Treatment of reinfarction after thrombolytic therapy for acute myocardial infarction - An analysis of outcome and treatment choices in the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO I) and assessment of the safety of a new thrombolytic(ASSENT 2) studies

Background--Early reinfarction after thrombolytic therapy is associated wit h adverse outcomes and increased mortality. Among patients with reinfarctio n in the 1992 Global Utilization of Streptokinase and Tissue Plasminogen Ac tivator for Occluded Coronary Arteries (GUSTO I) and the 1998 Assessment of the Safety of a New Thrombolytic (ASSENT 2) trials, we investigated tempor al and regional differences in the use of repeat thrombolysis, revasculariz ation (angioplasty and/or bypass surgery), or conservative measures and the outcomes of each management strategy. Methods and Results--Data from the 4% of patients (n=2301) who experienced reinfarction after thrombolytic therapy were:studied. Baseline characterist ics, 30-day mortality, and incidence of total and hemorrhagic strokes were compared among the 3 treatment groups. The 30-day mortality did not differ between the repeat thrombolysis and revascularization groups (P=0.72), and it was significantly lower among patients treated by these 2 strategies tha n in those treated conservatively (11% and 11% versus 28%, respectively; P< 0.001). Stroke rates did not differ significantly between the 3 treatment s trategies (P=0.49). From 1992 to 1998, the percentage of reinfarction patie nts treated with repeat thrombolysis decreased from 29.3% to 18.5% in US ce nters and from 51.4% to 41.9% in all other centers (P<0.001). In contrast, use of revascularization procedures increased from 33.5% to 47.9% in US cen ters and from 8.1% to 23.0% in all other centers (P<0.001). Conclusions--Repeat thrombolysis and revascularization are associated with significantly lower mortality among reinfarction patients. Randomized trial s are necessary to assess the exact risks and benefits of rethrombolysis ve rsus interventional revascularization in this subset of high-risk patients presenting with reinfarction after thrombolytic therapy.