STREPTOKINASE FOR ACUTE MYOCARDIAL INFARCTION IN THE ELDERLY

Authors

  • Azmat Ehsan Qureshi
  • Nasir Ali Jafri
  • Ahmed Noeman
  • Samra Yasmin
  • Hamid Khalil

Abstract

Background: Acute myocardial infarction is one of the leading causes of death in the elderly, however clinical data reveals a disproportionately lower use of thrombolytics because of fear of complications especially intracranial haemorrhage. Our objective was to evaluate the safety of most commonly used thrombolytic streptokinase in elderly patients presenting with acute myocardial infarction. Methods: This descriptive case series was conducted at Punjab Institute of Cardiology, Lahore from September to December 2012 (4 months). One hundred elderly patients presenting with acute myocardial infarction were randomly selected for the study keeping in view the inclusion and exclusion criteria. All patients were thrombolysed with streptokinase within 12 hours of onset of symptoms and were monitored and investigated for electrical, mechanical and biochemical complications. Results: Out of one hundred patients 77 (77%) were males and 23 (23%) were females. Mean age was 73.39±5.29 years. The two most common complications of streptokinase were hypotension (33%) and bleeding (19%). Major bleed occurred only in 3 (3%) patients. No patient developed intracranial haemorrhage. Other complications included arrhythmias (6%), allergic reactions (4%), raised LFTs (6%) and raised RFTs (7%). No patient died of streptokinase related complications. Conclusions: Use of streptokinase for acute myocardial infarction should not be discouraged in the elderly.Keywords: Acute myocardial infarction, Streptokinase, Thrombolytics

References

Malik JA, Khan GQ. Adverse effect profile of Streptokinase therapy in patients with acute myocardial infarction: a prospective study. JK practitioners 2004;11(2):106–9

Bilal H, Niaz Z, Shah ZH, Razzaq A, Ahsen W, Saleem A et al. Complications of Streptokinase during infusion in acute myocardial infarction. Ann King Edward Med Uni 2006;12(2):220–2.

Brogden RN, Speight TM, Avery GS. Streptokinase: a review of its clinical pharmacology, mechanism of action and therapeutic uses. Drugs 1973;5(5):357–445.

McNel J&J, Krum H. Cardiovascular Disorders In Avery's Drug Treatment Eds Speight TM, Halford NHG Adis International Auckland 1997;809–96.

Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet 1988;2(8607):349–60

GruppoItaliano per lo Studio della Streptochinasinell' Infartomiocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;1(8478):397–402.

Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation 2004;110:e82–292

White HD, Chew DP: Acute myocardial infarction. Lancet 2008;372:570–84.

Brown DL, Topol EJ. The Late Assessment of Thrombolytic Efficacy (LATE) Trial: Impact and Implications. Developments in Cardiovascular Medicine 1994;160:121–34

Randomised trial of late thrombolysis in patients with suspected acute myocardial infarction. EMERAS (EstudioMulticéntrico Estreptoquinasa Repúblicas de América del Sur) Collaborative Group. Lancet 1993;342:767–72.

Baigent C, Collins R, Appleby P, Parish S, Sleight P, Peto R. ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. The ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. BMJ 1998;316(7141):1337–43

Ahmed S, Qureshi MBA, Abbas MZ, Chaudhry MK, Ghani MU. A comparative study of complications in patients of Myocardial Infarction managed with and without Streptokinase. Pak J Cardiol 2004;15(2):61–7.

Vestracte M, Verhaehge R, Peerlinek K, Boogarets MA. Hematological Disorders In Averys Drug Treatment Eds Speight TM, Flolford NHG Adis International Auckland 1997;1163–1251

Miller DRW, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990;113:949–60

Thiemann D. Primary angioplasty vs thrombolysis in elderly patients. JAMA 2000 283(5):601–2

Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994;343(8893):311–22.

de Boer MJ, Ottervanger JP, van 't Hof AW, Hoorntje JC, Suryapranata H, Zijlstra F; Zwolle Myocardial Infarction Study Group Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy. J Am Coll Cardiol 2002;39(11):1723–8

Antman EM, Morrow DA, McCabe CH, Murphy SA, Ruda M, Sadowski Z et al; ExTRACT-TIMI 25 Investigators. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med 2006;354(14):1477–88.

Asdaghi N, Butcher KS, Hill MD. Risks and benefits of thrombolysis in the elderly. Int J Stroke 2012;7(2):142–9.

Franken M, Nussbacher A, Liberman A, Wajngarten M. ST Elevation Myocardial Infarction in the elderly. J Geriatr Cardiol 2012;9(2):108–14.

Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW et al; American Heart Association Council on Clinical Cardiology; Society of Geriatric Cardiology. Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007;115(19):2570–89.

Weaver WD, Litwin PE, Martin JS, Kudenchuk PJ, Maynard C, Eisenberg MS et al. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Coll Cardiol 1991;18:657–62.

Maggioni AP, Maseri A, Fresco C; Franzosi MG, Mauri F, Santoro E et al. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis, N Engl J Med 1993;329:1442–8

Devlin W, Cragg D, Jacks M, Friedman H, O’Neill W, Grines C. Comparison of outcome in patients with acute myocardial infarction aged >75 years with that in younger patients. Am J Cardiol 1995;75: 573–6

Maynard C, Every NR. Thrombolysis versus primary angioplasty in older patients with acute myocardial infarction. Drugs Aging 1999;14:427–35

Haase KK, Schiele R, Wagner S, Fischer F, Burczyk U, Zahn R et al. In-hospital mortality of elderly patients with acute myocardial infarction. data from the MITRA (Maximal Individual Therapy in Acute myocardial infarction) registry. Clin Cardiol 2000;23:831–6

Hannan EL, Racz MJ, Arani DT, Ryan TJ, Walford G, McCallister BD. Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction, J Am Coll Cardiol 2000;36:1194–1201

Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2(8607):349–60

An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med1993;329:673–82.

Gore JM, Sloan M, Price TR, Randall AM, Bovill E, Collen D et al. Intracerebral hemorrhage, cerebral infarction, and subdural hematoma after acute myocardial infarction and thrombolytic therapy in the Thrombolysis In Myocardial Infarction study: TIMI phase II, pilot and clinical trial. Circulation.1991;83:448–59.

Gurwitz JH, Gore JM, Goldberg RJ, Rubison M, Chandra N, Rogers WJ. Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction. Ann Intern Med 1996;124:283–91.

De Jaegere PP, Arnold AA, Balk AH, Simoons ML. Intracranial hemorrhage in association with thrombolytic therapy: incidence and clinical predictive factors. J Am Coll Cardiol 1992;19:289–94.

Stenestrand U, Wallentin L. Fibrinolytic therapy in patients 75 years and older with ST segment elevation myocardial infarction: one year follow up of a large prospective cohort. Arch Intern Med 2003;163:965–71.

Collins R. Optimizing thrombolytic therapy of acute myocardial infarction: Age is not a contraindication. Circulation. 1991;84(Suppl II):II230.

ISIS-3: a randomized comparison of streptokinase vs tissue plasminogen activator vsanistreplase and of aspirin and heparin vs heparin alone among 41,299 cases of suspected acute myocardial infarction. Lancet.1992;339:753–70.

Gore JM, Granger CB, Simoons ML, Sloan MA, Weaver WD, White HD et al. Stroke after thrombolytic therapy: mortality and functional outcomes in the GUSTO-1 trial. Global Use of Strategies to Open Occluded Coronary Arteries. Circulation. 1995;92:2811–8

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Published

2014-12-01