Circulation, Vol 90, 2658-2665, Copyright © 1994 by American Heart Association
NS Kleiman, HD White, EM Ohman, AM Ross, LH Woodlief, RM Califf, DR Holmes Jr, E Bates, M Pfisterer and A Vahanian
BACKGROUND: A paradoxical increased risk of death has been reported during
the first 24 hours after thrombolysis for myocardial infarction. The
mechanism of this phenomenon is not known, nor is its relation to the
success or failure of reperfusion. The present study was a prospectively
designed analysis of deaths occurring within the first 24 hours in the
GUSTO trial. METHODS AND RESULTS: There were 41,021 patients enrolled in
GUSTO, a randomized comparison of streptokinase with intravenous or
subcutaneous heparin, accelerated tissue-type plasminogen activator (TPA),
and combination of streptokinase and TPA. An angiographic mechanistic
substudy examined reperfusion (using the TIMI flow grading criteria) 90
minutes after the assigned thrombolytic regimen was begun in 1567 patients.
There were 1125 deaths (2.8%) within 24 hours ("early deaths") and 1726
additional deaths (4.2%) after 24 hours but within 30 days ("later
deaths"). At the time of presentation, the most potent predictors of early
death were hypotension and sinus tachycardia. In a multiple logistic
regression model, lower systolic blood pressure, shorter height, higher
heart rate, and the absence of prior smoking distinguished early death from
later death. Reinfarction occurred in 26 patients (2.4%), shock in 572
patients (52%), atrioventricular block in 308 patients (28%), and tamponade
in 106 patients (10%) dying early compared with 262 (15%), 788 (46%), 396
(23%), and 74 (4%) respective patients dying later. There were no
differences in early mortality among the thrombolytic regimens for the
first 6 hours after randomization. By 24 hours, however, mortality was
2.89% for streptokinase recipients, 2.84% for combination therapy
recipients, and 2.36% for accelerated TPA recipients (P = .005). There was
little difference among patients with differing flow grades in the infarct
artery during the first 4 hours, although mortality was 2.35% for patients
with flow grade 0 or 1, 2.92% for patients with flow grade 2, and 0.89% for
patients with flow grade 3. CONCLUSIONS: Even with aggressive management
regimens, mortality within the first 24 hours accounted for a large
proportion of postthrombolytic deaths. Patients dying early were more
likely to present with pump failure than were those dying later and were
more likely to diet of events related to left ventricular dysfunction,
although cardiac tamponade also accounted for a significant minority of
these deaths. Thus, the severity of the clinical presentation rather than
the underlying risk factors predicts early mortality. Based on the
angiographic substudy data, it appears that rather than hastening early
mortality, successful restoration of complete antegrade flow in the
infarct-related artery protects against early death.
ARTICLES
Mortality within 24 hours of thrombolysis for myocardial infarction. The importance of early reperfusion. The GUSTO Investigators, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries
Department of Medicine, Baylor College of Medicine, Houston, Tex.
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