ABSTRACT
BACKGROUND: Limited data are available on the impact and safety of fibrinolytic therapy (FT) in left - side prosthetic valve acute thrombosis (PVAT). Study objective: To improve our knowledge about the FT role in left -side PVAT. DESIGN: Bibliographic search and analysis. METHODS: MEDLINE search from January 1970 to January 2007. Studies were classified according to the evidence level recommendations of the American College of Chest Physicians and included if they had objective diagnosis of left-side PAVT and FT efficacy assessment (hemodynamic, echocardiographic or fluoroscopic improvement). New York Heart Association class was used to establish functional state. Data on clinical characteristics, diagnosis strategy, anticoagulation status, fibrinolytic and heparin regimens, cardiovascular adverse events, outcome, and follow-up were also required. RESULTS: A systematic search produced a total of 900 references. Each abstract was analyzed according to the predetermined criteria. Thirty-two references with 904 patients constitute the subject of this analysis. Only one trial had evidence III and thirty-one evidence V. FT was more used in young female patients (64%) with prosthetic mitral valve thrombosis (77%), and clinical instability (82%). Transesophageal echocardiogram had a higher thrombus detection rate (100%). Although several fibrinolytic regimens were used in a first or second course, streptokinase was the most frequent agent (61%). Clinical improvement was observed in 86% of the patients, objective success in 78%, and failure in 14%. Rescue fibrinolysis was done in 17%. Complications: peripheral and cerebral embolism rate was 5% and 4%, respectively. Major bleeding 4% and intracranial hemorrhage 1%. CONCLUSIONS: The available evidence demonstrates that in PVAT fibrinolytic therapy improves the outcome in younger, more ill patients, especially females, independently of the fibrinolytic regimen used with a low complications rate.
Subject(s)
Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Young Adult , Heart Valve Diseases , Heart Valve Diseases , Heart Valve Prosthesis/adverse effects , Thrombolytic Therapy , Thrombosis , Thrombosis , Acute DiseaseABSTRACT
OBJECTIVE: The registry intends to establish the safety and security of one-hour 100 mg alteplase infusion and 50 mg in 30 minutes to facilitate percutaneous coronary intervention (PCI) in a cardiology hospital with primary angioplasty program (24 hours 365 days a year) with current doses of unfractionated heparin and enoxaparin. METHODS AND RESULTS: REALSICA II is a prospective registry that included 103 patients with final diagnosis of ST elevation myocardial infarction in which Alpert's quality criteria were used. Seventy two patients were under one-hour 100 mg alteplase infusion and thirty one under 30 minutes 50 mg alteplase infusion to facilitate PCI. Patients were young and predominantly males. In both groups > 50% had extensive ST elevation myocardial infarction and 68% were Killip & Kimball I. The majority received reperfusion > 3 hours after the onset of symptoms. In-hospital and follow-up treatment were compliant with Mexican Cardiology Society guidelines. ECG reperfusion was observed in 59% and TIMI III flow in 19% of PCI group. Any intracranial hemorrhage was observed. Global cardiovascular mortality was 11%. Patients under PCI had low incidence of recurrent ischemia and reinfarction. CONCLUSION: REALSICA registry showed in non-complicate acute myocardial infarction ST elevation safety and security of one-hour 100 mg alteplase infusion with current recommended unfractionated heparin and enoxaparin doses in ST elevation myocardial infarction. In complicated patients the regimen to facilitate PCI was associated with increased hemorrhagic complications and requires further research.
Subject(s)
Aged , Female , Humans , Male , Middle Aged , Angioplasty, Balloon, Coronary , Acute Coronary Syndrome , Fibrinolytic Agents , Registries , Tissue Plasminogen Activator , Combined Modality Therapy , Mexico , Myocardial InfarctionABSTRACT
Acute coronary syndromes have a heterogeneous clinical presentation with a broad spectrum for mortality and adverse events. It is mandatory to identify high risk groups for percutaneous coronary intervention and intensive antithrombotic treatment or common risk for standard treatment. In contemporaneous medicine it is important to get adequate risk stratification because the impact of hospitalary costs, antithrombotic and reperfusion treatment on health systems. The current pathophysiology of atherosclerosis is moving from a disease secondary to cholesterol deposit, to an inflammatory disease. In the stratification process, familiar history, chest pain, ST dynamic abnormalities, left ventricular wall motion abnormalities, all have predictive value. The association of indirect endothelial dysfunction, micro or macronecrosis and ventricular dysfunction markers increase this value. In our experience a close relationship among abnormal fibrinolysis, inflammation and anticoagulation proteins with adverse events has been proved in acute coronary syndromes. Other interesting finding--for it accessibility--in acute myocardial infarction under coronary percutaneous intervention is persistent ST elevation, leukocytes and fibrinogen predictive value. In population allelic polymorphisms -455A and -148T and fibrinogen ( >450 mg/dL) were associated with coronary disease. These polymorphisms improve risk stratification of coronary disease to establish a better secondary prevention and treatment.
Subject(s)
Humans , Angina, Unstable/blood , Myocardial Infarction/blood , Acute Disease , Biomarkers/blood , Risk Assessment , SyndromeABSTRACT
Las estrategias de reperfusión en la fase temprana del infarto con elevación del ST-T tienen como principal objetivo restituir y mantener la perfusión tisular. La terapia fibrinolítica puede considerarse como el tratamiento estándar por su accesibilidad y efectividad para disminuir daño miocárdico y mortalidad. La principal imperfección de esta estrategia de reperfusión radica en el porcentaje no despreciable de fracaso terapéutico y reoclusión por fenómenos de resistencia y retrombosis. La terapia fibrinolítica asociada al ácido acetilsalicílico, puede considerarse como el avance más importante en el tratamiento del infarto con elevación del ST-T. En el sitio del daño vascular, la trombosis inducida por trombina y agregación plaquetaria son los factores más importantes en la fisiopatología de los SCA y el principal mecanismo que puede limitar la efectividad de la terapia fibrinolítica. El conocimiento actual de la fisiopatología subyacente a la trombosis coronaria sugiere que la terapia fibrinolítica puede fracasar para inducir lisis óptima del trombo y refuerza el raciocinio para la combinación de estrategias antitrombóticas y de reperfusión. Podría mejorar su efectividad, un tratamiento adjunto antiplaquetario y antitrombínico intenso y moderno, que a través de diferentes mecanismos modificaría los principales componentes del trombo coronario. El propósito de este artículo es revisar y discutir los mecanismos de resistencia a la terapia fibrinolítica, las estrategias modernas para mejorar la perfusión que incluyen dosis aceleradas de fibrinolíticos, fibrinólisis facilitada, experiencia con heparina de bajo peso molecular y el posible papel de los nuevos antitrombóticos que han demostrado efectividad en el tratamiento de los síndromes coronarios agudos sin elevación del ST-T.
The main targets in reperfusion strategies in early ST-T elevation acute myocardial infarction phase are to improve and sustain tisular perfusion. Due to its accessibility and effectiveness in reducing myocardial damage and mortality, fibrinolytic therapy has been considered as the standard treatment. The most serious fibrinolytic therapy dilemma is the high failure and reoclusion rate, secondary to resistance and rethrombosis phenomena. In ST-T elevation acute myocardial infarction, therapy fibrinolytic in combination with aspirin could be considered the most important treatment advance. In the injury vascular setting, thrombosis induced by thrombin and platelet aggregability is the responsible mechanism and could limit the effectiveness of fibrinolytic therapy. The current knowledge of coronary thrombus physiopathogenesis establishes the limitations of fibrinolytic therapy in the achievement of optimal lysis, and suggests the necessity of antithrombotic and reperfusion strategy combination. Through this synergism it is feasibly to modify thrombus components improving efficiently. The propose of this review is to deeply analyze the fibrinolytic therapy resistance mechanisms, the modern approach to improve tisular perfusion, including accelerated fibrin-olytic regimens, facilitated fibrinolysis, low molecular weight heparin experience and the role of new antithrombotic drugs, that has proved effectiveness in non-ST elevation acute myocardial syndromes treatment. (Arch Cardiol Mex 2003; 73:46-58).