Efficacy of high dose intravenous heparin for treatment of left ventricular thrombi with high embolic risk

Pulmonary Artery Stump Thrombus in a Patient With Remote History of Rastelli Procedure

•Atrial tachyarrhythmia may develop in Rastelli patients after decades. •Thrombus can form in the PA stump after the Rastelli procedure. •TEE remains crucial to rule out intracardiac thrombus before cardioversion.

Dilemmas in hematology: consults in patients with arterial thrombosis

Arterial thrombotic events, particularly ischemic stroke and myocardial infarction, are common, and mostly occur due to atherosclerotic disease or arrhythmias. The diagnosis and management of the majority of such events occurs without the involvement of a hematologist, following established guidelines or pathways. In this review, we discuss 3 scenarios in which optimal management is less certain. These scenarios concern patients with a left ventricular thrombus, in whom the duration and choice of anticoagulant has been debated, patients with ischemic stroke and a patent foramen ovale, in whom the role of patent foramen ovale closure requires careful consideration, and the role of thrombophilia testing in young patients after a stroke or myocardial infarction, which remains an area of contention. We consider the available evidence and published guidelines in order to provide a practical, evidence-based approach to these 3 clinical scenarios.

Left ventricular thrombosis: new perspectives on an old problem

Left ventricular thrombosis (LVT) is a major risk factor for systemic thromboembolism and might complicate both the acute and the chronic phase of ischaemic heart disease after myocardial infarction and, less frequently, non-ischaemic cardiomyopathies. The pathophysiology of thrombus formation is complex and involves the three aspects of Virchow's triad: blood stasis, prothrombotic state, and tissue injury. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. Of note, anticoagulation therapy with heparin and vitamin K antagonists decreases the risk of embolic stroke though exposing patients to an undeniable risk of bleeding complications. Although limited data on the off-label use of direct oral anticoagulants have reported safety and efficacy for LVT resolution, yet more evidence is needed to justify their use in clinical practice.

Perioperative management of antithrombotic treatment

End-stage liver disease is characterized by multiple and complex alterations of hemostasis that are associated with an increased risk of both bleeding and thrombosis. Liver transplantation further challenges the feeble hemostatic balance of patients with decompensated cirrhosis, and the management of antithrombotic treatment during and after transplant surgery, which is particularly difficult. Bleeding was traditionally considered the major concern during and early after surgery, but it is increasingly recognized that transplant recipients may also develop thrombotic complications. Pathophysiology of hemostatic complications during and after transplantation is multifactorial and includes pre-, intra-, and postoperative risk factors. Risk stratification is important, as it helps the identification of high-risk recipients in whom antithrombotic prophylaxis should be considered. In recipients who develop thrombosis during or after surgery, prompt treatment is indicated to prevent graft failure, retransplantation, and death.

Resolution of left ventricular thrombus by edoxaban after failed treatment with warfarin overdose: A case report

RATIONALE

Although novel oral-anticoagulants are widely used in patients with atrial fibrillation (AF) for stroke prevention, there was only limited evidence for their use in left ventricular (LV) thrombus.

PATIENT CONCERNS

A 41-year-old man who presented with acute onset of right-hand clumsiness and aphasia even under high international normalized ratio (INR: 7.64) from warfarin use. He was previously treated with warfarin for the LV thrombus and non-valvular AF. Brain magnetic resonance imaging (MRI) showed multiple acute infarction in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke.

DIAGNOSIS

The repeated transthoracic echocardiogram still revealed LV thrombus (1.27 × 0.90 cm), which failed to respond to warfarin therapy.

INTERVENTIONS

Due to acute infarctions occurred under supratherapeutic range of INR, we switched warfarin to edoxaban (dose: 60 mg/day) after INR decreased to less than 2.

OUTCOMES

The thrombus disappeared after receiving edoxaban for 23 days, and no more recurrent stroke was noted for more than 6 months.

LESSONS

This is the first case demonstrates that while facing ineffective treatment of warfarin for LV thrombus, edoxaban could be safely and effectively used under this situation.

Hypercoagulability in End-stage Liver Disease: Review of Epidemiology, Etiology, and Management

In this review, we analyze the epidemiology of thromboses related to end-stage liver disease (ESLD), discuss causes of hypercoagulability, describe susceptible populations, and critically evaluate proposed prophylaxis and treatment of thromboses. Classically, ESLD has been regarded as a model for coagulopathy, and patients were deemed to be at high risk for bleeding complications. Patients with ESLD are not auto-anticoagulated, and they do not have a lower risk of portal vein thrombosis, intracardiac thrombus formation, pulmonary embolism or hepatic artery thrombosis. Though the cause of hypercoagulability is multifactorial, endothelial dysfunction likely plays a central role for all patients with ESLD. Some subpopulations, such as patients with nonalcoholic steatohepatitis and autoimmune conditions, are at increased risk of thrombotic events as are patients of Hispanic ethnicity. The science behind prophylaxis of different types of clotting and treatment of thromboses is developing rapidly. A number of medications, including low molecular weight heparin, unfractionated heparin, aspirin, vitamin K antagonists, and direct oral anticoagulants can be used, but clear guidelines are lacking. Acute intraoperative clotting can be associated with high mortality. Routine use of transesophageal echocardiography can be helpful in early recognition and treatment of intraoperative thrombosis. Heparin should be reserved for cases of intracardiac thrombus/pulmonary embolism without hemodynamic instability. In unstable patients, low dose of recombinant tissue plasminogen activator can be used. In this new era of heightened awareness of thrombotic events in ESLD patients, prospective randomized trials are urgently needed to best guide clinical practice.

"Bailout" Endovascular Treatment of Acute Aortic Occlusion

A 37-year-old man who had a recent history of acute myocardial infarction (AMI) 3 months ago presented to the emergency department with acute ischemia of lower limbs. A CT aortography was performed, where left ventricle thrombi and acute thromboembolic occlusion of aortoiliac bifurcation were depicted. He was urgently transferred to the operation theatre, where Fogarty embolectomy was initially unsuccessful. He was managed by primary deployment of balloon expandable (BE) covered stents in the aortic bifurcation followed by thrombectomy of the left ventricle (LV) under extracorporeal circulation by cardiothoracic surgeons 2 days after initial operation. He was discharged in good general condition after 20 days under warfarin and aspirin therapy.

Left ventricular thrombus and systemic embolism after painless myocardial infarction in a young female

Oral contraceptives are widely used because of their reliability. Although oral contraceptives are known to increase the risk of thromboembolic events, there are extremely few reports of oral contraceptive–induced left ventricular thrombus. Herein, we report a 37-year-old non-smoking female, who had regularly taken oral contraceptives for 14 years, developed an anterior myocardial infarction concomitant with left ventricular thrombus, bilateral segmental renal infarctions, and lower limb ischemia. Medical treatment with a combination of dual antiplatelet therapy and anticoagulants completely relieved her symptoms.

Complete Resolution of the Left Ventricular Pedunculated Thrombus with Tirofiban Infusion in a Patient with Severe Left Ventricular Dysfunction

A 28-year-old man was admitted with symptoms of heart failure. Echocardiography revealed severe left ventricular dysfunction, apical aneurysm, and a 40 × 11 mm sized mobile thrombus attached to apical septum with a narrow stalk. The patient had anterior myocardial infarction two years ago. Heparin infusion was started at 1000 IU/hour for 48 hours. There was no detected change on the size of the thrombus. Surgery recommended to the patient was refused by him because of the procedural risks. Tirofiban infusion was started. Repeat echocardiography showed significant reduction in thrombus size after 24 hours, and complete resolution of the thrombus after 48 hours. To our knowledge, this is the first case with left ventricular mobile thrombus treated successfully with tirofiban infusion.

Emergent Management of Intracardiac Thrombosis during Liver Transplantation

Intraoperative thromboembolism is a well-documented complication associated with orthotopic liver transplantation (OLT) but its identification and intraoperative treatment are still an emerging topic in anesthesia. Intracardiac thrombus during OLT is associated with a high mortality rate. There are only a few reports describing the successful management of thromboembolism during OLT. We describe a case where routine intraoperative transesophageal echocardiography during a live donor liver transplantation enabled early detection of an intracardiac thrombus with subsequent successful heparin treatment. Our case suggests that if an intracardiac thrombus is identified early (before hemodynamic instability occurs), the use of IV heparin may be a safe therapeutic option.

Use of Heparin in Acute Ischemic Stroke: Is There Still a Role?

Heparin has long been a contested therapy in acute ischemic stroke (AIS). In current practice, heparin is considered on a case-by-case basis, but there is no consensus as to the appropriate timing of anticoagulation or for which ischemic stroke subtypes heparin may be beneficial. To provide better clarity on this issue, we review current research focusing on the use of heparin in AIS in each stroke subtype and subsequently make recommendations to provide readers with a systematic approach to managing complex stroke patients for which acute anticoagulation may be valuable. We conclude that there are certain subpopulations of ischemic stroke patients that may derive benefit from heparin when given acutely, including patients with symptomatic large artery stenosis >70 %, non-occlusive intraluminal thrombus, and in patients with high-risk cardiac conditions including left ventricular thrombus, left ventricular assist devices, and mechanical heart valves.

Penetrating Cardiac Injury Managed Without Surgery but with Systemic Heparinisation

A 36-year-old woman presented to hospital after a penetrating chest injury. She was haemodynamically stable. Echocardiography revealed left ventricular thrombus, with minimal pericardial effusion and no associated cardiac injuries. Intravenous anticoagulation was commenced for her intracardiac thrombus and her pericardial effusion was monitored with serial echocardiography. She remained well, was converted to warfarin and discharged home day 12 post admission, with cautious follow-up given her risk of late effusion and tamponade. Follow-up imaging revealed resolution of her intracardiac thrombus. She remains well to date.

Left ventricular mass: myxoma or thrombus?

Patient with embolic episode should always be evaluated for cardiac mass. Mass in left ventricular can be a myxoma or thrombus even in a normal functioning heart. In either case, mobile mass with embolic potential should be surgically resected.

Delayed left ventricular apical thrombus formation following discontinuation of dual anti-platelet therapy

Delayed de novo left ventricular apical thrombus following a distant antero-apical myocardial infarction has to our knowledge not been previously reported. Herein we describe a patient who developed an apical thrombus 18 months after his initial infarct following cessation of dual anti-platelet therapy for a traumatic subdural haematoma requiring surgical evacuation.

Anti-Jo-1 myositis and the antiphospholipid syndrome showing right ventricular thrombus: a novel overlap syndrome with atypical presentation

It has long been recognized that patients with myositis and positive anti-Jo1 antibody tend to be associated with interstitial lung disease. Recent studies revealed that such patients may also have fever, Raynaud's phenomenon, mechanic's hand, polyarthralgia, or usually mild, self-limiting, non-erosive or erosive polyarthritis known as antisynthetase syndrome. The hallmark of this disorder is the presence of the autoantibodies that recognize the aminoacyl-tRNA synthetases, which play a critical role in protein synthesis. The most well recognized of the autoantibodies is anti-histidyl (Jo-1). Antisynthetase syndrome cases associated with other autoimmune diseases are rarely reported. We here present a case of antisynthetase syndrome presented with right ventricle thrombus and deep vein thrombosis in the lower limbs. Secondary antiphospholipid syndrome was then diagnosed after a series of examinations. The patient was successfully treated with anticoagulant alone without surgical thrombectomy. Our case revealed that clinical physicians should watch for thrombotic complications when facing patients with antisynthetase syndrome. Medical therapy with anticoagulants alone may be an alternative treatment option in patients with right ventricle thrombus who cannot tolerate surgical thrombectomy.

Intracardiac thrombus: diagnosis, complications and management

Intracardiac thrombus is a condition of increasing clinical significance not only because of its potential complications but also because of the lack of clinical evidence to guide clinicians in selecting optimal therapies. Thus, 2 recent cases encountered at the Vanderbilt University Medical Center illustrate the clinical challenges one may encounter in patients with intracardiac thrombus. A careful review of the diagnostic challenges, potential complications and current recommendations for management are presented.

Mobile left ventricular thrombus in left ventricular dysfunction: case report and review of literature

INTRODUCTION

Left ventricular (LV) thrombi carry a high risk of embolization. Therapeutic recommendations like treatment with low molecular heparin and intravenous unfractionated heparin (UFH), thrombolysis or surgical thrombectomy have failed to reach a consensus.

CASE DESCRIPTION

A 56-year-old female patient presented in cardiogenic shock to the emergency department. Echocardiography demonstrated a dilated LV with a severely depressed global systolic function and a large LV apical thrombus. Treatment with UFH was initiated as well as a treatment with catecholamines for stabilizing the patient's hemodynamic situation. On the follow-up echocardiographic examination, extensive free-floating parts of the thrombus could be documented. Given the high risk of embolization in a now hemodynamically stable situation, emergency surgical embolectomy was performed.

DISCUSSION

A conservative procedure might be useful for bridging till surgical treatment is available and/or the risk due to surgery is acceptable.

CONCLUSION

In absence of evidence-based guidelines for the treatment of LV thrombi, individualized management options concerning surgical, embolization and bleeding risk must be taken into account.

Successful medical management of a left ventricular thrombus and aneurysm following failed thrombolysis in myocardial infarction

We report the case of a patient with an extensive anterior myocardial infarction complicated by left ventricular systolic dysfunction, left ventricular apical thrombus and an apical left ventricular aneurysm following failed thrombolysis. We obtained serial two-dimensional echocardiograms at short intervals in the acute phase and also during the months of recovery and follow up. The patient was successfully and exclusively medically managed.

Left ventricular thrombus in patients with acute myocardial infarction:Case report and Caribbean focused update

Despite the well documented benefit of echocardiography in acute coronary syndromes, its wide-scale use in the Caribbean is limited by access, health literacy and affordability. Because of the limited use of echocardiography in the region, routine complications of acute myocardial infarction (AMI) are not fully appreciated and may go unrecognized, further contributing to increased cardiovascular morbidity and mortality. It is therefore necessary to bring focus to this common clinical condition and highlight the clinical utility of echocardiography in facilitating timely and accurate diagnosis. We report here a case of large left ventricular (LV) thrombus in a patient with AMI. Coronary angiography showed completely occluded left anterior descending artery (LAD) with angiographically normal remaining vessels. Immediate anticoagulation was commenced with heparin and overlapped with warfarin. No Primary Angioplasty (PA) was done based on the evidence from occluded artery trial. LV thrombus was completely resolved on echocardiography at three months. No evidence of thrombo-embolism was found during the resolution of LV thrombus.

Acute Stroke and Limb Ischemia Secondary to Catastrophic Massive Intracardiac Thrombus in a 40-Year-Old Patient With Dilated Cardiomyopathy

Dilated cardiomyopathy has been associated with left ventricular (LV) thrombosis which leads to substantial morbidity and mortality as a site for systemic emboli. We report an interesting case of a stroke and acute limb ischemia secondary to a large mobile pedunculated LV thrombus in 40-year-old patient with dilated cardiomyopathy.

A black mobile mass: diagnosis and management

The diagnosis and treatment of left ventricular apical thrombi after myocardial infarction are still not well established. Fibrinolytic treatment, heparin treatment and surgical removal might be therapeutic options. We present the case of a 37 year old man who came into the Emergency department complaining of pleuritic chest pain. ECG revealed an evolving anterior wall infarction and transthoracic echocardiogram showed a big mobile thrombus in the ventricular apex. In order to confirm diagnosis and to differentiate other entities like pseudoaneurysm, contrast echocardiography and cardiac MRI with late gadolinium enhancement were performed and allowed a definitive diagnosis. Our patient was treated with intravenous heparin and then with oral anticoagulation. Two months later, echocardiogram showed an apical non-mobile and smaller thrombus.

Practical prescribing of intravenous unfractionated heparin

Intravenous unfractionated heparin is sometimes poorly managed in NHS hospitals. This article investigates why this is so and reviews the evidence for optimal unfractionated heparin prescribing, using it to make some suggestions as to how doctors can improve this.

Treatment of intracardiac thrombi with argatroban

Intracardiac thrombi are well known complications associated with diverse cardiac diseases and venous thromboembolism. Therapeutic recommendations like thrombolysis, surgical thrombectomy, or treatment with low molecular heparin and intravenous unfractionated heparin based on small numbers of patients or retrospective case series have failed to reach a consensus. We report on the use of argatroban, a new direct thrombin inhibitor in 4 patients with intracardiac thrombi. Therapy was effective in all patients with complete resolution of thrombi. Treatment was complicated by recurrent strokes with complete neurological recovery in one patient. Therapy of intracardiac thrombi by argatroban is safe and effective. The drug requires no dosage adjustments for age, sex, or renal impairment, including in dialysis-dependent patients. Argatroban has been found to increase predictably activated partial thromboplastin time (aPTT) and activated clotting time (ACT) in a dose-dependent manner.

Treatment of massive cardiac thrombi in a patient with protein C and protein S deficiency

Myocarditis and dilated cardiomyopathy is characterized by dilatation of all four cardiac chambers and decreased systolic function of the heart, especially in the left ventricle. In this report we presented a patient with myocarditis or dilated cardiomyopathy and deficiency of protein C and protein S with biventricular multiple intracardiac thrombi. Standard heparin infusion and acetyl salicylic acid was begun. On the 10th day of hospitalization the right ventricular thrombus disappeared, and on the 24th day all thrombi in the left ventricle disappeared. During the treatment we did not observe any complication such as hemorrhagia or embolism. We think that patients with dilated cardiomyopathy or myocarditis should be evaluated for hemostatic disorders, and should be anticoagulated if any of these disorders are presented.

Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: results and follow-up of seven cases

BACKGROUND

Left ventricular mobile thrombi carry high risk of embolism and need early treatment in which the appropriate treatment is still controversial. Because most patients with mobile thrombi have low ejection fraction and also accompanying heart failure symptoms, decision of surgical treatment is not always easy and thus effective medical treatment is crucial.

METHOD

In this paper we present, treatment and follow-up of seven patients with mobile thrombi who underwent fibrinolytic treatment between 2002 and 2006.

RESULTS

In four cases, mobile thrombi disappeared completely while echocardiographically regressed to lower size with decreased mobility in the other three patients. On 6th month follow-up, complete lysis of the thrombi in six patients was observed with warfarin treatment. No major complications were seen in the patients.

CONCLUSION

In case of mobile left ventricular thrombi with concomitant low ejection fraction and heart failure fibrinolytic treatment might be a therapeutic option.

Treatment of left ventricular thrombi with a low molecular weight heparin

BACKGROUND

Once a diagnosis of left ventricular thrombus has been established, the classical attitude consists in the administration of unfractionated heparin relayed by oral anticoagulation therapy. However, the use of unfractionated heparins in this indication was only assessed in an open, non-randomized study with no control group, including 23 patients. On the other hand, although low molecular weight heparins are routinely used in some departments, there are no studies available concerning these agents in this indication. The aim of this study was to evaluate the feasibility of low molecular weight heparin therapy in patients with left ventricular thrombi.

METHODS

The study was a prospective, non-randomized, open-label trial. All patients with a new left ventricular thrombus diagnosed between September 2000 and September 2003 received enoxaparine 100 IU/kg twice daily for a mean duration of 13 days. A relay treatment with fluindione was initiated on day 5. The left ventricular thrombus outcome was followed for 3 weeks by bi-weekly transthoracic echocardiography.

RESULTS

26 left ventricular thrombi were diagnosed over the 3-year study period: 19 in post-infarct patients with a history of anterior myocardial infarction and 7 in patients with dilated cardiomyopathy. The mean thrombus area decreased from 2.30+/-0.32 to 0.36+/-0.11 cm2 (p<0.0001). Nineteen thrombi out of twenty-six (73%) disappeared during the treatment period. No thrombocytopenia or hemorrhagic events were observed. One transient ischemic attack was reported.

CONCLUSION

This preliminary study suggests that low molecular weight heparins are well tolerated and efficient in terms of left ventricular thrombi disappearance or size reduction.

Morphological Assessment of Left Ventricular Thrombus by Live Three-Dimensional Transthoracic Echocardiography

We report the usefulness of live three-dimensional transthoracic echocardiography (3DTTE) in the morphological assessment of a left ventricular thrombus. Using live 3DTTE, the thrombus could be easily viewed end-on and from the sides. In addition, by cropping the 3D images sequentially in transverse (horizontal or short axis), longitudinal (vertical or long axis), frontal, and oblique planes, the degree and extent of lysis within the thrombus, which represents an integral part of the clot-resolution process, could be comprehensively assessed. The site of attachment of the thrombus in the left ventricular apex and its morphology could also be fully evaluated in three dimensions by live 3DTTE.

[Analysis of risk factors and comparison of heparin and hemodilution therapies for retinal artery occlusion]

No standards are available for the treatment of central retinal artery occlusion (CRAO). The aim of this study was to compare data about visual acuity development under heparin treatment with those from hemodilution. Data on 139 patients suffering from CRAO between 1991 and 2000 were examined retrospectively. Risk factors were listed. Therapies were compared in 38 of these patients, 23 of whom received full heparinization and 15 of whom received hemodilution. Many risk factors were shown. Neither therapy showed serious complications. Visual acuity improved significantly, by three or more lines, in five of 23 patients (21.7%) under full heparinization and six of 15 patients (40%) receiving hemodilution. Differences were not significant. For ethical reasons, the normal cause of disease in these patients cannot be studied and is still unknown. Because of many vascular risk factors, we recommend adapted therapies. Treatments should be examined in controlled studies.

Rapid resolution of left ventricular thrombus in antiphospholipid syndrome

A 43-year-old male with recurrent cerebral infarctions and high titers of antiphospholipid antibodies was found to have a thrombus in his left ventricular outflow tract by transthoracic echocardiography. This thrombus disappeared after less than 24 hours of intravenous heparin therapy due to resolution or asymptomatic embolism. Left ventricular thrombi in patients with antiphospholipid syndrome and rapid disappearance of left ventricular thrombi with heparin therapy are infrequently reported occurrences.

A giant left ventricular thrombus in a patient with acute myocardial infarction--a case report

The authors report a patient with acute anteroseptal myocardial infarction with a giant left ventricular thrombus at the apex. The patient also had nephrotic syndrome due to diabetic nephropathy. Coronary angiography showed 90% stenosis at segment 6 of the left anterior descending coronary artery. Percutaneous transluminal coronary angioplasty and intracoronary stenting were performed on the 30th day, and effective coronary blood flow was obtained. Heparin was injected intravenously for the first 7 days, and warfarin was administered thereafter. The left ventricular thrombus disappeared after 46 days. No evidence of arterial thromboembolism was found during the disappearance of the left ventricular thrombus as determined by echocardiography.

Comparison of outcomes of percutaneous mitral valvuloplasty versus mitral valve replacement after resolution of left atrial appendage thrombi by warfarin therapy

This study assesses the efficacy of oral anticoagulation in resolving left atrial appendage (LAA) thrombi and evaluates clinical outcomes of percutaneous mitral valvuloplasty after resolution of LAA thrombi compared with mitral valve replacement. Warfarin therapy is successful in resolving LAA thrombi; percutaneous mitral valvuloplasty after resolution of LAA thrombi is an effective alternative to surgical treatment.

Ischemic cerebral infarction after rt-PA and heparin therapy for acute myocardial infarction. The TIMI-II pilot and randomized clinical trial combined experience

BACKGROUND AND PURPOSE

Ischemic cerebral infarction (CI) is a serious complication of acute myocardial infarction (MI). Little information exists on CI after thrombolytic therapy for MI.

METHODS

Of 3924 MI patients treated with recombinant tissue plasminogen activator (rt-PA) and heparin, 29 (0.7%) developed CI after treatment. All CI patients had detailed neurological evaluations, and 27 (93%) had CT scans centrally reviewed.

RESULTS

Age range was 40 to 74 years (mean, 60 years); 25 patients (86%) were men, and 22 (76%) were white. The electrocardiographic location of MI was anterior in 22 (76%) and nonanterior in 7 (24%). Five CIs occurred within 6 hours, 4 between 6 to 24 hours, 8 during the remainder of the first week, 10 during the second week, and 2 others distributed over the 4 weeks after study entry. Six of 29 CIs did not involve the cerebral cortex; 9 patients (31%) had multiple CIs. Of 28 CIs thought to be embolic in origin, 17 showed strong evidence for at least one cardiac abnormality (mural clot, wall-motion abnormality, aneurysm, or atrial fibrillation) known to be associated more specifically with embolism than MI. Eight of 27 CIs (30%) with CT scans had hemorrhagic transformation of varying degrees; 5 were symptomatic.

CONCLUSIONS

The time of occurrence and sites of CI after rt-PA and heparin therapy for acute MI are similar to those reported during the prethrombolytic era.