Unrecognized major bleeding following thrombolysis for acute myocardial infarction presenting with syncope

Complete atrioventricular block and syncope sometimes are the presenting signs of acute myocardial infarction. In a presyncopal attempt to assume sitting position, the patient may fall and suffer consequent trauma. Once in hospital, this sequence of events may be overlooked by both the patient and admitting physicians. Moreover, physical examination initially may not be revealing. We report on two such patients who developed massive subcutaneous bleeding following thrombolytic and heparin treatment. We conclude that these patients constitute a specific group with a relatively high risk of trauma and bleeding at the gluteal region following thrombolytic therapy. Special attention must be given to these patients.

Resolution of ST-segment elevation after streptokinase therapy in anterior versus inferior wall myocardial infarction

BACKGROUND

Resolution of ST-segment elevation is the best bedside predictor of myocardial reperfusion.

HYPOTHESIS

This study was conducted to examine the resolution of ST-segment elevation after streptokinase therapy in anterior versus inferior acute myocardial infarction (MI) and to corroborate it with echocardiographic and coronary angiographic data.

METHODS

The study population consisted of 70 patients, 35 each in the anterior and inferior MI groups. The electrocardiograms (ECGs) were recorded before, on completion of, and on Days 1 and 2 post streptokinase therapy. The resolution of ST segment determined from post-streptokinase ECGs was compared between the two groups and correlated with echocardiographic and coronary angiographic data.

RESULTS

On completion of and on Day 1 post streptokinase therapy, ST-segment resolution in both groups was not significantly different. On Day 2 post streptokinase therapy, resolution of the ST segment per lead was significantly lower in anterior than that in inferior MI (61 +/- 21% anterior vs. 77 +/- 21% inferior, p 0.003). The number of patients with akinesis of infarct-related ventricular wall was significantly higher (17 anterior vs. 7 inferior, p 0.02), and left ventricular ejection fraction was significantly lower in anterior MI (39 +/- 7% anterior vs. 48 +/- 8% inferior, p < 0.01). There was no significant difference in coronary angiographic data. One patient in each group demonstrated normal coronary arteries.

CONCLUSIONS

The resolution of ST-segment elevation on the completion of and on Day 1 post streptokinase therapy was comparable between anterior and inferior MI. The significantly less frequent resolution of ST-segment elevation in anterior MI on Day 2 post streptokinase could be due to more akinesis, larger infarct size, and worse systolic function rather than due to failure to open the infarct-related vessel.

Prognostic role of plasminogen-activator-inhibitor-1 levels in treatment with streptokinase of patients with acute myocardial infarction

BACKGROUND

The antifibrinolytic effect of plasminogen-activator-inhibitor type 1 (PAI-1) may be responsible for delays in reperfusion and/or reinfarctions after streptokinase (STK) therapy in patients with acute myocardial infarction (AMI).

HYPOTHESIS

This study aimed to demonstrate the prognostic role of pretreatment PAI-1 levels for the outcome of STK therapy in patients with AMI, depending on reperfusion and/ or reinfarction.

METHODS

The mean pretreatment PAI-1 level of 104 patients with AMI, treated with STK, determined by chromogenic method, was 5.8 +/- 8.6 U/ml, range 0.3-66.2 U/ml. Streptokinase therapy was successful when reperfusion was achieved, as assessed noninvasively, without subsequent reinfarction; it failed when reperfusion was delayed and/or reinfarction developed.

RESULTS

Fibrinolysis with STK failed significantly in patients with elevated pretreatment PAI-1 levels (p < 0.05), especially with levels >4.0 U/ml (p< 0.01). The mean pretreatment PAI-1 level was significantly higher in unsuccessfully treated patients. Multivariate statistical testing demonstrated that among pretreatment variables, elevated PAI-1 activity was the most significant independent risk factor of failed fibrinolysis with STK.

CONCLUSIONS

Among pretreatment variables, elevated pretreatment PAI-1 activity in patients with AMI was the most significant independent risk factor of failed fibrinolysis with STK, especially at levels > 4.0 U/ml.

Increased levels of plasma thrombomodulin in patients with acute myocardial infarction who had thrombolytic therapy and achieved successful reperfusion

BACKGROUND

There is a growing body of evidence from animal and in vitro studies for the existence of reperfusion injury after thrombolytic therapy for acute myocardial infarction (AMI), but the patient data are limited.

HYPOTHESIS

We aimed to examine the plasma thrombomodulin (TM) levels as a marker of endothelial injury and to investigate the effect of successful reperfusion on these levels.

METHODS

The study included 32 patients who had a first episode of acute myocardial infarction (AMI) and received intravenous streptokinase therapy.

RESULTS

Thrombomodulin levels increased significantly at 60 min after thrombolysis compared with the levels before thrombolytic therapy (0 min) in 21 (66%) patients who had successful reperfusion (49.09 +/- 10.51 vs. 25.76 +/- 5.55 ng/ml, p < 0.001). There was no difference between the TM levels at 0 and at 60 min of thrombolysis in the remaining 11 (34%) patients who could not achieve reperfusion (27.81 +/- 6.32 vs. 28.72 +/- 7.28 ng/ml, p = 0.35).

CONCLUSION

There was a significant increase in TM levels at 60 min after thrombolysis in a group of patients with AMI who achieved successful reperfusion; this increase may have been caused by the activation/injury of endothelial cells. Data also suggest that the increment in TM levels may be predictive of the potential success of thrombolytic therapy.

The effect of thrombolytic therapy on left ventricular aneurysm formation in acute myocardial infarction: relationship to successful reperfusion and vessel patency

BACKGROUND

Although there is increasing evidence for the beneficial effect of thrombolytic therapy on global left ventricular (LV) function in acute myocardial infarction (AMI), the data concerning the early effect of thrombolytic therapy on the incidence of left ventricular aneurysm (LVA) formation and its relationship to clinical and angiographic determinants are limited.

HYPOTHESIS

The study aimed to determine the independent factors involved in the development of LVA and to evaluate whether thrombolytic therapy has any preventive effect on the development of LVA in AMI.

METHODS

In all, 350 consecutive patients suffering from a first attack of AMI were included. Of these, 205 who arrived within 12 h of onset of symptoms received thrombolytic therapy (thrombolytic group) and the remaining 145 patients served as control group. All patients received aspirin and maximal-dose anticoagulation with intravenous heparin therapy. Early successful reperfusion was assessed by enzymatic and electrocardiographic evidence, and late vessel patency was evaluated according to Thrombolysis in Myocardial Infarction (TIMI) classification. Patients with TIMI grade 2 or 3 flow were considered to have vessel patency.

RESULTS

The overall incidence of LVA was 11.7% (41/350), and no statistical difference was found between the incidence of LVA between the two groups (11.7 vs. 11.7%, p>0.05). However, the patients receiving thrombolytic therapy and exhibiting a patent infarct-related artery (PIRA) (n = 125, 61%), had a significantly reduced incidence of LVA compared with those who did not (7.2 vs. 18.8%, p= 0.015). In univariate analysis, vessel patency, proximal left anterior descending artery (LAD) stenosis, total LAD occlusion, multivessel disease, and hypertension were found to be important factors in LVA formation after AMI. After adjustment for other clinical and angiographic variables, total LAD occlusion (odds ratio [OR] 3.62,95% confidence interval [CI] 2.45-8.42, p = 0.0014), absence of PIRA (OR 2.92, 95% CI 1.41-09, p = 0.0037) and proximal LAD stenosis (OR 2.11, 95% CI 1.05-4.71, p = 0.045) remained the independent determinants of LVA formation after AMI.

CONCLUSION

Our data indicate that not all patients who received thrombolytic therapy, but only those with PIRA had evidently reduced the incidence of LVA. Patients with total LAD occlusion, with proximal LAD stenosis, and without PIRA were found to have increased risk for formation of LVA after AMI. These findings indicate that the presence of vessel patency has a preventive effect on LVA formation in AMI.

Atypical clinical manifestation of antiphospholipid syndrome

Antiphospholipid syndrome is a disorder characterized by recurrent venous or arterial thrombosis and/or recurrent abortions associated with persistently elevated levels of antiphospholipid antibodies. In some patients antiphospholipid syndrome occurs in association with systemic lupus erythematosus, or other autoimmune disorders or malignancies. Antiphospholipid syndrome can be induced by certain drugs. A correct diagnosis of this disease is necessary as it is potentially associated with serious and sometimes life-threatening complications. Clinical presentations of antiphospholipid syndrome may vary widely even in the same patient. The time between individual manifestations of the disease also varies considerably. Therefore its early detection requires a strong index of suspicion especially when thrombosis occurs at unusual sites or non-specific symptoms predominate in the clinical presentation. We report a case of a 20-year-old woman with a recent history of pulmonary embolism who was admitted to the hospital because of severe symptomatic anemia. Once the diagnosis of antiphospholipid syndrome coexisting with systemic lupus erythematosus as a primary disorder has been established, implemention of specific treatment resulted in markedly improved condition.

[Anticoagulant and thrombolytic agents in acute coronary syndromes]

The term acute coronary syndrome (ACS) pertains to the instable and life-threatening forms of a clinically manifest coronary artery disease with biochemical and/or electro-cardiographic evidence of myocyte cell death. In detail, it includes the unstable angina pectoris, the non-ST segment elevation myocardial infarction (NSTEMI) the ST segment elevation myocardial infarction (STEMI) and as well the sudden cardiac death. As early reperfusion of ischaemic myocardium is the most effective way for limiting infarct size by restoring the balance between myocardial oxygen supply and demand, it is the most important therapeutic goal to achieve early and complete antegrade flow in the occluded or restricted vessel, related with a reduction of short and longtime complications as heart failure and severe arrhythmias. It is generally accepted, that the primary percutaneous coronary intervention (PCI) is the method of choice in acute myocardial infarction (STEMI) to restore TIMI-3 blood flow in occluded coronary arteries, if this can be performed within two hours of symptom onset and by a highly specialized team. Since these requirements are only met in 20% of hospitals caring for patients with STEMI in Germany, the therapy with thrombolytic and anticoagulant agents plays still an important role. Apart from a rapid and effective prehospital primary care, it depends furthermore on a differentiated anticoagulatory and antithrombotic therapy during coronary intervention to get optimal results.

Thrombolytic therapy for late thrombosis of a bioprosthetic mitral valve: atypical diagnostic echocardiographic features and a review of the literature

Bioprosthetic valves are generally considered to carry a low risk of valve thrombosis, obviating the need for long-term anticoagulation in most patients. Few reports exist of the diagnostic characteristics and management of bioprosthetic valve thrombosis. Herein is presented a case of critical bioprosthetic mitral valve thrombosis in which successful clinical and hemodynamic resolution was achieved with intravenous thrombolysis. A current review of the bioprosthetic valve thrombosis literature is also presented.

A case of venous gangrene, treated successfully with thrombolytic therapy and skin grafting

Venous gangrene is a rare condition. We report a case of venous gangrene, treated successfully with thrombolytic therapy and subsequently by skin grafting.

Intrapleural streptokinase treatment in children with empyema

Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.

[Clinical features in 65 patients with acute myocardial infarction underwent successful thrombolytic therapy post cardiopulmonary resuscitation]

OBJECTIVE

To analyze the clinical features of patients with acute myocardial infarction underwent successful thrombolytic therapy post cardiopulmonary resuscitation.

METHODS

This retrospective analysis included 65 patients with acute myocardial infarction underwent successful intravenous thrombolysis post cardiopulmonary resuscitation. The cases were collected from Chinese Journal Full-text Database from 1996 to 2006, only patients met the recanalization criteria of coronary artery were included.

RESULTS

Most of the patients were male (93.8%, 61/65) and aged less than 65 years (81.5%, 53/65). Cardiopulmonary resuscitation was performed within 5 min after cardiac arrest in 63 patients (96.9%). Defibrillation was performed 3.2 times per patient, chest compression in 52 patients (80.0%) and tracheal intubation in 21 patients (32.3%). The restoration time of spontaneous circulation were achieved within 10 min in 36 cases (55.4%), between 11 - 30 min in 19 cases (29.2%)and between 31 - 107 min in 10 cases (15.4%). Thrombolysis agents (urokinase, recombinant streptokinase or recombinant tissue-type plasminogen activator) were given intravenously at 172 +/- 92 min after acute myocardial infarction. Mild hemorrhage was seen in 12 cases (18.5%) and there was no report on severe hemorrhage event. The hemorrhage incidence tended to be higher than that of reported large Chinese thrombolysis trials (11.1% - 15.1%, P > 0.05).

CONCLUSION

Thrombolytic therapy was relatively safe and effective for those middle-aged male AMI patients received rapid cardiopulmonary resuscitation (< 5 min after cardiac arrest) and with shorter spontaneous circulation restoration time (<30 min).

ST segment resolution post MI--a predictor of better outcomes

OBJECTIVE

To compare, the post Myocardial Infarction in-patient outcome of patients with early ST resolution to those without ST resolution on ECG, in a South Asian population.

METHODS

This was a prospective study done at the Punjab Institute of Cardiology, Lahore. Consecutive patients of ST elevation myocardial infarction, who were not treated with primary angioplasty but were thrombolysed were recruited at the time of arrival in the emergency department. Streptokinase was administered to all patients as the agent of thrombolysis. ECG was acquired at baseline and at 60 minutes post streptokinase administration. Patients were subsequently divided into two groups (A) Patients with ST segment resolution, after 60 minutes of administration of streptokinase (B). Patients without ST segment resolution, after 60 minutes of administration of streptokinase. This cohort was followed up through the in hospital stay for major complications which were recurrent ischaemic chest pain ,heart failure, arrhythmias and death, during the follow up period (Mean stay 3.01+/- 0.77 days).

RESULTS

A total of 148 patients were included in this prospective study. There were 122 males and 26 females. In group A complications developed in 33 (35%) out of 95 patients and 43 (81%) out of 53 patients in group B (p< 0.001). Recurrent chest pain was present in 19 (20%) patients of group A and 31 (59%) patients of group B (p<0.001).Heart failure was the most common complication observed in both groups, 26 (27%) patients in group A and 33 (62%) patients in group B (p<0.001). Arrhythmias were more common in group B, with 17 (32%) patients from group B and 9 (10%) from group A developing this complication (p<0.001).

CONCLUSIONS

The extent of ST segment resolution provides useful information about early clinical outcome in post-myocardial infarction patients.

Acute pulmonary embolism advances in treatment

Recent advances in interventional cardiology, pharmacotherapeutics and modern surgical management in tertiary cardiac care centers have tremendously improved the present treatment of Pulmonary Embolism (PE). CT pulmonary angiography (CTPA), nuclear lung scan (V/Q scan), D-dimer test and modern echocardiography have revolutionized the diagnostic methodology and risk assessment criteria. Cardiogenic shock or systolic hypotension (BP < 90 mmHg) and presence of right ventricular dysfunction (or failure) are two principal criteria which govern the severity of pulmonary embolism. While all patients of pulmonary embolism require anticoagulation, systemic thrombolytic therapy is the mainstay of initial treatment in massive and submassive pulmonary embolism. When thrombolysis is contraindicated or has failed, urgent surgical embolectomy or catheter embolectomy may be life saving procedures in severe pulmonary embolism.

Short- and long-term mortality in patients with ST-elevation myocardial infarction treated with different therapeutic strategies. Results from WIelkopolska REgional 2002 Registry (WIRE Registry)

BACKGROUND

Although primary coronary angioplasty seems to be the best treatment in acute myocardial infarction (MI), thrombolytic therapy still remains the most common reperfusion strategy particularly in smaller centers. Nowadays, different regional networks are developed to improve the treatment of patients with MI.

AIM

To analyse the effects of different therapeutic strategies on 30-day and long-term mortality (median time 18.3 months) after ST-elevation MI (STEMI) in a population of 3 350 000 people from the Wielkopolska Region.

METHODS

In 2002, 3780 patients with STEMI entered the registry. Complete data were available for 3564 (94.3%) patients. Depending on therapeutic strategies, patients were divided into five groups: the PCI group--direct percutaneous coronary angioplasty (PCI) in small cathlab, 'selected patients', n=381 (10.7%); the PA group--aged <70, treated with tissue plasminogen activator (rt-PA) up to 4 hours from the onset of chest pain, n=479 (13.4%); the IS group - invasive strategy in every patient, 24-hour duty, setting of unselected patients with STEMI, n=989 (27.7%); the SK group--patients receiving standard streptokinase treatment up to 12 hours from the onset of chest pain, n=584 (16.4%); the NR group--no reperfusion therapy, n=1131 (31.7%).

RESULTS

The 30-day mortality rate in the groups above was: 3.15, 4.38, 4.54, 9.25, and 12.5% respectively (p <0.001). Long-term mortality rate was: 4.2, 9.4, 9.4, 14.4, and 18.50% respectively (p <0.001). The rate of urgent PCI in the PA group was 25% and in the SK group--11% (p <0.001).

CONCLUSIONS

Treatment with rt-PA in patients under 70 years of age and up to 4 hours from pain onset may be an alternative to an invasive strategy. However, a quarter of those patients require urgent PCI. In long-term observation the mortality benefit can be clearly seen only in patients with early PCI.

[ln-hospital mortality after ST-segment elevation myocardial infarction according to reperfusion therapy]

BACKGROUND

Primary angioplasty is considered the best reperfusion therapy in the treatment of ST-segment elevation myocardial infarction (STEMI). However, thrombolysis is the reperfusion method most commonly used, due to its wide availability, reduced costs and ease of administration.

AIM

To compare in-hospital mortality in STEMI patients according to reperfusion therapy.

MATERIAL AND METHODS

Patients admitted to Chilean hospitals participating in the GEMI network, from 2001 to 2005, with STEMI were included. They were divided in three groups: a) treated with thrombolytics, b) treated with primary angioplasty, c) without reperfusion procedure. In-hospital mortality according to gender, was analyzed in each group, using a logistic regression method, to assess risk factors associated with mortality.

RESULTS

We included 3,255 patients. Global mortality was 9.9% (7.5% in men and 16.7% in women, p<0.001). Mortality in patients treated with thrombolytics, was 10.2% (7.6% in men and 18.7% in women, p<0.01). The figure for patients treated with primary angioplasty, was 4.7% (2.5% in men and 13% in women, p<0.01), and in patients without reperfusion, was 11.6% (9.8% in men and in 15.4% women, p<0.01). In each group women were older, had a higher prevalence of hypertension and a higher percentage of Killip 3-4 infarctions. Logistic regression showed that angioplasty, compared with no reperfusion, was associated with a reduced mortality only in men. The use of thrombolytics in women was associated with a higher mortality.

CONCLUSIONS

Primary angioplasty was the reperfusion therapy associated to the lower mortality in STEMI. Use of thrombolytics in women was associated with a higher mortality rate than in non reperfused women.

[The efficacy of alteplase in pulmonary embolism treatment]

The results of pulmonary embolism treatment with streptase in 76 patients are discussed. All patients had submassive or massive pulmonary embolism. 66 (86%) of patients recovered. Thrombolysis with the use of heparin was performed in 9 patients, death occurred in 5 of them. Of 20 patients treated with "Actilize", death was reported in three cases. Authors consider alteplase to be highly effective in the treatment of massive pulmonary embolism. In case of late diagnostics of pulmonary embolism, especially recurrent, thrombolytic therapy remains to be effective up to 2 weeks after primary embolization.

Acute anuric renal failure with streptokinase therapy in a patient with acute venous thromboembolic disease and the review of renal side effects of streptokinase

The benefits of thrombolytic therapy in acute myocardial infarction are now well established. However many uncertainties, such as adverse effects, are still remain in venous thromboembolic disease. We describe a unique patient who treated with streptokinase for the methylen tetrahydrofolate reductase mutation associated acute deep vein thrombosis and massive pulmonary embolism. After therapy patient developed acute anuric renal failure without an evidence of bleeding or immunologic reaction and we would like to review the renal side effects of streptokinase in patients with venous thromboembolic disease.

[Perftoran in complex therapy of acute myocardial infarction in elderly patients]

One of actual problems is the choice of a method to treat geriatric patients with acute myocardial infarction. 220 elderly patients with acute myocardial infarction were examined; 93 of them were given standard thrombolytic therapy, 62 patients were given perftoran and 65 patients were given combined therapy by streptase and perftoran. Efficiency of the therapy was estimated by results of ECG and clinical data. The obtained results prove that timely application of combined therapy by streptase and perftoran in complex treatment of acute myocardial infarction in elderly patients promotes efficacy of the treatment.

Intraventricular streptokinase after intraventricular hemorrhage in newborn infants

BACKGROUND

Hydrocephalus following intraventricular hemorrhage (IVH) is still one of the most serious complications of premature birth. Ventriculoperitoneal shunt surgery cannot be carried out early and permanent dependence on a shunt is associated with several serious complications. Streptokinase could be useful in the treatment of post-hemorrhagic hydrocephalus. This form of therapy is based on the hypothesis that multiple blood clots in the cerebrospinal fluid (CSF) are the initial cause of post-hemorrhagic ventricular dilatation and lysis of clots could reopen the pathways of circulation and re-absorption of CSF.

OBJECTIVES

To determine the effect of intraventricular streptokinase after intraventricular hemorrhage on the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk for, or actually developing post-hemorrhagic hydrocephalus (PHH).

SEARCH STRATEGY

Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976 until October 2000, as well as the MEDLINE database (via PubMed) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) up to April 2007. Personal contacts were used.

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized controlled trials evaluating the use of injection of streptokinase into the CSF in infants having or at risk for post-hemorrhagic hydrocephalus.

DATA COLLECTION AND ANALYSIS

Details of patient selection, patient allocation and the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, meningitis, and secondary hemorrhage.

MAIN RESULTS

Two randomized trials evaluated intraventricular streptokinase in infants developing post-hemorrhagic ventricular dilatation were identified When intraventricular streptokinase was compared with conservative management of post-hemorrhagic ventricular dilatation, the numbers of deaths and babies with shunt dependence were similar in both groups. No information on the effect of intraventricular streptokinase on disability is available. There is cause for concern about meningitis and secondary intraventricular hemorrhage, but numbers are insufficient to quantify the risks.

AUTHORS' CONCLUSIONS

Intraventricular fibrinolytic therapy with streptokinase, given when post-hemorrhagic ventricular dilatation is established, cannot be recommended for neonates following IVH. A conservative approach with CSF drainage applied only to symptomatic raised intracranial pressure seems appropriate.

Time course of platelet aggregation during thrombolytic treatment of massive pulmonary embolism

We studied changes in platelet aggregation and fibrinogen levels during thrombolysis with massive or submassive pulmonary embolism. Fifteen patients were randomized into ultrahigh-dose streptokinase (UH-SK n = 8) or alteplase (tPA n = 7) groups. Arterial blood samples were taken before and after thrombolysis every 4 h between 4 and 36 h, and once daily between 2 and 30 days. In-vitro platelet aggregation was examined as spontaneous (0.9% NaCl) and induced aggregation with adrenaline 10 micromol/l, collagen 2 microg/ml and ADP 10 micromol/l. D-dimer and fibrinogen were measured every 8 h on first day, and later as above. In the UH-SK group, adrenaline-induced platelet aggregation decreased at 4 and 8 h compared with baseline (P < 0.03). Adrenaline-induced platelet aggregation was significantly lower in the UH-SK group than in the tPA group at 36 h and on day 3 (P < 0.03). Platelet aggregation induced by ADP was lower at 4 h than at baseline in the UH-SK group (P < 0.05). Collagen-induced platelet aggregation was lower at 4 and 8 h than at baseline (P < 0.05) in the UH-SK group. Compared with baseline, fibrinogen levels decreased in both groups after thrombolysis. D-dimer levels were elevated in both groups at 8 h (tPA group, P < 0.0004; UH-SK group, P < 0.05). Spontaneous platelet aggregation, major bleeding or re-embolism was not documented. Platelet aggregation decreased after thrombolysis with UH-SK for 12 h, in comparison tPA caused an insignificant decrease. Fibrinogen level decreased with UH-SK treatment for 5 days but in case of tPA we could not measure significant changes. According to our findings, tPA is a more suitable drug but streptokinase is also effective because of its cost-benefit ratio.

Empyema thoracis

OBJECTIVE

To review the management of Empyema Thoracis in the surgical department of Kathmandu Medical College Teaching Hospital.

METHODS

Thirteen cases with Empyema thoraces treated in the surgical department of the hospital with different modalities of treatment was taken for study and analyzed for morbidity, mortality, and hospital stay.

RESULTS

there was a single mortality in the thoracotomy group. Video assisted thoracic surgery or VATS debridement or deloculation was successful in the eight of the patients with shorter stay in the hospital. One patient who refused surgery was treated with streptokinase with good result.

CONCLUSION

Streptokinase may be effective in the treatment of empyemas. Video assisted thoracic surgery or VATS has definite advantage over traditional surgery in terms decreased morbidity, mortality, earlier hospital discharge and cosmesis in the treatment of empyema.

Cerebral Gas Embolism Caused by Pleural Fibrinolytic Treatment

Background and Purpose— Intrapleural fibrinolytic therapy is a technique used to treat empyemas and parapneumonic effusions. Cerebral air embolism is an unusual potentially severe complication of this technique.

Summary of Case— A patient with parapneumonic pleural effusion underwent pleural lavage with streptokinase when he suddenly demonstrated focal neurological signs and seizures. The CT revealed multiple air-isodense spots in right hemisphere of the brain, suggesting cerebral air embolism. As a result of early diagnosis and emergency hyperbaric oxygenation, the patient recovered without delayed sequelae.

Conclusions— Air embolism is a potentially severe complication which can occur during fibrinolytic pleural lavage, and clinicians should be aware of this risk. In this context, the onset of acute focal neurological signs or seizures should suggest the possibility of air embolism and lead to the transfer of the patient close to a hyperbaric facility within a few hours.

The influence of acute-phase levels of haemostatic factors on reperfusion and mortality in patients with acute myocardial infarction treated with streptokinase

BACKGROUND

The fibrinolytic system and von Willebrand factor (vWF) have been shown to play a role as risk factors for myocardial infarction. We performed this prospective cohort study to determine if components in the fibrinolytic system or vWF before or during treatment of AMI with streptokinase (SK) could predict reperfusion, recurrent ischaemia, reinfarction or mortality at one year, or mortality at five years. Reperfusion and recurrent ischaemia were assessed by continuous vectorcardiography. The setting was Umeå university hospital and Skellefteå county hospital, Sweden.

RESULTS

139 patients were included; successful reperfusion was obtained in 53%. tPA activity, PAI-activity, PAI-mass concentration and vWF were analysed immediately on arrival and after 4 and 10 h. High fibrinolytic activity, measured as tPA activity > 25 U/L after the start of treatment, was associated with reperfusion. No significant associations between pre-treatment levels of the fibrinolytic variables or vWF and reperfusion or recurrent ischaemia were found. Elevated levels of PAI-1 mass concentration and PAI-1 activity after the start of SK treatment were associated with a higher risk for death at one year, but not at five years. High levels of vWF were associated with worse prognosis but not when corrected for age.

CONCLUSION

Pre-treatment levels of PAI-1, vWF and tPA activity showed no association with reperfusion or recurrent ischaemia. Elevated levels of PAI-1 activity after the start of treatment were associated with worse prognosis.