• 
• 

Three Part Question

In [patients with isolated posterior MI, based on the use of accessory chest leads] is [thrombolysis better than conservative management] at [reducing mortality and/or morbidity]

Clinical Scenario

A 68 year old gentleman attends the emergency department with two hours of ongoing central chest pain radiating into both arms. He is pale and sweaty, has vomited twice and has a history of angina. Examination shows him to have BP 90/55 and he has bibasal crepitations. 12 lead ECG is unremarkable but convinced clinically he is having a myocardial infarction you repeat the ECG using posterior leads which show ST elevation indicating a posterior MI. You have no access to angioplasty at this time and wonder whether he would benefit from thrombolysis.

Search Strategy

Medline 1966 to 9/01 and EMBASE 1980 to 9/01 using the OVID interface
[{exp Myocardial infarction OR (myocard$ adj5 infarct$).af OR (heart attack).af} AND {exp Fibrinolysis/ OR exp Thrombolytic Therapy/ OR exp Fibrinolytic Agents/ OR exp Tissue Plasminogen Activator/ OR exp Streptokinase/ OR exp Urinary Plasminogen Activator/ OR thromboly$.af. OR fibrinoly$.af OR streptokinase.af OR urokinase.af OR alteplase.af OR APSAC.af OR reteplase.af OR (plasminogen adj5 activator).af} AND {posterior.af}]LIMIT to human and English Language

Search Outcome

59 papers found on Medline 56 on Embase,none of which answered the three part question

Comment(s)

All studies performed so far on thrombolysis in posterior MI are either based on presumed posterior based on reciprocal changes on the standard 12 lead or on the use of accessory leads to show "posterior extension" of inferior ST elevation. No studies thusfar have addressed the isolated posterior with insufficient evidence for thrombolysis on the standard 12 lead, and a large scale investigation is required.

Clinical Bottom Line

There is currently no evidence to confirm or refute the use of thrombolysis in isolated posterior MI with no reciprocal changes.