Influence of time to treatment on early infarct-related artery patency after different thrombolytic regimens. ALKK-Study Group.

BACKGROUND: In an in vitro model, recombinant tissue-type plasminogen activator was significantly more effective than streptokinase in dissolving 24-hour-old human blood clots. Therefore there might be a difference in the effect of time to treatment on the efficacy of these fibrinolytics with different fibrin specificity in patients with acute myocardial infarction. METHODS AND RESULTS: The effect of the interval between symptom onset and initiation of therapy on the efficacy of 6 different thrombolytic regimens was studied in a retrospective analysis of 6 angiographic trials with similar design. The patency of the infarct-related artery was assessed by angiography 90 minutes after initiation of thrombolysis in patients who were seen within 6 hours after symptom onset. Patency rates of patients with an interval of 3 hours between symptom onset and start of therapy were compared. There was no difference for Thrombolysis in Myocardial Infarction (TIMI) grade 3 perfusion after front-loaded alteplase (72.5% vs 76. 3%) and reteplase (63.6% vs 63.2% ) between the 2 groups. In contrast, in patients treated with streptokinase (36.8% vs 27.6%, P =.09), anisoylated plasminogen streptokinase activator complex (59. 5% vs 34.8%, P =.004), and urokinase (62.3% vs 41.7%, P =.03), TIMI 3 patency decreased with the increasing interval between symptom onset and initiation of therapy. CONCLUSIONS: We conclude from our data that the thrombolytic efficacy of recombinant tissue-type plasminogen activator and reteplase does not decrease with the increasing interval between symptom onset and initiation of therapy. In contrast, after anisoylated plasminogen streptokinase activator complex, streptokinase, and urokinase treatment, a decrease in patency, especially TIMI-3 patency in patients treated after >3 hours after symptom onset, was observed. These results may influence the choice of the thrombolytic agent in patients who are seen >3 hours after symptom onset.

Determinants of infarct size in patients successfully treated by intracoronary thrombolysis.

In 125 patients successfully treated by intracoronary thrombolysis, data were analyzed to determine the amount of regional wall motion impairment. In 85 patients with complete occlusion of the affected vessel and successful recanalization, ventriculographic study could be performed immediately after recanalization of the vessel and repeated 3 days thereafter. Unexpectedly, no correlation could be seen between the amount of wall motion impairment and the time interval of coronary vessel occlusion. For assessment of other influencing factors two subgroups were analyzed, one with large infarction despite short occlusion time and the other with small infarction despite long occlusion time. The significant differences between these two groups was in regard to the occluded coronary vessels: In the first group, most patients had anterior infarctions caused by left anterior descending (LAD) occlusion, whereas in the second group, there were no LAD occlusions at all. According to the data that we compiled, the location of the occluded coronary vessel was the most important factor in determining infarct size. Taking this into account, recovery of the impaired wall motion up to the third day after infarction was separately analyzed in LAD occlusion or inferior infarction and was found to be more pronounced in the first. Immediate recovery after recanalization however, which could be analyzed in 40 patients who had angiographic studies before recanalization as well as afterwards, was more pronounced in inferior infarction.

Fungal arthritis simulating juvenile rheumatoid arthritis.

Petriellidium boydii is often isolated from maduromycosis but has recently been associated with arthritis. A previously healthy 6-year-old boy developed chronic purulent arthritis of the knee after a bicycle accident. Culture of aspirate grew no pathogens and antibiotic treatment had no effect. Culture of synovial fluid grew P boydii, which responded initially to amphotericin but reappeared after six months. Subsequent treatment with miconazole was stopped after development of haematuria. The fungus was sensitive to ketoconazole, and treatment with this drug cured the infection. With the introduction of ketoconazole it is of practical importance to recognise fungal infections.