Thrombolysis: past, present, and future

Acute Pancreatitis-Progress and Challenges: A Report on an International Symposium

An international symposium entitled "Acute pancreatitis: progress and challenges" was held on November 5, 2014 at the Hapuna Beach Hotel, Big Island, Hawaii, as part of the 45th Anniversary Meeting of the American Pancreatic Association and the Japanese Pancreas Society. The course was organized and directed by Drs. Stephen Pandol, Tooru Shimosegawa, Robert Sutton, Bechien Wu, and Santhi Swaroop Vege. The symposium objectives were to: (1) highlight current issues in management of acute pancreatitis, (2) discuss promising treatments, (3) consider development of quality indicators and improved measures of disease activity, and (4) present a framework for international collaboration for development of new therapies. This article represents a compilation and adaptation of brief summaries prepared by speakers at the symposium with the purpose of broadly disseminating information and initiatives.

Anaphylactic shock associated with intravenous thrombolytics

Adverse events including intracerebral hemorrhage and reperfusion arrhythmias are well known to occur with thrombolytic therapy. We report a case report of anaphylactic reaction directly attributable to intravenous (IV) recombinant tissue plasminogen activator and identify additional cases through review of the Food and Drug Administration Adverse Event Reporting System. A systematic review of Adverse Event Reporting System was performed for allergic adverse events occurring in conjunction with IV thrombolytics. We reviewed 924 adverse events which occurred between 2004 and 2012 that were associated with thrombolytics. We subsequently acquired detailed individual safety reports of 33 cases in which allergic events were documented. Out of the 33 reports, there were 12 cases (age range, 57-93 years) of adverse allergic reaction directly attributable to IV thrombolytics. Allergic reactions included angioedema, facial swelling, urticaria, skin rash, cutaneous hypesthesia, hypotension, anaphylactic shock, and death. Of the patients who were reported to suffer from allergic adverse events, 11 received IV alteplase and 1 received IV reteplase. Most reactions associated with IV alteplase resolved with withdrawal of medication and treatment with diphenhydramine and steroids ± epinephrine. There was 1 death directly attributable to allergic reaction in a patient who received IV reteplase for MI.Although IV alteplase is identical to endogenous tissue plasminogen activator, it appears to be the most common cause of allergic reaction among currently used thrombolytics, with or without concomitant administration of angiotensin-converting enzyme inhibitors. A greater awareness among physicians may result in prompt recognition and treatment.

[Coronary flow and hemorrhagic complications after alteplase and streptokinase administration in patients with acute myocardial infarction]

BACKGROUND/AIM

Up-to-date treatment of acute myocardial infarction (AIM) has been based on as early as possible establishment of circulation in ischemic myocardium whether by the use of fibrinolythic therapy and/or urgent coronary intervention which significantly changes the destiny of patients with AMI, but also increases the risk of bleeding. The aim of this study was to compare coronary flow and bleeding complications in patients with acute myocardial infarction with ST-elevation (STEMI) after administration of alteplase or streptokinase.

METHODS

The study included 254 patients with STEMI. The group I (n = 174) received streptokinase, and the group II (n = 80) received alteplase. We followed frequency of complications such as bleeding and hypotension in the investigated groups of patients, based on the TIMI classification of bleeding, as well as the transience of infarction artery in accordance with TIMI flow.

RESULTS

The patients with myocardial infarction after administration of alteplase had statistically significantly higher coronary flow (TIMI-3), 72.5% as compared to the patients who received streptokinase, 39.2%. Hypotension as complication of fibrynolythic therapy administration occurred in a significantly higher percentage in the group of patients who received streptokinase. There was no statistically significant difference in the appearance of major bleeding in the groups of patients who received streptokinasis and alteplase (6.9% and 7.5%, respectively). Also, there was no difference in the appearance of minor and minimal bleeding among the investigated groups of patients.

CONCLUSION

It was shown that alteplase in a higher number of patients provided TIMI-3 coronary flow as compared to streptokinese. In comparison with streptokinase, a combination of alteplase, enoxaparin and double antiplatelet therapy enabled earlier achievement of coronary flow through previously blocked coronary artery that was more complete (higher frequency of TIMI-3 flow). There were no statistically significant difference in frequency of bleeding, first of all major bleeding, between the groups treated by alteplase and streptokinase.