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EDITOR - Sutton1 pointed out the possible flaws in the observation
made by Drenth et al2 on the controversial and unclear matter of rescue
thrombolysis. We would like to point out the inherent haemorrhagic risk
of rescue thrombolysis and the possible benefit in selected patients, in
our experience.
Upto 20% of clinicians in the U.K. resort to rescue thrombolysis in
the event of failure of primary thrombolysis.3 The only randomised study
comparing rescue thrombolysis with placebo showed mild improvement in left
ventricular function in patients who failed to achieve systemic lysis with
the initial thrombolysis with streptokinase, as measured by serum
fibrinogen.4
Between January 96 and January 98 we identified 24 patients of 418
patients admitted with first ever myocardial infarction, who received
rescue thrombolysis with tPA. Failure of thrombolysis was judged by
absence of ECG ST resolution (>70% persisting) on post-thrombolytic ECG
done one hour after completion of thrombolysis. Serum fibrinogen was not
routinely measured due to time constraints. Streptokinase was the initial
thrombolytic agent in 22 patients, tPA in 2.
8 of these patients (33%) had bleeding complications. 5 patients had
minor bleeding - hemoptysis, epistaxis and haematemesis. One patient
needed blood transfusion for fall in hemoglobin, 2 patients died within
the hour of rescue thrombolysis with catastrophic neurological
deterioration suggesting massive intracerebral bleed. This represents a
significant risk of haemorrhagic stroke as compared to the large
randomised trials (8.3% vs 1.0%). On the positive side, 12 patients (50%)
showed ECG ST resolution following rescue thrombolysis (3 anterior, 9
inferior), there were no left ventricular failure or deaths in this group.
The excess bleeding complication after rescue thrombolysis would not be a
surprise given that one is introducing full dose tPA into an already
partial lytic state induced by streptokinase.
5.7% of patients admitted with first ever myocardial infarction had
rescue thrombolysis in this retrospective study. The number even though
small presents a decision-making dilemma for the treating physician
especially when access to prompt rescue angioplasty is not uniformly
available. Routine measurement of serum fibrinogen is time consuming and
could reduce the time window for optimal therapy. However the benefit of
repeating thrombolysis (especially in younger patients and extensive
anterior infarcts with high risk of heart failure) has to be weighed
against risk of major haemorrhage. This can only be achieved with
randomised controlled trials.
References:
1. Sutton AGC. Rescue thrombolysis for failure of primary
thrombolysis cannot be justified. BMJ 1999;318:261.
2. Drenth JPH, Uppelschoten A, Hooghoudt THE, Lamfers EJP. Rescue
thrombolysis may work even though primary thrombolysis has failed. BMJ
1998;317:147.
3. Prendergast BD, Shandall A, Buchatter MB. What do we do when
thrombolysis fails? A United Kindgdom Survey. Int J Cardiol. 1997;61(1):39
-42.
4. Mounsey JP, Skinner JS, Hawkins T, MacDermott AFN, Furniss SS, Adams
PC, et al. Rescue thrombolysis: alteplase as adjuvant treatment after
streptokinase in acute myocardial infarction. Br Heart Journal 1995;74:348
-353.
Rescue Thrombolysis increases haemorrhagic risk
EDITOR - Sutton1 pointed out the possible flaws in the observation
made by Drenth et al2 on the controversial and unclear matter of rescue
thrombolysis. We would like to point out the inherent haemorrhagic risk
of rescue thrombolysis and the possible benefit in selected patients, in
our experience.
Upto 20% of clinicians in the U.K. resort to rescue thrombolysis in
the event of failure of primary thrombolysis.3 The only randomised study
comparing rescue thrombolysis with placebo showed mild improvement in left
ventricular function in patients who failed to achieve systemic lysis with
the initial thrombolysis with streptokinase, as measured by serum
fibrinogen.4
Between January 96 and January 98 we identified 24 patients of 418
patients admitted with first ever myocardial infarction, who received
rescue thrombolysis with tPA. Failure of thrombolysis was judged by
absence of ECG ST resolution (>70% persisting) on post-thrombolytic ECG
done one hour after completion of thrombolysis. Serum fibrinogen was not
routinely measured due to time constraints. Streptokinase was the initial
thrombolytic agent in 22 patients, tPA in 2.
8 of these patients (33%) had bleeding complications. 5 patients had
minor bleeding - hemoptysis, epistaxis and haematemesis. One patient
needed blood transfusion for fall in hemoglobin, 2 patients died within
the hour of rescue thrombolysis with catastrophic neurological
deterioration suggesting massive intracerebral bleed. This represents a
significant risk of haemorrhagic stroke as compared to the large
randomised trials (8.3% vs 1.0%). On the positive side, 12 patients (50%)
showed ECG ST resolution following rescue thrombolysis (3 anterior, 9
inferior), there were no left ventricular failure or deaths in this group.
The excess bleeding complication after rescue thrombolysis would not be a
surprise given that one is introducing full dose tPA into an already
partial lytic state induced by streptokinase.
5.7% of patients admitted with first ever myocardial infarction had
rescue thrombolysis in this retrospective study. The number even though
small presents a decision-making dilemma for the treating physician
especially when access to prompt rescue angioplasty is not uniformly
available. Routine measurement of serum fibrinogen is time consuming and
could reduce the time window for optimal therapy. However the benefit of
repeating thrombolysis (especially in younger patients and extensive
anterior infarcts with high risk of heart failure) has to be weighed
against risk of major haemorrhage. This can only be achieved with
randomised controlled trials.
References:
1. Sutton AGC. Rescue thrombolysis for failure of primary
thrombolysis cannot be justified. BMJ 1999;318:261.
2. Drenth JPH, Uppelschoten A, Hooghoudt THE, Lamfers EJP. Rescue
thrombolysis may work even though primary thrombolysis has failed. BMJ
1998;317:147.
3. Prendergast BD, Shandall A, Buchatter MB. What do we do when
thrombolysis fails? A United Kindgdom Survey. Int J Cardiol. 1997;61(1):39
-42.
4. Mounsey JP, Skinner JS, Hawkins T, MacDermott AFN, Furniss SS, Adams
PC, et al. Rescue thrombolysis: alteplase as adjuvant treatment after
streptokinase in acute myocardial infarction. Br Heart Journal 1995;74:348
-353.
Competing interests: No competing interests