TREATMENT AND OUTCOME OF PATIENTS WITH ACUTE MYOCARDIAL-INFARCTION AND PRIOR CEREBROVASCULAR EVENTS IN THE THROMBOLYTIC ERA - THE ISRAELI THROMBOLYTIC NATIONAL SURVEY

Background: Patients with a history of stroke presenting with acute my ocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are avail able on the risks vs the benefits of thrombolysis in patients with ari acute MI and a prior cerebrovascular event (PCE). Methods: Data were derived from 2 nationwide surveys of 2012 consecutive patients with ac ute MI admitted to all 25 coronary care units in Israel during 1992 an d 1994. Thrombolytic therapy was given to patients with a PCE at the d iscretion of the treating physicians. Outcomes were compared between p atients with an acute MI with and without a PCE and between patients w ith a PCE treated with or excluded from thrombolysis. Results: Patient s with a PCE (n=115 [6%]) were older, with higher rates of atheroscler otic risk factors and in-hospital complications than their counterpart s without a prior event (n=1897). They were treated less often with th rombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after mu ltivariate adjustments for clinical characteristics (adjusted hazard r atio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acut e MI and a PCE who were treated with thrombolysis (n=29 [25%]) were co mpared with 46 patients found ineligible for thrombolysis primarily be cause of their PCE. The timing of the PCE was com parable in both grou ps (one fifth in the preceding year), while prior transient ischemic a ttacks were more prevalent among patients who had undergone thrombolys is. The patients who were treated with thrombolysis (n=29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and P-blockers more often than thei r counterparts (n=46). In-hospital intracranial hemorrhage did not occ ur in either group. The 1-year mortality rates were 2-fold higher amon g patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64). Conclusions: These findings, derived from 2 nationwide su rveys of consecutive patients with acute MI, suggest that patients wit h PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our pr eliminary data, may be beneficial in selected patients with an acute M I with a nonrecent PCE.