RESCUE THROMBOLYSIS - ALTEPLASE AS ADJUVANT TREATMENT AFTER STREPTOKINASE IN ACUTE MYOCARDIAL-INFARCTION

Background-In acute myocardial infarction patients who do not reperfus e their infarct arteries shortly after thrombolytic treatment have a h igh morbidity and mortality. Management of this high risk group remain s problematic, especially in centres without access to interventional cardiology. Additional thrombolytic treatment may result in reperfusio n and improved left ventricular function. Methods-Failure of reperfusi on was assessed non-invasively as less than 25% reduction of ST elevat ion in the electrocardiographic lead with maximum ST shift on a pretre atment electrocardiogram. 37 patients with acute myocardial infarction who showed electrocardiographic evidence of failed reperfusion 30 min utes after 1.5 MU streptokinase over 60 minutes were randomly allocate d to receive either alteplase (tissue type plasminogen activator (rt-P A) 100 mg over three hours) (19 patients) or placebo (18 patients). 43 patients with electrocardiographic evidence of reperfusion after stre ptokinase acted as controls. Outcome was assessed from the Selvester Q wave score of a predischarge electrocardiogram and a nuclear gated sc an for left ventricular ejection fraction 4-6 weeks after discharge. R esults-Among patients in whom ST segment elevation was not reduced aft er streptokinase, alteplase treatment resulted in a significantly smal ler electrocardiographic infarct size (14% (8%) v 20% (9%), P = 0.03) and improved left ventricular ejection fraction (44 (10%) v 34% (16%), P = 0.04) compared with placebo. This benefit was confined to patient s who failed fibrinogenolysis after streptokinase (fibrinogen > 1 g/l) . In patients in whom ST segment elevation was reduced after streptoki nase, infarct size and left ventricular ejection fraction were not sig nificantly different from those in patients treated with additional al teplase. Conclusion-Patients without electrocardiographic evidence of reperfusion after streptokinase may benefit from further thrombolysis with alteplase.