hemodynamic instability, is uncertain. We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA) alone in patients with sPE. We searched PubMed, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar (from inception through May 2022) for studies comparing outcomes of CDT versus SA in sPE. Studies were identified, and data were extracted by 2 independent reviewers. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 90-day, and 1-year mortality, major and minor bleeding, and need for blood transfusion. A total of 12 studies (1 randomized, 11 observational) with 9,789 patients were included. Compared with SA, CDT was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p &lt;0.00001), 30-day mortality (RR 0.37, 95% CI 0.18 to 0.73,p=0.004), 90-day mortality (RR 0.36, 95% CI 0.17 to 0.72, p=0.004), and a tendency toward lower 1-year mortality (RR 0.56, 95% CI 0.29 to 1.05,p=0.07). The risks of major bleeding (RR 1.31, 95% CI 0.57 to 3.01, p=0.53), minor bleeding (RR 1.67, 95% CI 0.77 to 3.63,p=0.20), and the rates of blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p=0.08) were similar between the 2 strategies. In conclusion, in patients with sPE, CDT is associated with significantly lower in-hospital, 30-day, and 90-day mortality and a tendency toward lower 1-year mortality with similar bleeding rates compared with SA. This study expands the evidence supporting CDT as first-line therapy for sPE, and randomized controlled trials are indicated to confirm our findings.

Thrombolysis Experience in Costa Rica Compared Against Individual Patient Data from two Randomized Controlled Trials

ObjectivesWe sought to compare thrombolysis outcomes from the Costa Rican Stroke Registry Program (CRSRP) with published individual patient data from NINDS and CLOTBUST-ER trials using matching and outcome modeling from randomized clinical trials (RCTs). Materials and methodsA retrospective observational study matching subjects on baseline characteristics, from the CRSRP, the control arm of CLOTBUST-ER, and the interventional arm of NINDS trials. Day 7-10/discharge modified Rankin Score (mRS), and early mortality was compared between matched subjects. A mortality model derived from RCTs was developed, and outcomes were compared at similar baseline NIHSS scores. CRSRP symptomatic hemorrhage (SICH) rate was compared with an Ibero-American cohort (IAC). ResultsOf 540 CRSRP patients, 351 received rt-PA under 3 hours and were matched with NINDS subjects yielding 292 pairs; 161 CRSRP subjects treated within 4.5 hours were matched with CLOTBUST-ER subjects resulting in 151 pairs. The proportion of patients achieving excellent outcomes (mRS 0-1) did not differ between CRSRP and either NINDS or CLOTBUST-ER (CRSRP vs NINDS: 36.6% vs 32.9%, p=0.3; CRSRP vs CLOTBUST-ER: 26.5% vs 24.5%, p=0.8). Mortality was higher for CRSRP vs CLOTBUST-ER (7.3% vs 0.7%, p=0.006), but not vs NINDS (6.5% vs 4.5%, p=0.4). A pooled mortality model derived from 15 RCTs representing 4410 patients (R2=0.39) showed CRSRP and NINDS within expected mortality, while CLOTBUST-ER showed lower than expected mortality. CRSRP SICH rate equaled IAC (5.7% vs 5.7%; p=0.9). ConclusionsFunctional outcomes and SICH of thrombolysed Costa Rican patients compared favorably with published datasets, with a potential increase in early mortality.

Contemporary practice patterns and outcomes of systemic thrombolysis in acute pulmonary embolism

ObjectiveAlthough systemic thrombolysis (ST) is the standard of care in the treatment of high-risk pulmonary embolism (PE), large variations in real-world usage exist, including its use to treat intermediate-risk PE. A paucity of data is available to define the outcomes and practice patterns of the ST dose, duration, and treatment of presumed and imaging-confirmed PE. MethodsWe performed a multicenter retrospective study to evaluate the real-world practice patterns of ST use in the setting of acute PE (presumed vs imaging-confirmed intermediate- and high-risk PE). Patients who had received tissue plasminogen activator for PE between 2017 and 2019 were included. We compared the baseline clinical characteristics, tissue plasminogen activator practice patterns, and outcomes for patients with confirmed vs presumed PE. ResultsA total of 104 patients had received ST for PE: 52 with confirmed PE and 52 with presumed PE. Significantly more patients who had been treated for presumed PE had experienced cardiac arrest (n = 47; 90%) compared with those with confirmed PE (n = 23; 44%; P < .01). Survival to hospital discharge was 65% for the patients with confirmed PE vs 6% for those with presumed PE (P < .01). The use of ST was contraindicated for 56% of the patients with confirmed PE, with major bleeding in 26% but no intracranial hemorrhage. ConclusionsThe in-hospital mortality of patients with confirmed acute PE has remained high (35%) in contemporary practice for those treated with ST. A large proportion of these patients had had contraindications to ST, and the rates of major bleeding were significant. Those with confirmed PE had had a higher survival rate compared with those with presumed PE, including those with cardiac arrest. This observation suggests a limited role for empiric thrombolysis in cardiac arrest situations.

FACTORS INFLUENCING THE OUTCOME OF THROMBOLYSIS IN ACUTE MYOCARDIAL INFARCTION

Introduction: Coronary heart disease has been dened as "impairment of heart function due to inadequate blood ow to the heart compared to its needs, caused by obstructive changes in the coronary circulation to the heart." It is the cause of 25-30% of death in most of the industrialized countries. In India also, it is a major public health problem. It is aptly called by WHO as the modern epidemic. The increasing incidence of coronary heart disease may be a reection of increased longevity, adoption of high-fat diet based on meats, decreased exercise, modern lifestyle, made possible by increasing afuence. The primary goal of thrombolytic therapy is rapid, complete and sustained restoration of infarct related artery blood ow. Success rate of thrombolysis and thus the overall reduction in mortality is different among different agents used. To nd out the overall success rate of thrombolysis in intensive care unit. Find outAIMS &amp; Objective: whether the following parameters inuence the outcome of thrombolysis and determine their role in the success/ failure of thrombolysis. Material and Methods: Patients were included who is, presence of typical chest pain suggestive of Acute myocardial infarction along with ECG evidence Criteria for thrombolysis being 2 mm or more ST elevation in two contiguous precordial leads or 1 mm or more ST elevation in two contiguous limb leads. Time window of 12 hrs. from the onset of pain to the initiation of thrombolysis. All patients received streptokinase 1.5 million units in 100ml of normal, saline over 60Drug Therapy : minutes, Aspirin was given to all patients, Use of heparin, -blockers, ACE Inhibitors was according to ICU protocols, which was in accordance with ACC/AHA recommendations. Success was dened by: Clinical-Denition of success of thrombolysis: complete subsidence of chest pain, Electrocardiographically-more than 50% ST resolution in a lead which showed maximum ST elevation initially. ST elevation is measured manually, 80ms after J point from isoelectric line. Preceding PR segment is taken as isoelectric line. Patients were analyzed for success of thrombolytic therapy at 90 minutes after initiation of thrombolytic therapy, applying the above mentioned criteria. Those who underwent successful thrombolysis were grouped into group A. Those with failed thrombolysis -Group B. The following parameters were analyzed: Age, Gender, Smoking status, Drinking status, Diabetes mellitus, Systemic Hypertension, Location of Myocardial Infarction, Time interval between the onset of pain and the initiation of thrombolytic therapy, Killip grading. Patients with inferior wall myocardial infarction had a betterResults: outcome than anterior wall myocardial infarction. Alcohol, smoking and age were factors which inuence the outcome, but were not statistically signicant. Early thrombolysis had a better out come when compared to other predictors. Success rate was 64% in those patients thrombolysed within 4 hrs. from the onset of symptoms. Time window was found to be the most powerful factor inuencing the outcome of thrombolysis in patients with acute myocardial infarction. The successConclusion: rate was signicantly higher with a lower Killip grading and the outcome worsened as the grading increased.

Magnetic Resonance Imaging or Computed Tomography for Suspected Acute Stroke: Association of Admission Image Modality with Acute Recanalization Therapies, Workflow Metrics, and Outcomes.

ObjectiveTo examine rates of intravenous thrombolysis (IVT), mechanical thrombectomy (MT), door‐to‐needle (DTN) time, door‐to‐puncture (DTP) time, and functional outcome between patients with admission magnetic resonance imaging (MRI) versus computed tomography (CT).MethodsAn observational cohort study of consecutive patients using a target trial design within the nationwide Swiss‐Stroke‐Registry from January 2014 to August 2020 was carried out. Exclusion criteria included MRI contraindications, transferred patients, and unstable or frail patients. Multilevel mixed‐effects logistic regression with multiple imputation was used to calculate adjusted odds ratios with 95% confidence intervals for IVT, MT, DTN, DTP, and good functional outcome (mRS 0–2) at 90 days.ResultsOf the 11,049 patients included (mean [SD] age, 71 [15] years; 4,811 [44%] women; 69% ischemic stroke, 16% transient ischemic attack, 8% stroke mimics, 6% intracranial hemorrhage), 3,741 (34%) received MRI and 7,308 (66%) CT. Patients undergoing MRI had lower National Institutes of Health Stroke Scale (median [interquartile range] 2 [0–6] vs 4 [1–11]), and presented later after symptom onset (150 vs 123 min, p < 0.001). Admission MRI was associated with: lower adjusted odds of IVT (aOR 0.83, 0.73–0.96), but not with MT (aOR 1.11, 0.93–1.34); longer adjusted DTN (+22 min [13–30]), but not with longer DTP times; and higher adjusted odds of favorable outcome (aOR 1.54, 1.30–1.81).InterpretationWe found an association of MRI with lower rates of IVT and a significant delay in DTN, but not in DTP and rates of MT. Given the delays in workflow metrics, prospective trials are required to show that tissue‐based benefits of baseline MRI compensate for the temporal benefits of CT. ANN NEUROL 2022;92:184–194

Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability: A Meta-Analysis.

Randomized controlled trials for the use of alteplase in acute ischemic stroke have excluded or had little representation of patients with prestroke disability, and the benefit of alteplase in this population remains uncertain. We performed a systematic review and meta-analysis to examine the outcomes of thrombolysis in patients with premorbid disability. We performed a systematic review in accordance with the Meta-Analysis of Observational Studies in Epidemiology guidelines and retrieved studies reporting intravenous thrombolysis (IVT) in patients with prestroke disability (modified Rankin Scale score, 3-5) with acute ischemic stroke, either compared with untreated patients or treated patients without premorbid disability. The primary outcome was the return to premorbid disability at 90 days. Secondary outcomes included rate and odds ratio of favorable functional outcome at 90 days (modified Rankin Scale score 0-2 or return to premorbid modified Rankin Scale), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Eight articles were included involving 103 988 patients. Patients with disability treated with IVT had better odds of returning to baseline function compared with those who did not receive IVT (odds ratio, 7.26 [95% CI, 2.51-21.02]). Mortality and rates of sICH were not significantly different between patients with disability treated with IVT and those not treated, although there were numerically more sICHs in the IVT group. Return to baseline function was not significantly different between patients with and without prestroke disability (odds ratio, 1.46 [95% CI, 0.75-2.83]). The rates of sICH were not significantly different in patients with and without premorbid disability. However, mortality was 3× higher in patients with premorbid disability than in those without premorbid disability (38.2% versus 12.6%). The use of IVT in patients with disability was associated with better outcomes compared with patients who did not receive IVT without statistically significant added risks of sICH or mortality. When compared with those without disability, there was no significant difference in the return to baseline function or sICH. High-quality data comparing treated versus untreated patients with premorbid disability are needed to clarify this issue. URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

Thrombolysis, time-to-treatment and in-hospital outcomes among young adults with ischaemic stroke in China: findings from a nationwide registry study in China

Background and purposeWe aimed to determine whether young adults (<50 years) with acute ischaemic stroke (AIS) are more likely to receive intravenous tissue plasminogen activator (IV tPA) and have shorter...