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Three Part Question

In [reinfarction after thrombolytic therapy for acute myocardial infarction] does [rethrombolysis] reduce [mortality]?

Clinical Scenario

A 61 year old male with no previous cardiac history presents with chest pain and a diagnosis of acute myocardial infarction is made. He is thrombolysed but the pain does not settle and the electrocardiogram shows persistent ST elevation after two hours. You wonder whether rethrombolysis would be of any benefit and reduce mortality.

Search Strategy

Medline 1990 – 01/05 using the Ovid interface.
[(exp rethrombolysis OR rethrombolysis.mp) AND (exp myocardial infarction OR myocardial infarction.mp OR MI.mp ) AND (exp reinfarction OR reinfarction.mp )] LIMIT to human AND English language.

Search Outcome

Altogether 4 papers were found of which one was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Barbash et al 2001 Israel	2301 patients reinfarcted of which 874 were rethrombolysed	Retrospective comparative analysis	30 day mortality	Significantly reduced in the rethrombolysed and revascularized group compared to conservative treatment group	The relative advantages and disadvantages of interventional revascularization compared with repeat thrombolysis for reinfarction have not been quantified Low event rates, particularly for overall stroke and intracranial hemorrhage, leave the analysis underpowered to make strong comparative conclusions between treatment strategies for these important safety outcomes
			Incidence of overall strokes	No significant difference in the three groups

Comment(s)

There is only one study addressing this question and although it was a large study using the database of two major trials it does not quantify the advantages and disadvantages of interventional revascularization compared with repeat thrombolysis for reinfarction. Randomized trials are necessary to assess the exact risks and benefits of rethrombolysis versus interventional revascularisation. However, the study does show reduced mortality rates with rethrombolysis in reinfarcted patients.

Clinical Bottom Line

The available evidence suggests that rethrombolysis reduces mortality in patients with acute myocardial infarction.

References

1. Barbash GI. Birnbaum Y. Bogaerts K et al. Treatment of Reinfarction After Thrombolytic Therapy for Acute Myocardial Infarction. Circulation 103(7)954-960, Feb 20 2001.