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TIMI grade 3 flow and reocclusion after intravenous thrombolytic therapy: a pooled analysis
N A Barbagelata1, C B Granger, E Oqueli
1Fundación Favaloro, Buenos Aires, Argentina.
Insights
Accelerated tissue-plasminogen activator (TPA) best establishes early Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow in acute myocardial infarction treatment. However, reocclusion rates varied among thrombolytic agents, with APSAC showing the lowest rates.
Area of Science:
- Cardiology
- Pharmacology
- Medical Imaging
Background:
- Thrombolytic agents are crucial for treating acute myocardial infarction (AMI).
- Physiologic efficacy is measured by early, sustained TIMI grade 3 flow and reocclusion rates.
- Intravenous thrombolysis utilizes agents like TPA, APSAC, and streptokinase.
Purpose of the Study:
- To systematically review angiographic studies on thrombolytic agents for AMI.
- To compare the efficacy of accelerated and standard-dose TPA, APSAC, and streptokinase.
- To analyze TIMI grade 3 flow and reocclusion rates.
Main Methods:
- Systematic overview of 15 studies (5475 observations) for TIMI flow.
- Systematic overview of 27 studies (3147 observations) for reocclusion.
- Analysis of angiographic data at 60, 90, and 180 minutes post-thrombolysis.
Main Results:
- Accelerated TPA achieved 63.2% TIMI grade 3 flow at 90 minutes.
- Standard-dose TPA, APSAC, and streptokinase showed lower rates of TIMI grade 3 flow.
- Reocclusion rates were 11.8% for standard TPA, 6.0% for accelerated TPA, 4.2% for streptokinase, and 3.0% for APSAC.
- Accelerated TPA demonstrated decreased patency at 180 minutes.
Conclusions:
- Accelerated TPA is the most effective agent for achieving early TIMI grade 3 flow.
- APSAC demonstrated the lowest reocclusion rates.
- Thrombolytic efficacy varies significantly among agents, impacting treatment strategies for AMI.
Abstract:
Early and sustained flow of grade 3 according to Thrombolysis in Myocardial infarction (TIMI) criteria and reocclusion rates are the key measures that define the physiologic efficacy of thrombolytic agents in the treatment of acute myocardial infarction. We performed a systematic overview of angiographic studies after intravenous thrombolysis with accelerated and standard-dose tissue-plasminogen activator (TPA), anisoylated plasminogen streptokinase activator complex (APSAC), and streptokinase. There were 5475 angiographic observations from 15 studies for TIMI flow analysis and 3147 angiographic observations from 27 studies for reocclusion. At 60 and 90 minutes, the rates of TIMI grade 3 flow were 57.1% and 63.2%, respectively, with accelerated TPA, 39.5% and 50.2% with standard-dose TPA, 40.2% and 50.1% with APSAC, and 31.5% at 90 minutes with streptokinase. Overall reocclusion with standard-dose TPA was 11.8% versus 6.0% for accelerated TPA, 4.2% for streptokinase, and 3.0% for APSAC. Although the incidence of TIMI grade 3 flow increased over time with all thrombolytic regimens, decreased patency was observed at 180 minutes with accelerated TPA. Still, accelerated TPA is the most effective agent to establish early (90-minute) TIMI grade 3 flow.