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(Circulation. 2001;103:954.)
© 2001 American Heart Association, Inc.

Clinical Investigation and Reports

Treatment of Reinfarction After Thrombolytic Therapy for Acute Myocardial Infarction

An Analysis of Outcome and Treatment Choices in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) and Assessment of the Safety of a New Thrombolytic (ASSENT 2) Studies

Gabriel I. Barbash, MD, MPH; Yochai Birnbaum, MD; Kris Bogaerts, MSc; Michael Hudson, MD; Emmanuel Lesaffre, PhD; Yuling Fu, MD; Shaun Goodman, MD; Katrijn Houbracken, MD; Kurt Munsters, MSc; Chris B. Granger, MD; Karen Pieper, MSc; Robert M. Califf, MD; Eric J. Topol, MD; Frans Van de Werf, MD, PhD

From Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (G.I.B.); Rabin Medical Center, Belinson Campus, Petah Tiqva, Israel (Y.B.); the Biostatistical Centre (K.B., E.L.) and the Department of Cardiology (K.H., K.M., F.V.d.W.), Catholic University, Leuven, Belgium; Duke Clinical Research Institute, Durham, NC (M.H., C.B.G., K.P., R.M.C.); Division of Cardiology, Alberta University, Alberta, Canada (Y.F.); the Canadian Heart Research Centre, University of Toronto, Toronto, Canada (S.G.); and the Cleveland Clinic Foundation, Cleveland, Ohio (E.J.T.).

Correspondence to Gabriel I. Barbash, MD, MPH, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv, Israel 64239. E-mail gabi{at}tasmc.health.gov.il

Background—Early reinfarction after thrombolytic therapy is associated with adverse outcomes and increased mortality. Among patients with reinfarction in the 1992 Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO I) and the 1998 Assessment of the Safety of a New Thrombolytic (ASSENT 2) trials, we investigated temporal and regional differences in the use of repeat thrombolysis, revascularization (angioplasty and/or bypass surgery), or conservative measures and the outcomes of each management strategy.

Methods and Results—Data from the 4% of patients (n=2301) who experienced reinfarction after thrombolytic therapy were studied. Baseline characteristics, 30-day mortality, and incidence of total and hemorrhagic strokes were compared among the 3 treatment groups. The 30-day mortality did not differ between the repeat thrombolysis and revascularization groups (P=0.72), and it was significantly lower among patients treated by these 2 strategies than in those treated conservatively (11% and 11% versus 28%, respectively; P<0.001). Stroke rates did not differ significantly between the 3 treatment strategies (P=0.49). From 1992 to 1998, the percentage of reinfarction patients treated with repeat thrombolysis decreased from 29.3% to 18.5% in US centers and from 51.4% to 41.9% in all other centers (P<0.001). In contrast, use of revascularization procedures increased from 33.5% to 47.9% in US centers and from 8.1% to 23.0% in all other centers (P<0.001).

Conclusions—Repeat thrombolysis and revascularization are associated with significantly lower mortality among reinfarction patients. Randomized trials are necessary to assess the exact risks and benefits of rethrombolysis versus interventional revascularization in this subset of high-risk patients presenting with reinfarction after thrombolytic therapy.

Key Words: myocardial infarction • trials • thrombolysis • revascularization • reinfarction

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