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GISSI update. Which patients with myocardial infarction should receive thrombolysis?
M G Franzosi1, A P Maggioni, G Tognoni
1GISSI Coordinating Center, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy.
Insights
Thrombolysis is a recommended treatment for most acute myocardial infarction (AMI) patients, including the elderly and those with inferior AMI, despite underutilization. Early treatment within 12 hours maximizes benefits for eligible patients.
Area of Science:
- Cardiology
- Clinical Trials
- Evidence-Based Medicine
Background:
- Randomized clinical trials establish thrombolysis as a key treatment for acute myocardial infarction (AMI).
- An estimated 40% of AMI patients are eligible for fibrinolytic therapy, yet actual utilization is significantly lower.
- Discrepancies between established knowledge and clinical practice stem from assumptions of inefficacy in certain subsets and controversial contraindications.
Purpose of the Study:
- To evaluate the efficacy of thrombolysis across diverse patient populations with acute myocardial infarction (AMI).
- To address misconceptions regarding contraindications and subgroup inefficacy for thrombolytic therapy.
- To promote wider application of evidence-based thrombolysis in AMI management.
Main Methods:
- Analysis of large-scale, randomized clinical trials and meta-analyses involving patients with acute myocardial infarction (AMI).
- Assessment of treatment efficacy across various demographic and clinical subgroups, including age and infarction location.
- Review of drug utilization data and clinical practice guidelines.
Main Results:
- Thrombolysis demonstrates significant life-saving potential, particularly in elderly AMI patients, with benefits potentially two to three times higher than general estimates.
- Treatment efficacy extends up to 12 hours from symptom onset, and inferior myocardial infarction patients benefit from thrombolytic therapy.
- ST depression is the only exception among trial participants for whom thrombolysis is not recommended.
Conclusions:
- Thrombolysis should be considered a recommended treatment for nearly all acute myocardial infarction (AMI) patients, barring clear contraindications.
- Expanding thrombolytic therapy to all eligible AMI patients is a primary public health goal.
- Challenging controversial contraindications and subgroup assumptions is crucial for improving patient outcomes.
Abstract:
Large-scale, randomized clinical trials have produced over the last few years a wide consensus about the role of thrombolysis in the treatment of acute myocardial infarction (AMI). It has been estimated from the trials with broader inclusion criteria that about 40% of the patients admitted to coronary care units with AMI are eligible for fibrinolytic therapy and can benefit from it. On the other hand, drug utilization data suggest that only a fraction of eligible patients actually receive thrombolysis. A reason for this dissociation between knowledge and practice lies in the widespread assumption that thrombolysis is inefficacious in particular population subsets, as well as in the setting of a number of contraindications based on controversial evidence. Age per se does not represent a contraindication to thrombolysis, which could display a lifesaving potential two or three times that estimated for the general population of patients with AMI. Although it has been shown that the sooner thrombolytic treatment is provided after the onset of symptoms the more effective it is, the available evidence seems to indicate that the effect could well extend up to 12 h from the onset of symptoms. Patients with an inferior myocardial infarction should also receive thrombolytic treatment on the basis of the results of a meta-analysis carried out on 12,000 patients. Very misleading recommendations for practice can be produced by adjusting the main results so as to conveniently allow for subgroup findings, regardless of their degree of epidemiologic, biologic, and pathophysiologic consistency. For all categories of patients included in the population trials (with the exception of those with ST depression), thrombolysis should be considered a recommended treatment. From an epidemiologic perspective, the extension of the benefits of thrombolytic therapy to all AMI patients for whom the drug is not clearly contraindicated is a goal of primary importance.