Recurrent ischemia after thrombolysis for acute myocardial infarction

Background Reliable predictors have yet to be found for recurrent ischemia after thrombolysis for acute myocardial infarction (AMI), nor do we know wh ether early angiography can herald recurrent ischemia. This study sought to investigate the relationship between recurrent ischemia and cardiac proced ures after thrombolysis for AMI. Methods The Global Utilization of Streptokinase and Tissue Plasminogen Acti vator for Occluded Coronary Arteries (GUSTO-I) trial prospectively studied recurrent ischemia, which was defined as the presence of angina and changes in hemodynamics or the electrocardiogram. Cox regression analysis was used to identify predictors of recurrent ischemia. Other variables examined inc luded time to coronary angiography and revascularization. Results of 21,772 US GUSTO-I patients, 6313 (29%) had recurrent ischemia be fore discharge. Women (hazard ratio [HR] 1.25, 95% confidence interval [Cl] 1.17-1.33) and patients with hypercholesterolemia (HR 1.14, 95% Cl 1.07-1. 22) or prior angina (HR 1.40, 95% Cl 1.32-1.49) had a higher likelihood of recurrent ischemia. Current smoking and hours to thrombolysis were inversel y related to recurrent ischemia (HR 0.86, 95% Cl 0.81-0.92, HR 0.97, 95% Cl 0.95-0.99, respectively). Patients who underwent angiography before recurr ent ischemia had a marginally increased risk of ischemia within 12 hours af ter angiography (HR 1.2, 95% Cl 1.1-1.4); ultimately, they had a considerab ly lower risk 1 week after angiography than did patients without angiograph y (HR 0.57, 95% Cl 0.45-0.72). Conclusions Female sex, hypercholesterolemia, prior angina, and nonsmoking status weakly predict recurrent ischemia. Early coronary angiography reduce s recurrent ischemia, probably because high-risk patients are identified an d revascularized.