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eComment: Complications of late thrombolytic therapy in the elderly

Goztepe Safak Hospital Cardiovascular Surgery Clinic, Istanbul, Turkey

Post-infarct ventricular septal defect following thrombolytic intracranial bleed

We read with great interest the article by Firstenberg et al. [1] presenting a case of post-myocardial infarction (MI) ventricular septal defect (VSD) and intracranial hemorrhage following thrombolytic therapy after acute stent occlusion. We would like to comment the authors' aritcle with our modest experience of similar complications.

Myocardial or aortic rupture, aortic dissection, intracranial hemorrhage, or even splenic rupture are potential fatal complications of thrombolytic therapy following acute myocardial infarction. They usually occur in elderly (>65 years of age), moderate body weight (<70 kg) female subjects. Hypertension at presentation and usage of tissue plasminogen activator (t-PA) rather than streptokinase have shown to be additional risk factors. Of the most important, timing of the lytic therapy is accepted as the critical factor for post-MI VSD and intracranial bleeding. Initiation of the therapy beyond 12 h following the onset of MI is a major risk. Although the mechanism behind such complications following thrombolytic agents is not clear, it is suggested that recanalization with medical thrombolysis may lead to microvascular hemorrhage, interstitial edema and contraction band necrosis as well as to a decrease in fibrinogen and elongated partial thromboplastin times especially with the usage of t-PA [2–4].

At our institution, we have been faced with one post-MI VSD and another intracranial bleeding in two female patients aged 74 and 78 years who underwent thrombolytic therapy at 12 and 18 h of the onset of symptoms for the left anterior descending coronary artery occlusion related acute MI. Both patients were managed accordingly and successfully (unpublished data). Since then we prefer to use mechanical recanalization in every particular case when it is possible. Medical revascularization is seldomly favoured and is done mostly in younger age group male patients.

In order to better study the risks of such complications, it would be more appropriate if the authors could give detailed information about the blood pressure of the patient on admission and at the time of the intervention. Additionally, what was the time interval between the diagnosis and the initiation of the thrombolytic therapy?

We would like to congratulate the authors for their successful management [1] in such a challenging case.

	References

Top References

 

1. Firstenberg MS, Blais D, Rea G, Bush CA. Post-infarct ventricular septal defect following thrombolytic intracranial bleed. Interact CardioVasc Thorac Surg 2009;8:379–381.[Abstract/Free Full Text]
2. Kaplan KL, Fitzpatrick P, Cox C, Shammas NW, Marder VJ. Use of thrombolytic therapy for acute myocardial infarction: effects of gender and age on treatment rates. J Thromb Thrombolysis 2002;13:21–26.[CrossRef][Medline]
3. Lincoff AM, Califf RM, Ellis SG, Sigmon KN, Lee KL, Leimberger JD, Topol EJ. Thrombolytic therapy for women with myocardial infarction: is there a gender gap? Thrombolysis and Angioplasty in Myocardial Infarction Study Group. J Am Coll Cardiol 1993;22:1780–1787.[Abstract]
4. Mallik S, Vaccarino V. Outcomes of thrombolytic therapy for acute myocardial infarction in women. Prog Cardiovasc Dis 2004;47:58–71.[CrossRef][Medline]

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