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A pooled analysis of coronary arterial patency and left ventricular function after intravenous thrombolysis for acute
C B Granger1, H D White, E R Bates
1Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710.
Insights
This meta-analysis shows accelerated tissue-type plasminogen activator (t-PA) offers superior early patency rates compared to other thrombolytic agents. Thrombolytic therapy modestly improves left ventricular ejection fraction over time.
Area of Science:
- Cardiology
- Pharmacology
- Medical Imaging
Background:
- Individual thrombolysis studies have limitations in sample size and data points.
- Assessing patency and left ventricular (LV) function requires comprehensive analysis.
Purpose of the Study:
- To provide a reliable estimate of patency and LV ejection fraction patterns after intravenous thrombolytic therapy.
- To compare the efficacy of different thrombolytic agents.
Main Methods:
- Systematic overview of 58 angiographic studies with 14,124 observations.
- Included agents: no thrombolytic, streptokinase, standard-dose t-PA, accelerated-dose t-PA, anistreplase (APSAC).
- Analyzed patency rates, reocclusion rates, and LV ejection fraction.
Main Results:
- Accelerated t-PA showed highest patency rates at 60-90 minutes (74-84%).
- Reocclusion rates were higher with t-PA compared to non-fibrin-specific agents (13.4% vs 8.0%).
- Thrombolytic therapy modestly improved mean LV ejection fraction compared to control (53% vs 47% by day 4).
Conclusions:
- Accelerated t-PA demonstrates superior early reperfusion.
- Thrombolytic therapy offers a modest but significant improvement in LV function.
- Long-term patency rates were similar across regimens after 2-3 hours.
Abstract:
Individual studies of patency rates and left ventricular (LV) function after thrombolysis have generally been limited by small numbers of observations, wide confidence intervals, and limited numbers of time points. To obtain a more reliable estimate of patterns of patency and LV ejection fraction, a systemic overview of angiographic studies was performed after intravenous thrombolytic therapy. A total of 14,124 angiographic observations from 58 studies evaluating patency after no thrombolytic agent, streptokinase, standard dose tissue-type plasminogen activator (t-PA), accelerated dose t-PA, or anistreplase (anisoylated plasminogen streptokinase activator complex [APSAC]) were included. At 60 and 90 minutes, streptokinase had the lowest patency rates of 48% and 51%, respectively, standard dose t-PA and APSAC had similar intermediate rates of approximately 60% and 70%, and accelerated t-PA had the highest patency rates of 74% and 84%. By 2 to 3 hours and longer, the patency rates were similar for the various regimens. Reocclusion rates in studies including 1,172 patients randomized to t-PA versus a nonfibrin-specific agent were higher after t-PA (13.4% vs 8.0%, p = 0.002). Ten studies enrolling 4,088 patients treated with thrombolytic therapy versus control demonstrated a modest improvement in mean LV ejection fraction in the thrombolytic group at each of the times after thrombolytic therapy: hour 4, day 1, day 4, day 7 to 10, and day 10 to 28 after thrombolysis. By 4 days, mean ejection fraction was 53% versus 47% (thrombolytic vs control therapy, p < 0.01); by 10 to 28 days it was 54.1% and 51.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)