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P08 Intraoperative emergency thrombolysis with rt-PA after early postoperative coronary artery bypass thrombosis
92
Session I: Thrombolysis in acute myocardial infarction I
P05 Acute myocardial infarction - time is survival. The Munich AMI
P07 Thrombolysis on patients over 65 years
Project C. WONHAS Kreiskrankenhaus MOnchen-Pasing, 1. Med. Department, Steinerweg 5, 81241 MOnchen, Germany
E. CHUQUIURE-VALENZUELA, U. JUAREZ, A. LASSES, H. GONZ,4LEZ, J. CARRILLO, C. LOPEZ, J. CASANOVA, C. MART[NEZ-SANCHEZAND E. LUPI Coronary Care Unit. Instituto Nacional de Cardiolog/a "lgnacio Chavez" Mexico City, Mexico
Aim: Two hundred thousand patients suffer from acute myocardial infarction in Germany every year. Sixty percent of these patients die, 40% of them before reaching a hospital. Improvement of prehospital diagnostics by 12-lead-ECG, recordable in the ambulance, should (as a pilot project), reduce the 'door to needle time' and increase the proportion of thrombolysis in AMI-patients at our hospital. Methods: By setting up a central alert office on 1 June 1997 the City of Munich made it possible for the patients to alann the nearest and most suitable emergency facility. The Lifepak-11-system (Physio Control) on our EMU is a portable unit consisting of ECG-recorder, defibrillator, and trans-thoracal-pacemaker. In combination with a mobile telephone it is possible since 1 July 1997 to pass on the ECG directly from the emergency site to the intensive care unit and to communicate with the hospital physicians at the ICU. Results: By these measures thrombolysis in AMI was increased by 129% (7 vs. 16) in the second 6 months of 199Z Door-to-needle-time was reduced by 48% (67 vs. 35 rain), recanalizing therapies increased by 9,5°/o (21 vs. 23). Conclusions: The new emergency car system led to an overall improvement in the treatment of patients with acute myocardial infarction and will be extended in the whole city. Simultaneously emergency physicians experienced in thrombolysis get increased opportunities for prehospital thrombolysis.
P06 Is there an influence of the time of admission to a hospital on the rate of thrombolysis in patients with acute myocardial infarction? R. ZAHN 1, A. KOCt-P, J. RUSTIGEI, S. SCHUSTER~, R. SCHIELE~, D. HARMJANZ3, B. BOPPERT4, M. GOTTWIK5, FOR DIE ALKK STUDIEN GRUPPE ~Ludwigshafen, 2Heidelberg, 3Celle, 4LiJdenscheid, 5NOmberg, Germany
Background: Intravenous thrombolysis is a standard therapy for patients with acute myocardial infarction (AMI), with clearly defined indications. However little is known about para-medical influences on the use of thrombolytics in such patients. The aim of the present study was to analyse the influence of the time of admission of the patients with AMI to a hospital on the rate of thrombolysis in such patients. Methods: Between 7/92 and 9/94 14 756 consecutive patients (pts) with AMI were registered by 66 hospitals for the '60-Minutes Myocardial Project'. Patients were distributed into a group 'regular working hours' ('on' hours): admission to the hospital Monday to Friday 8:00 to 17:00 and a second group: 'off working hours' ('off' hours) Monday to Friday 19:00 to 08:00 and weekend. Results: During 'on' hours 6340 pts (43%) and during 'off' hours pts (570/0) were treated. Parameter Men Age > 75 years iv thrombolysis Primary angioplasty Hospital mortality
All
"On' hours
"Off' hours
68.4% 22.5% 50.8% 1.4% 17%
67.3% 24% 47.1% 2% 16.2%
69.2% 21.4% 53.5% 1% 17.7%
OR (95% CI) 1.09 0.86 1.29 0.49 1.11
(1.02-1.17) (0.80-0.92) (1.21-1.38) (0.37-0.65) (1.01-1.21)
Logistic regression analysis showed 'off' hours to be an independent predictor for a higher rate of intravenous thrombolysis (OR = 1.17; CI 1.07-1.28). Conclusions: Base-line characteristics and treatment of pts with AMI who were admitted to a hospital during 'off' working hours were quite different from pts treated during 'on' hours. During 'off' hours the rate of pts treated with iv thrombolysis was higher, whereas during 'on' hours the rate of pts treated with primary angioplasty was higher. This indicates an influence of the time of admission on the choice of reperfusion therapy. Fibrinolysis & Proteolysis (1998) 12(Suppl 2), 91-113
Objective: To analyze the effectiveness of thrombolytic treatment and it's influence on clinical evolution in patients with acute myocardial infarction (AMI) over 65 years. Methods: We analyzed risk factors, AMI characteristic and localization, thrombolytic agents, clinical evolution, angiographics findings and revasculafizations procedures, in patients over 65 years with AMI without contraindications for thrombolytic therapy. Results: During 6 years, thrombolytic therapy was administrated to 126 patients over 65 years with AMI, with 71.28 _+5 years, the treatment average time of 3.4 hours; 106 received SK (84%) and 20 rt-PA (16%), 88 male (700/0) Risk factors of: smokers 80 (63°/0), diabetes mellitus 28 (220/0), hypertension 62 (49%) and previous angina 73 (58%), 9 with history AMI. Thirty-one patients had anterior wall AMI. Major bleeding was seen in 10 patients, and 2 with intracranial bleeding. Thirty-one pts developed left ventricular dysfunction; 36 had post-MI angina and 9 reinfarction, 3 patients had ventticular rupture. From the clinical reperfusion criteria 63% had arrythmias, ventricular ectopy and slow ventricular tachycardla were the most frequent, and early electrocardiography evolution in 96% of the patients were observed. Seventy-one patients went under coronariographic studies, in 70% vessel patency was found, but only 32% with TIMI 2-3 flux. Twenty-nine percent patients undergo CBAG and in 37% PTCA was practised, 19 patient died on the first 10 days, 14 died from cardiogenic shock, 3 from arrythrnias and two myocardial rupture.
P08 Intraoperative emergency thrombolysis with rt-PA after early postoperative coronary artery bypass thrombosis M. BREUER, A. SCHOTZ, J. WEINGARTNER, B. GANSERA, W. EICHINGER, B. KEMKES Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Germany
Background: Acute graft occlusion early postoperatively after CABG is a rare but dramatic complication, mostly making resuscitation necessary. Emergency reoperation with reanastomosing of the relevant grafts is the common usual procedure to restrict the otherwise unavoidable myocardial damage. We perform in such cases additionally an intraoperatively intracoronary installed rt-PA lysis. Methods: Since 1994 15 patients (0.330/0) underwent emergency reoperation within the first 12 hours after CABG due to clinical signs of acute graft thrombosis. In six of these patients (group Ii) intraoperative rt-PA lysis has been performed. We applicated up to 100 mg rt-PA, locally into the coronary artery after inspection and reopening of the bypass-anastomosis of the relevant vessel/s. Results: In group I (n = 9; 7 m, 2 f) without lysis, 33% (n = 3) of the patients could not be stabilized after renewing of the bypasses, not even with the help of high dose medicamental support. The other patients of group I survived but all of them showed highly elevated CK-Ievels (CKmax x = 1254 u/l; 965-1431 U/I) and the corresponding signs in ECG. In comparison the CK-levels in group II ranged between 342-632 U/1 (x = 465 U/l, P < 0.01). M1 patients of group II survived. Postoperative bleeding in both groups was comparable with that of other redoing procedures (520-1560 ml). Condttsions: Reoperation of acute thrombotic bypass occlusion after CABG is affected by a high mortality. If additionally rt-PA lysis was performed, a sufficient myocardial perfusion seems to be restored. Due to the local application and the short period of effectiveness of rt-PA the bleeding after lysis therapy is negligible. The intraoperative lysis with rt-PA after acute graft occlusion seems to re-establish the entire macro- and microcirculation of the relevant myocardial area thus preventing an otherwise unavoidable myocardial infarction. The application procedure is easy, tysis-associated complications could not be observed.
© Harcourt Brace & Co. Ltd 1998
Session I: Thrombolysis in acute myocardial infarction I
P05 Acute myocardial infarction - time is survival. The Munich AMI
P07 Thrombolysis on patients over 65 years
Project C. WONHAS Kreiskrankenhaus MOnchen-Pasing, 1. Med. Department, Steinerweg 5, 81241 MOnchen, Germany
E. CHUQUIURE-VALENZUELA, U. JUAREZ, A. LASSES, H. GONZ,4LEZ, J. CARRILLO, C. LOPEZ, J. CASANOVA, C. MART[NEZ-SANCHEZAND E. LUPI Coronary Care Unit. Instituto Nacional de Cardiolog/a "lgnacio Chavez" Mexico City, Mexico
Aim: Two hundred thousand patients suffer from acute myocardial infarction in Germany every year. Sixty percent of these patients die, 40% of them before reaching a hospital. Improvement of prehospital diagnostics by 12-lead-ECG, recordable in the ambulance, should (as a pilot project), reduce the 'door to needle time' and increase the proportion of thrombolysis in AMI-patients at our hospital. Methods: By setting up a central alert office on 1 June 1997 the City of Munich made it possible for the patients to alann the nearest and most suitable emergency facility. The Lifepak-11-system (Physio Control) on our EMU is a portable unit consisting of ECG-recorder, defibrillator, and trans-thoracal-pacemaker. In combination with a mobile telephone it is possible since 1 July 1997 to pass on the ECG directly from the emergency site to the intensive care unit and to communicate with the hospital physicians at the ICU. Results: By these measures thrombolysis in AMI was increased by 129% (7 vs. 16) in the second 6 months of 199Z Door-to-needle-time was reduced by 48% (67 vs. 35 rain), recanalizing therapies increased by 9,5°/o (21 vs. 23). Conclusions: The new emergency car system led to an overall improvement in the treatment of patients with acute myocardial infarction and will be extended in the whole city. Simultaneously emergency physicians experienced in thrombolysis get increased opportunities for prehospital thrombolysis.
P06 Is there an influence of the time of admission to a hospital on the rate of thrombolysis in patients with acute myocardial infarction? R. ZAHN 1, A. KOCt-P, J. RUSTIGEI, S. SCHUSTER~, R. SCHIELE~, D. HARMJANZ3, B. BOPPERT4, M. GOTTWIK5, FOR DIE ALKK STUDIEN GRUPPE ~Ludwigshafen, 2Heidelberg, 3Celle, 4LiJdenscheid, 5NOmberg, Germany
Background: Intravenous thrombolysis is a standard therapy for patients with acute myocardial infarction (AMI), with clearly defined indications. However little is known about para-medical influences on the use of thrombolytics in such patients. The aim of the present study was to analyse the influence of the time of admission of the patients with AMI to a hospital on the rate of thrombolysis in such patients. Methods: Between 7/92 and 9/94 14 756 consecutive patients (pts) with AMI were registered by 66 hospitals for the '60-Minutes Myocardial Project'. Patients were distributed into a group 'regular working hours' ('on' hours): admission to the hospital Monday to Friday 8:00 to 17:00 and a second group: 'off working hours' ('off' hours) Monday to Friday 19:00 to 08:00 and weekend. Results: During 'on' hours 6340 pts (43%) and during 'off' hours pts (570/0) were treated. Parameter Men Age > 75 years iv thrombolysis Primary angioplasty Hospital mortality
All
"On' hours
"Off' hours
68.4% 22.5% 50.8% 1.4% 17%
67.3% 24% 47.1% 2% 16.2%
69.2% 21.4% 53.5% 1% 17.7%
OR (95% CI) 1.09 0.86 1.29 0.49 1.11
(1.02-1.17) (0.80-0.92) (1.21-1.38) (0.37-0.65) (1.01-1.21)
Logistic regression analysis showed 'off' hours to be an independent predictor for a higher rate of intravenous thrombolysis (OR = 1.17; CI 1.07-1.28). Conclusions: Base-line characteristics and treatment of pts with AMI who were admitted to a hospital during 'off' working hours were quite different from pts treated during 'on' hours. During 'off' hours the rate of pts treated with iv thrombolysis was higher, whereas during 'on' hours the rate of pts treated with primary angioplasty was higher. This indicates an influence of the time of admission on the choice of reperfusion therapy. Fibrinolysis & Proteolysis (1998) 12(Suppl 2), 91-113
Objective: To analyze the effectiveness of thrombolytic treatment and it's influence on clinical evolution in patients with acute myocardial infarction (AMI) over 65 years. Methods: We analyzed risk factors, AMI characteristic and localization, thrombolytic agents, clinical evolution, angiographics findings and revasculafizations procedures, in patients over 65 years with AMI without contraindications for thrombolytic therapy. Results: During 6 years, thrombolytic therapy was administrated to 126 patients over 65 years with AMI, with 71.28 _+5 years, the treatment average time of 3.4 hours; 106 received SK (84%) and 20 rt-PA (16%), 88 male (700/0) Risk factors of: smokers 80 (63°/0), diabetes mellitus 28 (220/0), hypertension 62 (49%) and previous angina 73 (58%), 9 with history AMI. Thirty-one patients had anterior wall AMI. Major bleeding was seen in 10 patients, and 2 with intracranial bleeding. Thirty-one pts developed left ventricular dysfunction; 36 had post-MI angina and 9 reinfarction, 3 patients had ventticular rupture. From the clinical reperfusion criteria 63% had arrythmias, ventricular ectopy and slow ventricular tachycardla were the most frequent, and early electrocardiography evolution in 96% of the patients were observed. Seventy-one patients went under coronariographic studies, in 70% vessel patency was found, but only 32% with TIMI 2-3 flux. Twenty-nine percent patients undergo CBAG and in 37% PTCA was practised, 19 patient died on the first 10 days, 14 died from cardiogenic shock, 3 from arrythrnias and two myocardial rupture.
P08 Intraoperative emergency thrombolysis with rt-PA after early postoperative coronary artery bypass thrombosis M. BREUER, A. SCHOTZ, J. WEINGARTNER, B. GANSERA, W. EICHINGER, B. KEMKES Department of Cardiovascular Surgery, Klinikum Bogenhausen, Munich, Germany
Background: Acute graft occlusion early postoperatively after CABG is a rare but dramatic complication, mostly making resuscitation necessary. Emergency reoperation with reanastomosing of the relevant grafts is the common usual procedure to restrict the otherwise unavoidable myocardial damage. We perform in such cases additionally an intraoperatively intracoronary installed rt-PA lysis. Methods: Since 1994 15 patients (0.330/0) underwent emergency reoperation within the first 12 hours after CABG due to clinical signs of acute graft thrombosis. In six of these patients (group Ii) intraoperative rt-PA lysis has been performed. We applicated up to 100 mg rt-PA, locally into the coronary artery after inspection and reopening of the bypass-anastomosis of the relevant vessel/s. Results: In group I (n = 9; 7 m, 2 f) without lysis, 33% (n = 3) of the patients could not be stabilized after renewing of the bypasses, not even with the help of high dose medicamental support. The other patients of group I survived but all of them showed highly elevated CK-Ievels (CKmax x = 1254 u/l; 965-1431 U/I) and the corresponding signs in ECG. In comparison the CK-levels in group II ranged between 342-632 U/1 (x = 465 U/l, P < 0.01). M1 patients of group II survived. Postoperative bleeding in both groups was comparable with that of other redoing procedures (520-1560 ml). Condttsions: Reoperation of acute thrombotic bypass occlusion after CABG is affected by a high mortality. If additionally rt-PA lysis was performed, a sufficient myocardial perfusion seems to be restored. Due to the local application and the short period of effectiveness of rt-PA the bleeding after lysis therapy is negligible. The intraoperative lysis with rt-PA after acute graft occlusion seems to re-establish the entire macro- and microcirculation of the relevant myocardial area thus preventing an otherwise unavoidable myocardial infarction. The application procedure is easy, tysis-associated complications could not be observed.
© Harcourt Brace & Co. Ltd 1998