Acute MI: role of thrombolysis and intervention

Several issues confront the physician treating the patient with an acute infarction. If the patient is a thrombolytic candidate, a 20 to 30 per cent failure rate still exists, and it is difficult to predict on clinical grounds who has had a successful trial of thrombolytics or not; therefore, considerable clinical judgment must be applied. If the patient has relief of pain and diminished ST segment elevation, it is likely that thrombolytic therapy has been successful. Limitations concerning the benefits of thrombolytic or angioplasty therapy for the acute infarction also exist with regard to baseline patient characteristics. Older patients, especially women, seem to have more complications and less beneficial results from acute revascularization than do others. Patients with anterior infarctions as compared with posterior or inferior wall infarctions probably have a higher benefit from intracoronary thrombolysis. The acute myocardial infarction patient can be treated in multiple ways. Based on the preceding information and our own clinical experience, some recommendations can be made. Other sources with their own recommendations are available as well. First, because of the uncertainty still present in deciding optimum therapy for any given patient, as many patients as possible should be included in randomized prospective clinical trials that are now ongoing. If the patient or treating physician elects not to take part in such a trial, much of the therapy will be based on available resources. In small hospitals without acute catheterization or angioplasty facilities, intravenous thrombolytic therapy should be instituted as quickly as possible. In patients who are not able to receive thrombolytic therapy, acute catheterization with consideration for either angioplasty or acute bypass surgery should be undertaken if the patients are relatively young and early on in their course. Treatment of older patients, especially women, should be tempered by the knowledge that there are diminishing returns in aggressive approaches to these patients. It would appear that the presence of cardiogenic shock itself, although a predictor of higher cardiac mortality, should not preclude an aggressive approach and indeed this patient may benefit greatly from revascularization as well as pharmacologic and mechanical support of the cardiovascular system. If thrombolytic therapy without catheterization is undertaken, there remains the potential for either nonrevascularization or early closure.(ABSTRACT TRUNCATED AT 400 WORDS)