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Left ventricular thrombus in anterior acute myocardial infarction after thrombolysis. A GISSI-2 connected study
C Vecchio1, F Chiarella, G Lupi
1Divisione di Cardiologia, EO Ospedale Galliera, Genova, Italy.
Insights
Recombinant tissue-type plasminogen activator and streptokinase show similar efficacy in preventing left ventricular thrombi after myocardial infarction. Heparin did not reduce thrombi incidence but influenced their shape.
Area of Science:
- Cardiology
- Thrombosis Research
- Myocardial Infarction Treatment
Background:
- Streptokinase use is established for reducing left ventricular thrombosis post-myocardial infarction.
- The efficacy of other thrombolytic agents and adjunctive heparin remains less understood.
Purpose of the Study:
- To compare recombinant tissue-type plasminogen activator (rt-PA) and streptokinase in preventing left ventricular thrombi.
- To evaluate the additional benefit of subcutaneous heparin in patients receiving thrombolysis.
Main Methods:
- A randomized echocardiographic study (GISSI-2) involving 180 acute myocardial infarction patients.
- Patients were assigned to rt-PA, rt-PA plus heparin, streptokinase, or streptokinase plus heparin groups.
- Echocardiograms were performed within 48 hours of symptom onset and before hospital discharge.
Main Results:
- Left ventricular thrombi occurred in 28% of patients, with no significant difference between the four treatment groups.
- Mural thrombi were more common than protruding thrombi, particularly in patients receiving heparin.
- Embolic events were rare (0.5%) during hospitalization.
Conclusions:
- Both rt-PA and streptokinase demonstrate comparable rates of left ventricular thrombi after acute myocardial infarction.
- Subcutaneous heparin, initiated 12 hours after thrombolysis, did not reduce thrombi incidence but altered their morphology.
- Embolic events are infrequent during the predischarge period in patients treated with thrombolysis.
Background:
Streptokinase reduces the incidence of left ventricular thrombosis after acute myocardial infarction. However, it is unknown whether a similar effect can be obtained with different thrombolytic agents and whether subcutaneous calcium heparin can have an additional efficacy.
Methods And Results:
To compare the effects of two different thrombolytic agents combined or not with heparin on the incidence and features of left ventricular thrombi and their related embolic events, we performed a GISSI-2 ancillary echocardiographic study (the first echocardiogram obtained within 48 hours of symptoms onset and the second before hospital discharge) that enrolled 180 consecutive patients (mean age, 63 +/- 11 years, 142 men) with a first anterior acute myocardial infarction. Patients were randomized into four groups of treatment: recombinant tissue-type plasminogen activator (rt-PA) (n = 47), rt-PA plus heparin (n = 45), streptokinase (n = 39), and streptokinase plus heparin (n = 49). Left ventricular thrombosis was observed in 51 of 180 patients (28%). No significant differences were found concerning the incidence of thrombi in the four treatment groups. Mural shape of left ventricular thrombi was found more frequently than the protruding shape (71% versus 29% at the first examination, 64% versus 36% at the second), particularly in heparin-treated patients (93% versus 7% at first examination, 70% versus 30% at the second). Only one embolic event (0.5%) occurred during the hospitalization.
Conclusions:
We conclude that 1) the rate of left ventricular thrombi does not differ in patients with acute myocardial infarction treated either with streptokinase or rt-PA, 2) subcutaneous heparin, when begun 12 hours after intravenous thrombolysis, does not appear to further reduce the occurrence of thrombi but seems to influence the shape of left ventricular thrombi, and 3) during the predischarge period, embolic events are rare in patients treated by thrombolysis.