Thrombolytic therapy in selected patients with impending myocardial reinfarction

In selected patients with postinfarction angina and impending reinfarction, thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) or streptokinase is highly effective in avoiding a new myocardial infarction.

To avoid major cardiac events, we treated 14 consecutive patients with thrombolytic therapy because of impending reinfarction with ECG ST-segment elevation. Thirteen patients received rt-PA (100 mg over 3 hours), and one patient received streptokinase (1.5 million IU over 1 hour). All patients had failed to respond to maximal medical therapy with intravenous nitrates, beta-blockers, Ca-antagonists, heparin, and opiates.

In all patients, clinical and ECG signs of acute ischemia resolved completely within 1 hour after beginning thrombolysis, and no patient developed biochemical markers of myocardial infarction. Ten patients underwent coronary angiography: five had three-vessel disease, two had two-vessel disease, and three had one-vessel disease. The culprit lesion was located in the left anterior descending artery in eight cases and the right coronary artery in two. No patient showed intracoronary thrombus. Four patients underwent successful, semiurgent percutaneous transluminal coronary angioplasty; three received an elective and two an urgent coronary artery bypass graft.

Thrombolysis (or repeated thrombolysis) is effective in selected patients with clinical ECG signs of impending reinfarction. It can temporarily stabilize the condition of many patients, thus allowing safer mechanical revascularization to be performed.