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. 1997 Jun;77(6):512–516. doi: 10.1136/hrt.77.6.512

Impact of early accelerated dose tissue plasminogen activator on in-hospital patency of the infarcted vessel in patients with acute right ventricular infarction.

E Giannitsis 1, J Potratz 1, U Wiegand 1, U Stierle 1, H Djonlagic 1, A Sheikhzadeh 1
PMCID: PMC484792  PMID: 9227293

Abstract

OBJECTIVE: To assess the efficacy of early accelerated dose tissue plasminogen activator on in-hospital patency of the infarct related artery in patients with inferior myocardial infarction with and without right ventricular involvement. DESIGN: Single centre prospective assessment before discharge of infarct related vessel patency after early thrombolysis. SETTING: Tertiary cardiac referral centre at a university hospital. PATIENTS AND METHODS: 90 consecutive unselected patients with acute myocardial infarction, of whom 35 (39%) had electro-cardiographic evidence of right ventricular involvement (ST segment elevation greater than 0.1 mV in right precordial lead V4R), were studied. All patients received accelerated dose tissue plasminogen activator 100 mg within six hours from the onset of symptoms and had control angiography before discharge. MAIN OUTCOME MEASURES: Infarct related coronary artery patency using the Thrombolysis in Myocardial Infarction (TIMI) grading system before discharge. Incidence of prolonged systemic hypotension, sinus bradycardia, complete atrioventricular block, and ventricular tachyarrhythmia during early hospitalisation. RESULTS: Despite aspirin and bolus heparinisation before thrombolysis and high dose heparinisation thereafter for at least 48 hours the infarct related artery was more likely to be occluded (TIMI 0 or 1 flow) in patients with right ventricular involvement than in those without (69 v 29%, P < 0.001), as shown by control angiography performed a mean of 12.8 days after thrombolysis. These findings may be explained, at least in part, by predominant involvement of the proximal right coronary artery (66 v 31%, P < 0.05) and a low cardiac output syndrome, being indirectly reflected by a high incidence of prolonged hypotension (26 v 7%, P = 0.02), bradycardia (34 v 14%, P = 0.03), and complete atrioventricular block (37 v 5%, P = 0.0001). CONCLUSION: Primary angioplasty should be considered as the treatment of choice in patients with acute inferior infarction with right ventricular involvement because of the high failure rate of thrombolysis.

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Selected References

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  1. Abbottsmith C. W., Topol E. J., George B. S., Stack R. S., Kereiakes D. J., Candela R. J., Anderson L. C., Harrelson-Woodlief S. L., Califf R. M. Fate of patients with acute myocardial infarction with patency of the infarct-related vessel achieved with successful thrombolysis versus rescue angioplasty. J Am Coll Cardiol. 1990 Oct;16(4):770–778. doi: 10.1016/s0735-1097(10)80320-1. [DOI] [PubMed] [Google Scholar]
  2. Andersen H. R., Nielsen D., Lund O., Falk E. Prognostic significance of right ventricular infarction diagnosed by ST elevation in right chest leads V3R to V7R. Int J Cardiol. 1989 Jun;23(3):349–356. doi: 10.1016/0167-5273(89)90195-2. [DOI] [PubMed] [Google Scholar]
  3. Bates E. R., Califf R. M., Stack R. S., Aronson L., George B. S., Candela R. J., Kereiakes D. J., Abbottsmith C. W., Anderson L., Pitt B. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI-1) trial: influence of infarct location on arterial patency, left ventricular function and mortality. J Am Coll Cardiol. 1989 Jan;13(1):12–18. doi: 10.1016/0735-1097(89)90542-1. [DOI] [PubMed] [Google Scholar]
  4. Bates E. R., Topol E. J. Limitations of thrombolytic therapy for acute myocardial infarction complicated by congestive heart failure and cardiogenic shock. J Am Coll Cardiol. 1991 Oct;18(4):1077–1084. doi: 10.1016/0735-1097(91)90770-a. [DOI] [PubMed] [Google Scholar]
  5. Berger P. B., Ruocco N. A., Jr, Ryan T. J., Jacobs A. K., Zaret B. L., Wackers F. J., Frederick M. M., Faxon D. P. Frequency and significance of right ventricular dysfunction during inferior wall left ventricular myocardial infarction treated with thrombolytic therapy (results from the thrombolysis in myocardial infarction [TIMI] II trial). The TIMI Research Group. Am J Cardiol. 1993 May 15;71(13):1148–1152. doi: 10.1016/0002-9149(93)90637-r. [DOI] [PubMed] [Google Scholar]
  6. Berger P. B., Ruocco N. A., Ryan T. J., Frederick M. M., Podrid P. J. Incidence and significance of ventricular tachycardia and fibrillation in the absence of hypotension or heart failure in acute myocardial infarction treated with recombinant tissue-type plasminogen activator: results from the Thrombolysis in Myocardial Infarction (TIMI) Phase II trial. J Am Coll Cardiol. 1993 Dec;22(7):1773–1779. doi: 10.1016/0735-1097(93)90756-q. [DOI] [PubMed] [Google Scholar]
  7. Berger P. B., Ryan T. J. Inferior myocardial infarction. High-risk subgroups. Circulation. 1990 Feb;81(2):401–411. doi: 10.1161/01.cir.81.2.401. [DOI] [PubMed] [Google Scholar]
  8. Braat S. H., Brugada P., de Zwaan C., Coenegracht J. M., Wellens H. J. Value of electrocardiogram in diagnosing right ventricular involvement in patients with an acute inferior wall myocardial infarction. Br Heart J. 1983 Apr;49(4):368–372. doi: 10.1136/hrt.49.4.368. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Braat S. H., de Zwaan C., Brugada P., Coenegracht J. M., Wellens H. J. Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances. Am Heart J. 1984 Jun;107(6):1183–1187. doi: 10.1016/0002-8703(84)90275-8. [DOI] [PubMed] [Google Scholar]
  10. Chesebro J. H., Knatterud G., Roberts R., Borer J., Cohen L. S., Dalen J., Dodge H. T., Francis C. K., Hillis D., Ludbrook P. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987 Jul;76(1):142–154. doi: 10.1161/01.cir.76.1.142. [DOI] [PubMed] [Google Scholar]
  11. Gacioch G. M., Topol E. J. Sudden paradoxic clinical deterioration during angioplasty of the occluded right coronary artery in acute myocardial infarction. J Am Coll Cardiol. 1989 Nov 1;14(5):1202–1209. doi: 10.1016/0735-1097(89)90418-x. [DOI] [PubMed] [Google Scholar]
  12. Grines C. L., DeMaria A. N. Optimal utilization of thrombolytic therapy for acute myocardial infarction: concepts and controversies. J Am Coll Cardiol. 1990 Jul;16(1):223–231. doi: 10.1016/0735-1097(90)90482-5. [DOI] [PubMed] [Google Scholar]
  13. Kalan J. M., Gertz S. D., Kragel A. H., Berger P. B., Roberts W. C., Ryan T. J. Effects of tissue plasminogen activator therapy on the frequency of acute right ventricular myocardial infarction associated with acute left ventricular infarction. Int J Cardiol. 1993 Feb;38(2):151–158. doi: 10.1016/0167-5273(93)90174-f. [DOI] [PubMed] [Google Scholar]
  14. Kennedy J. W., Gensini G. G., Timmis G. C., Maynard C. Acute myocardial infarction treated with intracoronary streptokinase: a report of the Society for Cardiac Angiography. Am J Cardiol. 1985 Apr 1;55(8):871–877. doi: 10.1016/0002-9149(85)90709-x. [DOI] [PubMed] [Google Scholar]
  15. Kinn J. W., Ajluni S. C., Samyn J. G., Bates E. R., Grines C. L., O'Neill W. Rapid hemodynamic improvement after reperfusion during right ventricular infarction. J Am Coll Cardiol. 1995 Nov 1;26(5):1230–1234. doi: 10.1016/0735-1097(95)00311-8. [DOI] [PubMed] [Google Scholar]
  16. Klein H. O., Tordjman T., Ninio R., Sareli P., Oren V., Lang R., Gefen J., Pauzner C., Di Segni E., David D. The early recognition of right ventricular infarction: diagnostic accuracy of the electrocardiographic V4R lead. Circulation. 1983 Mar;67(3):558–565. doi: 10.1161/01.cir.67.3.558. [DOI] [PubMed] [Google Scholar]
  17. Lew A. S., Laramee P., Shah P. K., Maddahi J., Peter T., Ganz W. Ratio of ST-segment depression in lead V2 to ST-segment elevation in lead aVF in evolving inferior acute myocardial infarction: an aid to the early recognition of right ventricular ischemia. Am J Cardiol. 1986 May 1;57(13):1047–1051. doi: 10.1016/0002-9149(86)90672-7. [DOI] [PubMed] [Google Scholar]
  18. Lopez-Sendon J., Coma-Canella I., Alcasena S., Seoane J., Gamallo C. Electrocardiographic findings in acute right ventricular infarction: sensitivity and specificity of electrocardiographic alterations in right precordial leads V4R, V3R, V1, V2, and V3. J Am Coll Cardiol. 1985 Dec;6(6):1273–1279. doi: 10.1016/s0735-1097(85)80213-8. [DOI] [PubMed] [Google Scholar]
  19. Lopez-Sendon J., Coma-Canella I., Gamallo C. Sensitivity and specificity of hemodynamic criteria in the diagnosis of acute right ventricular infarction. Circulation. 1981 Sep;64(3):515–525. doi: 10.1161/01.cir.64.3.515. [DOI] [PubMed] [Google Scholar]
  20. Meijer A., Verheugt F. W., Werter C. J., Lie K. I., van der Pol J. M., van Eenige M. J. Aspirin versus coumadin in the prevention of reocclusion and recurrent ischemia after successful thrombolysis: a prospective placebo-controlled angiographic study. Results of the APRICOT Study. Circulation. 1993 May;87(5):1524–1530. doi: 10.1161/01.cir.87.5.1524. [DOI] [PubMed] [Google Scholar]
  21. Ohman E. M., Califf R. M., Topol E. J., Candela R., Abbottsmith C., Ellis S., Sigmon K. N., Kereiakes D., George B., Stack R. Consequences of reocclusion after successful reperfusion therapy in acute myocardial infarction. TAMI Study Group. Circulation. 1990 Sep;82(3):781–791. doi: 10.1161/01.cir.82.3.781. [DOI] [PubMed] [Google Scholar]
  22. Prewitt R. M., Gu S., Garber P. J., Ducas J. Marked systemic hypotension depresses coronary thrombolysis induced by intracoronary administration of recombinant tissue-type plasminogen activator. J Am Coll Cardiol. 1992 Dec;20(7):1626–1633. doi: 10.1016/0735-1097(92)90459-z. [DOI] [PubMed] [Google Scholar]
  23. Roth A., Miller H. I., Kaluski E., Keren G., Shargorodsky B., Krakover R., Barbash G. I., Laniado S. Early thrombolytic therapy does not enhance the recovery of the right ventricle in patients with acute inferior myocardial infarction and predominant right ventricular involvement. Cardiology. 1990;77(1):40–49. doi: 10.1159/000174578. [DOI] [PubMed] [Google Scholar]
  24. Schuler G., Hofmann M., Schwarz F., Mehmel H., Manthey J., Tillmanns H., Hartmann S., Kübler W. Effect of successful thrombolytic therapy on right ventricular function in acute inferior wall myocardial infarction. Am J Cardiol. 1984 Nov 1;54(8):951–957. doi: 10.1016/s0002-9149(84)80124-1. [DOI] [PubMed] [Google Scholar]
  25. Shah P. K., Maddahi J., Berman D. S., Pichler M., Swan H. J. Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction: clinical and hemodynamic correlates and implications for therapy and prognosis. J Am Coll Cardiol. 1985 Dec;6(6):1264–1272. doi: 10.1016/s0735-1097(85)80212-6. [DOI] [PubMed] [Google Scholar]
  26. Topol E. J., Califf R. M., Vandormael M., Grines C. L., George B. S., Sanz M. L., Wall T., O'Brien M., Schwaiger M., Aguirre F. V. A randomized trial of late reperfusion therapy for acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction-6 Study Group. Circulation. 1992 Jun;85(6):2090–2099. doi: 10.1161/01.cir.85.6.2090. [DOI] [PubMed] [Google Scholar]
  27. Verani M. S., Tortoledo F. E., Batty J. W., Raizner A. E. Effect of coronary artery recanalization on right ventricular function in patients with acute myocardial infarction. J Am Coll Cardiol. 1985 May;5(5):1029–1035. doi: 10.1016/s0735-1097(85)80002-4. [DOI] [PubMed] [Google Scholar]
  28. Verheugt F. W., Meijer A., Lagrand W. K., Van Eenige M. J. Reocclusion: the flip side of coronary thrombolysis. J Am Coll Cardiol. 1996 Mar 15;27(4):766–773. doi: 10.1016/0735-1097(95)00492-0. [DOI] [PubMed] [Google Scholar]
  29. Zehender M., Kasper W., Kauder E., Geibel A., Schönthaler M., Olschewski M., Just H. Eligibility for and benefit of thrombolytic therapy in inferior myocardial infarction: focus on the prognostic importance of right ventricular infarction. J Am Coll Cardiol. 1994 Aug;24(2):362–369. doi: 10.1016/0735-1097(94)90289-5. [DOI] [PubMed] [Google Scholar]
  30. Zehender M., Kasper W., Kauder E., Schönthaler M., Geibel A., Olschewski M., Just H. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med. 1993 Apr 8;328(14):981–988. doi: 10.1056/NEJM199304083281401. [DOI] [PubMed] [Google Scholar]

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