ST elevation myocardial infarction recurrent ischemia/infarction
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Overview
Reinfarction is defined as a recurrence of a myocardial infarction. The rate of reinfarction following fibrinolytic administration has been estimated to be 2% to 6%.
Definitions
Clinical predictors and timing of reinfarction following fibrinolytic administration
The frequency, timing, and clinical predictors of in-hospital reinfarction were evaluated in the Global Utilization of Streptokinase and Tissue plasminogen activator (alteplase) for Occluded coronary arteries (GUSTO I) and Global Use of Strategies To Open occluded coronary arteries (GUSTO III) populations [1]. Reinfarction developed in in 2,258 out of 55, 911 patients (4.3%). Reinfarction was diagnosed a median of 3.8 days after fibrinolytic administration. The specific fibrinolytic agent administered was not associated with the rate of reinfarction: streptokinase, 4.1%; alteplase, 4.3%; reteplase, 4.5%; combined streptokinase and alteplase, 4.4%; P=0.55. Multivariate predictors or reinfarction included the following: older age, shorter time to fibrinolytic administration, non-US enrollment, nonsmoking status, prior MI or angina, female gender, anterior MI, and lower systolic blood pressure.
Angiographic predictors of reinfarction following fibrinolytic administration
Gibson et al documented that angiographically confirmed reocclusion is observed more frequently among culprit arteries with TIMI grade 2 versus TIMI grade 3 flow (10.4% vs. 2.2%, p = 0.003), in ulcerated lesions (10.7% vs. 3.0%, p = 0.009) and in the presence of collateral vessels (18.2% vs. 5.6%, p = 0.03). Trends toward higher rates of reocclusion were observed among eccentric (7.3% vs. 2.3%, p = 0.06) and thrombotic (8.4% vs. 3.3%, p = 0.06) lesions. Reocclusion was associated with a more severe percent diameter stenosis on quantitative coronary angiography (77.9% vs. 73.9%, p = 0.04).[2].
Prognosis of reinfarction following fibrinolytic administration
In the combined GUSTO I and III experience, reinfarction was associated with a higher mortality at 30 days(11.3% versus 3.5% without reinfarction; odds ratio, 3.5; P<0.001) and from 30 days to 1 year (4.7% versus 3.2%; hazard ratio, 1.5; P<0.001). Significant multivariate predictors of in-hospital death or reinfarction included older age, higher Killip class, lower systolic and diastolic blood pressures, higher heart rate, the presence of an anterior MI, smoking, a history of prior MI, gender, and country of enrollment (all P<0.001) [1]. In contrast, Gibson et al did not find an increase in mortality between 30 days and 2 years in over 20,000 patients in the TIMI trials [3]. Higher mortality at 2 years was found to be due to an early divergence in mortality by 30 days and was not due to a significant increase in late mortality between 30 days and 2 years (4.38% [31/707] vs. 3.76% [685/18,206], p = NS).
Strategies to reduce reinfarction following fibrinolytic administration
Gibson et al reported in their analysis of over 20,000 patients from the TIMI trials that percutaneous coronary intervention performed at the time of the index hospitalization was associated with a lower rate of in-hospital recurrent MI (1.6% vs. 4.5%, p < 0.001) and lower two-year mortality (5.6% vs. 11.6%, p < 0.001). Likewise, coronary artery bypass graft (CABG) surgery was also associated with a lower rate of recurrent MI (0.7% vs. 4.3%, p < 0.001) as well as a lower two-year mortality rate (7.95% vs. 10.6%, p = 0.0008).
- ↑ 1.0 1.1 Hudson MP, Granger CB, Topol EJ; et al. (2001). "Early reinfarction after fibrinolysis: experience from the global utilization of streptokinase and tissue plasminogen activator (alteplase) for occluded coronary arteries (GUSTO I) and global use of strategies to open occluded coronary arteries (GUSTO III) trials". Circulation. 104 (11): 1229–35. PMID 11551872. Unknown parameter
|month=ignored (help) - ↑ Gibson CM, Cannon CP, Piana RN; et al. (1995). "Angiographic predictors of reocclusion after thrombolysis: results from the Thrombolysis in Myocardial Infarction (TIMI) 4 trial". J. Am. Coll. Cardiol. 25 (3): 582–9. PMID 7860900. Unknown parameter
|month=ignored (help) - ↑ Gibson CM, Karha J, Murphy SA; et al. (2003). "Early and long-term clinical outcomes associated with reinfarction following fibrinolytic administration in the Thrombolysis in Myocardial Infarction trials". J. Am. Coll. Cardiol. 42 (1): 7–16. PMID 12849652. Unknown parameter
|month=ignored (help)