Repeat thrombolysis for acute myocardial infarction P. Banerjee * , A.L. Clark, M.S. Norell Department of Cardiology, Castle Hill Hospital, Kingston upon Hull, HU16 5JQ, United Kingdom Received 7 March 2004; accepted 27 May 2004 Available online 19 September 2004 Abstract Background: Thrombolysis is still the first line of treatment for acute myocardial infarction in the United Kingdom. In a significant proportion of these patients thrombolytic therapy fails to restore patency of the occluded artery or is followed by early re-infarction. The best management of this group of patients is not clear although repeat doses of thrombolysis are commonly administered especially in the district general hospitals that do not have access to invasive facilities. We performed a retrospective clinical study to determine the outcome of repeat thrombolysis for acute myocardial infarction in patients with failed initial thrombolysis or early re-infarction. Methods: Ninety-two patients who received two or more doses of thrombolysis for acute myocardial infarction were compared with 98 contemporary similar patients who received only one dose of thrombolysis. Case notes of all patients were examined for retrospective analysis. Main outcome measures were death, heart failure and need for in-hospital revascularization. Results: Compared to the group thrombolysed once, in the rethrombolysed group there were significantly more deaths at 30 days ( p=0.0016), more heart failure (with lower mean ejection fraction), more cardiac arrests as well as more frequent coronary angiography and percutaneous coronary interventions (PCIs). The incidence of haemorrhage in the two groups did not differ. Conclusions: The need for repeat thrombolysis identifies a group of patients with a high risk of early complications. Although repeat thrombolysis is safe, these patients then need close monitoring with a view to early intervention. For such patients admitted to district general hospitals without interventional facilities early referral to a tertiary center should be considered. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Repeat thrombolysis; Acute myocardial infarction; Heart failure 1. Introduction The treatment of acute myocardial infarction (MI) with thrombolysis fails to achieve patency of the infarct related artery in 15–40%cases [1–4]. In those that reperfuse 10% will reocclude while still in the hospital [5–8]. Angiographic failure to reperfuse is associated with a higher incidence of early death, greater left ventricular dysfunction and overall a worse prognosis compared to those that reperfuse [9–12]. It is not clear what the best management should be in this large group of patients where primary thrombolytic therapy has failed. In the United Kingdom, at the moment, the management approach lies between a conservative approach (supportive treatment), repeat thrombolysis or rescue percutaneous coronary intervention (PCI) [13,14]. The availability of local hospital facilities often dictates manage- ment with conservative management or further thrombolysis being chosen where on-site cardiac catherization facilities are not available. Repeat thrombolysis is frequently used for failed thrombolysis although evidence to favour this practice is not strong [15–19]. A retrospective analysis of the treatment strategies employed on patients with early reinfarction in the GUSTO 1 and ASSENT 2 thrombolytic trials, however, demonstrated benefit of repeat thrombolysis over conservative treatment with antithrombotics and vaso- dilators [20]. In order to assess the outcome of repeat thrombolysis, as well as to investigate what important differentiating features separate successful from unsuccess- ful thrombolysis, we retrospectively studied a group of 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.05.067 * Corresponding author. Tel.: +44 1482 624087; fax: +44 1482 624085. E-mail address: pbanerjee@ukonline.co.uk (P. Banerjee). International Journal of Cardiology 102 (2005) 515 – 519 www.elsevier.com/locate/ijcard