Elsevier

The Lancet

Volume 343, Issue 8893, 5 February 1994, Pages 311-322
The Lancet

Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients

https://doi.org/10.1016/S0140-6736(94)91161-4Get rights and content

Abstract

Large randomised trials have demonstrated that fibrinolytic therapy can reduce mortality in patients with suspected acute myocardial infarction (AMI). The indications for, and contraindications to, this treatment in some categories of patient are disputed, examples being late presentation, elderly patients, and those in cardiogenic shock. This overview aims to help resolve some of the remaining uncertainties. From all trials of fibrinolytic therapy versus control that randomised more than 1000 patients with suspected AMI, information was sought and checked on deaths during the first 5 weeks and on major adverse events occurring during hospitalisation. The nine trials included 58 600 patients, amongwhom 6177 (10·5%) deaths, 564 (1·0%) strokes, and 436 (0·7%) major non-cerebral bleeds were reported. Fibrinolytic therapy was associated with an excess of deaths during days 0-1 (especially among patients presenting more than12 h after symptom onset, and in the elderly) but this was outweighed by a much larger benefit during days 2-35. This "early hazard" should not obscure the very clear overall survival advantage that is produced by fibrinolytic therapy. Benefit was observed among patients presenting with ST elevation or bundle-branch block (BBB)—irrespective of age, sex, blood pressure, heart rate, or previous history of myocardial infarction or diabetes—and was greater the earlier treatment began. Among the 45 000 patients presenting with ST elevation or BBB the relation between benefit and delay from symptom onset indicated highly significant absolute mortality reductions of about 30 per 1000 for those presenting within 0-6 h and of about 20 per 1000 for those presenting 7-12 h from onset, and a statistically uncertain benefit of about 10 per 1000 for those presenting at 13-18 h (with more randomised evidence needed in this latter group to assess reliably the net effects of treatment). Fibrinolytic therapy was associated with about 4 extra strokes per 1000 during days 0-1: of these, 2 were associated with early death and so were already accounted for in the overall mortality reduction, 1 was moderately or severely disabling, and 1 was not. This overview indicates that fibrinolytic therapy is beneficial in a much wider range of patients than is currently given such treatment routinely.

References (59)

  • Gd Chapman et al.

    Minimizing the risk of inappropriately administering thombolytic therapy (Thrombolysis and Angioplasty in Myocardial Infarction [TAMI] Study Group)

    Am J Cardiol

    (1993)
  • Cl Grines et al.

    Optimal utilization of thrombolytic therapy for acute myocardial infarction: concepts and controversies

    J Am Coll Cardiol

    (1990)
  • Ag Wasserman et al.

    Patient selection for thrombolytic therapy

    Am J Cardiol

    (1989)
  • AIMS Trial Study Group

    Long-term effects of intravenous anistreplase in acute myocardial infarction: final report of the AIMS study

    Lancet

    (1990)
  • S. MacMahon et al.

    Blood pressure, stroke and coronary heart disease. Part 1, prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias

    Lancet

    (1990)
  • R. Schroder et al.

    Impact of late coronary artery reperfusion on left ventricular function one month after acute myocardial infarction (results from the ISAM study)

    Am J Cardiol

    (1989)
  • Mb Honan et al.

    Cardiac rupture, mortality and the timing of thrombolytic therapy: a meta-analysis

    J Am Coll Cardiol

    (1990)
  • GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto miocardico)

    Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction

    Lancet

    (1986)
  • ISAM (Intravenous Streptokinase in Acute Myocardial Infarction) Study Group

    A prospective trial of intravenous streptokinase in acute myocardial infarction (ISAM): mortality, morbidity, and infarct size at 21 days

    N Engl J Med

    (1986)
  • AIMS (APSAC Intervention Mortality Study) Trial Study Group

    Effects of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial

    Lancet

    (1988)
  • Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of suspected acute myocardial infarction: ISIS-2

    Lancet

    (1988)
  • Comparison of intravenous urokinase plus heparin versus heparin alone in acute myocardial infarction

    Am J Cardiol

    (1991)
  • ISIS-3: a randomised trial of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin plus heparin vs aspirin alone among 41 299 cases of suspected acute myocardial infarction

    Lancet

    (1992)
  • Randomised trial of late thrombolysis in patients with suspected acute myocardial infarction

    Lancet

    (1993)
  • LATE Study Group

    Late Assessment of Thrombolytic Efficacy (LATE) study with alteplase 6-24 hours after onset of acute myocardial infarction

    Lancet

    (1993)
  • R. Collins et al.

    British Heart Foundation Surveys (1987 & 1989) of United Kingdom policies for acute myocardial infarction

    Br Heart J

    (1991)
  • Ma Pfeffer et al.

    Selection bias in the use of thrombolytic therapy in acute myocardial infarction

    JAMA

    (1991)
  • D. Gray et al.

    Impact of hospital thrombolysis policy on out-of-hospital response to suspected myocardial infarction

    Lancet

    (1993)
  • Er Bates

    Reperfusion therapy in inferior myocardial infarction

    J Am Coll Cardiol

    (1988)
  • Cited by (2868)

    • Chest Pain: Evaluation and Management

      2023, Physician Assistant Clinics
    View all citing articles on Scopus
    1

    Collaborators are listed at the end of the report.

    View full text