Long term follow up of patients with anterior myocardial infarction complicated by left ventricular thrombus in the thrombolytic era

Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge

Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.

Left ventricular wall motion abnormalities are associated with stroke recurrence

Objective:

To investigate the role of left ventricular wall motion abnormalities (LVWMA), unrelated to high-risk cardioembolic conditions, in stroke recurrence.

Methods:

This study included consecutive acute ischemic stroke patients. Transthoracic echocardiography was performed as a routine evaluation for stroke patients. The outcomes were the time to recurrent any stroke and ischemic stroke.

Results:

Among 4,316 acute ischemic stroke patients, 430 had LVWMA without high-risk cardioembolic sources. The median observation periods of patients at risk of any stroke and ischemic stroke were 24.5 and 24.7 months. During the follow-up, any stroke and ischemic stroke recurrence were observed in 310 (7.2%) and 250 (5.8%) patients. LVWMA were associated with outcomes after adjustment for traditional cardiovascular risk factors, laboratory and imaging variables, and therapeutic interventions (hazard ratio [HR] 1.707, 95% confidence interval [CI] 1.262–2.310 for any stroke; HR 1.709, 95% CI 1.222–2.390 for ischemic stroke). Moreover, LVWMA could still be considered as independent risk factors after correction for covariates that were significantly associated with outcomes in univariable regression (HR 1.747, 95% CI 1.292–2.364 for any stroke; HR 1.704, 95% CI 1.219–2.382 for ischemic stroke). There were no significant interactions between LVWMA and outcomes between the subgroups except for the statin treatment subgroup.

Conclusions:

This study suggests that LVWMA, even when unassociated with high-risk cardioembolic sources, could be an independent predictor for stroke recurrence in patients with ischemic stroke.

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.

Myocardial Infarction (MI) presenting as acute limb: an extremely rare presentation of MI

Acute embolic occlusion of the bilateral lower limbs from the left ventricular thrombus is an extremely rare medical condition that is not only limb threatening but also potentially life threatening. Several strategies are available but not even a single treatment modality is clearly the best. Here, we present an interesting case that presented with bilateral lower limb ischemia and was later found to have a big thrombus in the left ventricle as the source of the emboli.

Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era

BACKGROUND

Rapid reperfusion has been shown to decrease mortality and improve left ventricular (LV) function. Previous studies have reported that LV thrombus (LVT) is a major complication of ST-segment elevation acute anterior wall myocardial infarction (AMI). There are little data on LVT in the current primary percutaneous coronary intervention (PPCI) era. We sought to demonstrate the incidence of LVT after AMI in patients treated with PPCI compared with those treated with thrombolysis or with conservative management.

METHODS

In a 6-year period, 642 patients with anterior wall AMI and echocardiography were treated with PPCI (n = 297), thrombolysis (n = 128), or conservative treatment (n = 217). Left ventricular thrombus was defined as an echodense mass adjacent to an abnormally contracting myocardial segment.

RESULTS

The rate of LVT among anterior wall AMI was 6.2%. Predictors for LVT were reduced ejection fraction (adjusted relative risk 0.71, 95% CI 0.52-0.96) and severe mitral regurgitation (adjusted relative risk 2.48, 95% CI 1.0-6.44). There was no statistical difference in LVT rate according to treatment: 21 (7.1%) of 297 patients in the PPCI group, 10 (7.8%) of 128 patients in the thrombolytic group, and 9 (4.1%) of 217 patients in the conservative group (P = .28). Those in the thrombolytic group were characterized by shorter duration from symptom onset and were generally also treated with heparin/low-molecular weight heparin.

CONCLUSIONS

This is the largest report to evaluate the incidence of LVT formation after AMI. In the current era of rapid reperfusion by PPCI, the rate of thrombus formation is similar to that reported in the past and not different than for patients currently treated conservatively or with thrombolysis.

Plasma homocysteine level and left ventricular thrombus formation in acute anterior myocardial infarction patients following thrombolytic therapy with t-PA

AIMS

The aim of this study was to evaluate the relationship between homocysteine levels and the development of left ventricular thrombus in acute anterior myocardial infarction patients directed to thrombolytic therapy.

METHODS AND RESULTS

Seventy-nine patients presenting with ST elevated acute anterior myocardial infarction and treated with thrombolytic agent, t-PA, were included in the study. Two-dimensional echocardiography was used to divide patients into 2 groups according to the presence (n = 14) or absence (n = 65) of thrombus in the left ventricle following myocardial infarction. The levels of fasting plasma total homocysteine, total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, vitamin B12 and folic acid were assessed. There were no significant differences between two groups in terms of age, gender, hyperlipidemia and smoking. History of diabetes mellitus (28.57% versus 6.15%, p = 0.04), peak creatine phosphokinase levels (4153.54 +/- 1228.41 U/L versus 2456.92 +/- 1421.36 U/L, p < 0.001), mean left ventricular wall motion score index (2.21 +/- 0.18 versus 1.83 +/- 0.23, p < 0.001) and total fasting homocysteine levels (18.24 +/- 5.67 mmol/L versus 12.31 +/- 3.52 mmol/L, p < 0.001) were significantly higher in patients with left ventricular thrombus. In multivariate analysis; only diabetes mellitus (p = 0.03), higher wall motion score index (p = 0.001) and higher homocysteine levels (p = 0.04) were independent predictors of left ventricular thrombus formation.

CONCLUSION

Our results suggest that; diabetes mellitus, higher wall motion score index and hyperhomocysteinemia independently increases the risk for the development of left ventricular thrombus formation in patients with acute anterior myocardial infarction following thrombolytic therapy.

[Antithrombotic drugs in the prevention of ischemic stroke]

Stroke prevention cannot be dissociated from cardiovascular prevention in general. It is based on the correction of vascular risk factors, particularly hypertension and tobacco smoking, and on antithrombotic drugs which tackle the thrombo-embolic process which is the immediate cause of the ischemic event. Ischemic strokes exhibit considerable etiopathogenic diversity, the underlying cause modifying thrombus composition. In atherothrombotic brain infarction, platelets play a major role and antiplatelet drugs have a benefit/risk ratio better than that of oral anticoagulants, with a 25% reduction in the combined risk of ischemic stroke, myocardial infarction and vascular death. Antiplatelet drugs are also used in small artery diseases of the brain although the role of thrombosis is unknown and no specific trial has been devoted to this variety of cerebrovascular disease. In emboligenic cardiac diseases, atrial fibrillation in particular, stasis of the dilated left atrium favors coagulation phenomena, hence the much better efficacy of oral anticoagulants (presently vitamin K antagonists) both in primary and secondary prevention with a 70% risk reduction in cerebral infarction, compared with only 20% for aspirin. The expected benefit of antithrombotic drugs must be weighed against their inherent hemorrhagic risk, which is greatest for oral anticoagulants, slightly less for association of antiplatelet drugs and even less for each antiplatelet drug given alone. The use of antithrombotic drugs allows a targeted prevention of cerebral infarction. It is based on a triple case by case evaluation: that of the cause and of the risk it carries, that of the benefit expected from antithrombotic drugs, and that of their inherent hemorrhagic risk.

Complete lysis of left ventricular giant thrombus with fibrinolytic therapy in clopidogrel resistant patient

Sixty-year-old woman admitted with dyspnea and cough. Three weeks ago she underwent primary stenting for acute anterior myocardial infarction and received antiplatelet therapy (clopidogrel). Echocardiography and left ventriculography revealed left ventricular segmental dysfunction at anterolateral-apical region but no thrombus. On last admission, despite the clopidogrel therapy, echocardiography showed giant-partly mobil thrombus obliterated half of the left ventricle. Slow infusion of thrombolytic therapy was given and complete lysis occurred with uneventful course. Disclosure of such a rapidly evolving giant left ventricular thrombus in the clopidogrel non-responder is a rare clinical problem with potentially catastrophic consequences. Slow infusion of thrombolytic therapy may be effective and life saving.

Ischemic stroke after acute myocardial infarction. A population-based study

BACKGROUND AND PURPOSE

Modern treatment may have influenced the risk of stroke after myocardial infarction (MI). The purpose of this study was to examine the incidence of ischemic stroke during the first month after an acute MI in an unselected population, to identify predictors of MI-related stroke, and to investigate the secular trend in MI-related stroke incidence.

METHODS

In this case-control study, from a population of approximately 310000 25- to 74-year-old inhabitants, case subjects with a stroke within 1 month after an MI were prospectively recorded in the population-based Northern Sweden MONICA (Monitoring of Trends and Determinants in Cardiovascular Disease) study from 1985 to 1994. The same number of control subjects with an MI but without a stroke were matched for age, sex, and year when MI occurred.

RESULTS

One hundred twenty-four case subjects were recorded. Fifty-one percent (63/124) of the strokes occurred within 5 days after onset of MI. The odds ratios (ORs) of an MI-related stroke were for a history of hypertension 1.7 (95% confidence interval [CI], 1.0 to 3.2), previous stroke 2.4 (CI, 1.0 to 6.1), chronic atrial fibrillation 3.0 (CI, 1.1 to 9.2), onset of atrial fibrillation during the hospital stay 3.5 (CI, 1.4 to 10.1), ST-segment elevation 2.4 (CI, 1.4 to 4.6), and anterior infarction 1.5 (CI, 0.9 to 2.6). In a conditional multiple logistic regression model, previous stroke (OR, 2.8; CI, 1.1 to 7.6), chronic atrial fibrillation (OR, 3.8; CI, 1.3 to 11.0), new-onset atrial fibrillation (OR, 4.6; CI, 1.6 to 12.8), and ST-segment elevation (OR, 3.4; CI, 1.6 to 7.4) were independent predictors of stroke. MIs preceding stroke were larger and in 51% were located anteriorly. There was a decrease in the incidence and event rate of MI-related stroke during the study period (P < .01 and P < .05, respectively).

CONCLUSIONS

The risk of stroke is highest the first 5 days after MI. Only approximately half of the strokes occurring the first month after an MI are preceded by an anterior MI. The most important predictors of MI-related stroke are atrial fibrillation (chronic or new onset), ST elevation, and a history of a previous stroke. There is a long-term trend toward a lower incidence of MI-related stroke. These findings have important implications concerning both the pathophysiology and prevention of MI-related stroke.