Thrombolytic therapy

A Call for a Reconsideration of the Use of Fecal Occult Blood Testing in Emergency Medicine

BACKGROUND

Fecal occult blood testing (FOBT) was developed to detect microscopic bleeding caused by colorectal neoplasms. The role of FOBT in the emergency department (ED) is typically used for 5 different clinical workups: trauma, anemia, syncope, hypotension, and before the administration of systemic anticoagulants or thrombolytics.

OBJECTIVE

We scrutinized the literature to assess the utility of FOBT for its 5 most common applications in the emergent setting.

DISCUSSION

Logic and clinical evidence advocating for FOBT usage in the aforementioned situations are lacking. The test itself requires specific drug and dietary restrictions that are often violated or never met when patients present to the ED with acute pathologies. In addition, the poor sensitivity and specificity of the test in these scenarios dictate that neither a negative nor positive FOBT should change the subsequent clinical workup of patients presenting to the ED.

CONCLUSION

Clinical decision making should seldom be predicated on the results of a FOBT in the ED setting.

Thrombolysis with streptokinase during cardiopulmonary resuscitation: a single center experience and review of the literature

OBJECTIVE

To report our experience with use of thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with cardiac arrest due to myocardial infarction.

DESIGN

A case series.

METHODS

Thrombolytic therapy (streptokinase) was administered during cardiopulmonary resuscitation of 4 patients with suspected myocardial infarction as the cause of cardiac arrest.

RESULTS

3 of the 4 patients survived and were discharged from the hospital without any major complications or neurological sequela.

CONCLUSION

Thrombolysis with streptokinase during cardiopulmonary resuscitation of patients with suspected acute myocardial infarction is associated with reduced mortality and favorable neurological outcome.

Thrombolytic therapy after cardiac arrest and its effect on neurological outcome

OBJECTIVE

the aim of the study is to investigate the effect of thrombolytic therapy on neurological outcome in patients after cardiac arrest due to acute myocardial infarction. Laboratory investigations have demonstrated that thrombolytic therapy after cardiopulmonary resuscitation improves neurological function.

METHODS

from July 1991 to June 1996, patients with witnessed ventricular fibrillation cardiac arrest due to acute MI and successful restoration of spontaneous circulation admitted to the emergency department were analyzed retrospectively. A logistic regression model was used to assess the association between thrombolytic therapy and neurological outcome [best cerebral performance category (CPC) within 6 months after cardiac arrest].

RESULTS

all 157 patients [median age 57 years (IQR 50-69)] were analyzed. Thrombolytic therapy was applied in 42 patients (27%). With thrombolytic therapy good functional neurological recovery (CPC 1 or 2) was achieved more frequently (69 vs. 50%, P=0.03). After controlling for age, prehospital dosage of epinephrine, and the duration of cardiac arrest we found a non significant trend towards good neurological recovery when thrombolytic therapy was given (OR 1.9, 95% CI 0.8-4.6).

CONCLUSION

thrombolytic therapy after cardiac arrest due to acute myocardial infarction is associated with improved neurological outcome.

Prodromal unstable angina in acute myocardial infarction: prognostic value of short- and long-term outcome and predictor of infarct size

BACKGROUND

An estimated 50% of patients with myocardial infarction have prodromal unstable angina. There is controversy over whether prodromal unstable angina identifies a group of patients at lower risk of short- and long-term death and the clinical importance of recording this event.

METHODS

Of 207 patients enrolled at a single Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) site, 196 survived the 24 hours after presentation, achieved peak creatine kinase MB concentrations, and were classified as having either abrupt symptom onset or prodromal unstable angina in the 2 weeks before myocardial infarction. Creatine kinase MB peak was used to categorize infarct size as aborted myocardial infarction, minor myocardial damage, or extensive myocardial injury. Follow-up was performed at 24 hours, 30 days, 1 year, and 5 years. Multiple variables, including prodromal unstable angina, time to treatment, age, sex, previous infarction and infarct location, were analyzed for predicting infarct size. Also, these variables plus peak creatine kinase MB level and a combined variable of prodromal unstable angina and peak creatine kinase MB level were examined for predicting survival.

RESULTS

Mortality rate was 2.5% within 24 hours, 9.0% at 30 days, 13.5% at 1 year, and 27.1% at 5 years. Patients categorized as either aborted infarction or minor myocardial damage were significantly more likely to have prodromal unstable symptoms (81.3% vs 51.2%, P <.001) and better survival at each follow-up period. Prodromal presentation was the most significant predictor of infarct size category (P =.001). Five-year survival was predicted by age (P <.0001), peak creatine kinase MB level (P =.007), infarct location (P =.009), the combined variables (P =.029), and prodromal unstable angina (P =.017). Prodromal unstable angina had the highest odds ratio for 5-year survival at 3.83 (95% confidence interval 1.27-11.47).

CONCLUSIONS

Prodromal unstable angina is a strong predictor of infarct size and survival. Recognizing prodromal unstable angina is important for clinically assessing prognosis.

Consultation before thrombolytic therapy in acute myocardial infarction. Second National Registry of Myocardial Infarction (NRMI 2) Investigators

Among 57,398 thrombolytic recipients in the National Registry of Myocardial Infarction 2, consultation with another physician was sought in 64% before initiating lytic therapy, although presenting features were typical, rather than atypical, in most patients. Consultation significantly delayed the administration of lytic therapy and was associated with increased hospital mortality.

Effect of a patient's sex on the timing of thrombolytic therapy

STUDY OBJECTIVE

We sought to determine whether a patient's sex independently influences the interval from emergency department arrival to the initiation of thrombolytic therapy in acute myocardial infarction (AMI).

METHODS

We conducted a retrospective cohort study in two suburban EDs, one at a 929-bed tertiary care teaching hospital and the other at a 189-bed community hospital. Only patients found to be having an ST-segment-elevated AMI on their first ECG who were treated with a thrombolytic agent in the ED were eligible. We excluded patients who arrived at the ED after cardiac arrest or with a known AMI. We used as the main outcome measure the interval from ED arrival to initiation of thrombolytic therapy. Secondary outcome variables included time elapsed before ECG, interval between ECG and treatment, and 1-year mortality.

RESULTS

Entry criteria were satisfied by 328 patients. The 88 women experienced a mean 23-minute delay to treatment initiation compared with men (P < .01). This observation is not accounted for by age, race, time of day, medical history, sex of the physician, type of thrombolytic agent, hospital, or triage category. The longest delays were found in women treated by female physicians, although female physicians also waited longer than male physicians to administer thrombolytic therapy to men. The mean time elapsed before the first ECG was also 6 minutes longer for women (P < .01) Women had an increased 1-year mortality rate that was fully explained by their advanced age at the time of AMI.

CONCLUSION

We infer that a patient's sex may play a significant role in the observed delay in treatment for women. Our data, coupled with previously published work, strongly suggest a systematic negative effect for women in their interaction with the health care system during AMI. We suggest that variables other than systems issues affect the time elapsed before thrombolytic therapy.

Cocaine-induced myocardial infarction: treatment with thrombolytic therapy

Patients with cocaine-induced AMI may be added to the expanding list of eligible candidates for thrombolytic therapy. ED nurses are in key positions to identify patients for thrombolysis, evaluate patients' responses, and minimize complications. With the rising use of cocaine, increased consideration should be given to any relatively young patient with unexplained cardiovascular symptoms and history of cocaine use.

Treatment of myocardial infarction in the United States (1990 to 1993). Observations from the National Registry of Myocardial Infarction

BACKGROUND

Multiple clinical trials have provided guidelines for the treatment of myocardial infarction, but there is little documentation as to how consistently their recommendations are being implemented in clinical practice.

METHODS AND RESULTS

Demographic, procedural, and outcome data from patients with acute myocardial infarction were collected at 1073 US hospitals collaborating in the National Registry of Myocardial Infarction during 1990 through 1993. Registry hospitals composed 14.4% of all US hospitals and were more likely to have a coronary care unit and invasive cardiac facilities than nonregistry US hospitals. Among 240,989 patients with myocardial infarction enrolled, 84,477 (35.1%) received thrombolytic therapy. Thrombolytic recipients were younger, more likely to be male, presented sooner after onset of symptoms, and were more likely to have localizing ECG changes. Among the 60,430 patients treated with recombinant tissue-type plasminogen activator (rTPA), 23.2% received it in the coronary care unit rather than in the emergency department. Elapsed time from hospital presentation to starting rTPA averaged 99 minutes (median, 57 minutes). Among patients receiving thrombolytic therapy, concomitant pharmacotherapy included intravenous heparin (96.9%), aspirin (84.0%), intravenous nitroglycerin (76.0%), oral beta-blockers (36.3%), calcium channel blockers (29.5%), and intravenous beta-blockers (17.4%). Invasive procedures in thrombolytic recipients included coronary arteriography (70.7%), angioplasty (30.3%), and bypass surgery (13.3%). Trend analyses from 1990 to 1993 suggest that the time from hospital evaluation to initiating thrombolytic therapy is shortening, usage of aspirin and beta-blockers is increasing, and usage of calcium channel blockers is decreasing.

CONCLUSIONS

This large registry experience suggests that management of myocardial infarction in the United States does not yet conform to many of the recent clinical trial recommendations. Thrombolytic therapy is underused, particularly in the elderly and late presenters. Although emerging trends toward more appropriate treatment are evident, hospital delay time in initiating thrombolytic therapy remains long, aspirin and beta-blockers appear to be underused, and calcium channel blockers and invasive procedures appear to be overused.

Thrombolysis in acute myocardial infarction following prolonged cardiopulmonary resuscitation

Thrombolytic therapy was administered to a 64-year-old man with an acute anterolateral myocardial infarction who had received cardiopulmonary resuscitation (CPR) for 24 minutes. At the time of thrombolytic therapy, the patient was alert and without clinical or radiographic evidence of injury. The patient developed a retroperitoneal hematoma related to femoral line placement, as well as subcutaneous bruising of the anterior chest wall; both were self-limited. No long- term morbidity developed, and the myocardial infarction was aborted. The use of thrombolytic therapy for patients with acute myocardial infarction who have received CPR is reviewed. In the absence of clinical or radiographic evidence of trauma from CPR, patients with acute myocardial infarction should not be excluded from receiving thrombolytic therapy solely because of having had CPR or the duration of CPR.