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Treatment and Outcome of Patients With Acute Myocardial Infarction and Prior Cerebrovascular Events in the Thrombolytic Era
The Israeli Thrombolytic National Survey
David Tanne, MD;
Shmuel Gottlieb, MD;
Avraham Caspi, MD;
Hanoch Hod, MD, FACC;
Abraham Palant, MD;
Leonardo Reisin, MD;
Tiberio Rosenfeld, MD;
Benyamin Peled, MD;
Alon T. Marmor, MD;
Jonathan Balkin, MD;
Valentina Boyko, MSc;
Solomon Behar, MD;
for the Israeli Thrombolytic National Survey Group
Arch Intern Med. 1998;158:601-606.
Background Patients with a history of stroke presenting with acute myocardial infarction (MI) are often excluded from thrombolytic therapy owing to fear of intracranial hemorrhage. Few data, however, are available on the risks vs the benefits of thrombolysis in patients with an acute MI and a prior cerebrovascular event (PCE).
Methods Data were derived from 2 nationwide surveys of 2012 consecutive patients with acute MI admitted to all 25 coronary care units in Israel during 1992 and 1994. Thrombolytic therapy was given to patients with a PCE at the discretion of the treating physicians. Outcomes were compared between patients with an acute MI with and without a PCE and between patients with a PCE treated with or excluded from thrombolysis.
Results Patients with a PCE (n=115 [6%]) were older, with higher rates of atherosclerotic risk factors and in-hospital complications than their counterparts without a prior event (n=1897). They were treated less often with thrombolysis or mechanical reperfusion. The 1-year mortality rates were higher among patients with a PCE (28% vs 19%, P<.01), but not after multivariate adjustments for clinical characteristics (adjusted hazard ratio, 1.08; 95% confidence interval, 0.75-1.55). Patients with an acute MI and a PCE who were treated with thrombolysis (n=29 [25%]) were compared with 46 patients found ineligible for thrombolysis primarily because of their PCE. The timing of the PCE was comparable in both groups (one fifth in the preceding year), while prior transient ischemic attacks were more prevalent among patients who had undergone thrombolysis. The patients who were treated with thrombolysis (n=29) were older, had a higher rate of anterior infarction, and, while in the hospital, received aspirin, anticoagulants, and  -blockers more often than their counterparts (n=46). In-hospital intracranial hemorrhage did not occur in either group. The 1-year mortality rates were 2-fold higher among patients who had not undergone thrombolysis compared with those who had (33% vs 18%; adjusted hazard ratio, 2.44; 95% confidence interval, 0.78-7.64).
Conclusions These findings, derived from 2 nationwide surveys of consecutive patients with acute MI, suggest that patients with PCEs have an adverse outcome attributed to their older age and less favorable risk profile. Thrombolytic therapy, however, based on our preliminary data, may be beneficial in selected patients with an acute MI with a nonrecent PCE.
From the Neufeld Cardiac Research Institute (Drs Tanne, Gottlieb, Caspi, Hod, Palant, Reisin, Rosenfeld, Peled, Marmor, Balkin, and Behar and Ms Boyko) and the Department of Neurology (Dr Tanne), Sheba Medical Center, Tel Hashomer, Israel. Dr Tanne is now with the Department of Neurology, Center for Stroke Research, Henry Ford Hospital and Health Sciences Center, Detroit, Mich.
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