Làm tan huyết khối tĩnh mạch đối với đột quỵ do thiếu máu cục bộ cấp sau cơn nhồi máu cơ tim gần đây Cơ sở và mục đích — Tính an toàn của IV – rtPA (chất kích hoạt plasminogen mô tĩnh mạch) trong điều trị đột quỵ do thiếu máu cục bộ cấp tính (AIS) sau nhồi máu cơ tim (MI) gần đây vẫn còn là vấn đề tranh luận. Chúng tôi đã nghiên cứu sự an toàn của việc cung cấp IV – rtPA cho bệnh nhân AIS bị MI trong vòng 3 tháng trước đó. tháng. Bệnh nhân được chia thành 2 nhóm: được điều trị hoặc không được điều trị với liều IV – rtPA tiêu chuẩn cho AIS. Các biến chứng tim (vỡ / chèn ép tim, thuyên tắc huyết khối trong tim, hoặc loạn nhịp đe dọa tính mạng) được so sánh giữa các nhóm và được đánh giá theo loại NMCT (nhồi máu cơ tim không có đoạn ST chênh lên [STEMI], hoặc STEMI) và thời gian trôi qua giữa các mạch Các sự kiện. Kết quả — Một trăm lẻ hai bệnh nhân đã được bao gồm; 46 (45,1%) được lấy từ tổng quan tài liệu. Tuổi trung bình (khoảng tứ phân vị) là 64 (53–75) tuổi, và 69 (67,6%) là nam giới. Bốn mươi bảy (46,1%) nhận IV – rtPA. Trong nhóm được điều trị, lần lượt 25 bệnh nhân (53,2%) và 23 (48,9%) có AIS, MI và STEMI đồng thời, so với 12 (21,8%; P = 0,002) và 36 (65,5%; P = 0,110) bệnh nhân không được điều trị. Bốn (8,5%) bệnh nhân được điều trị bằng IV – rtPA chết vì vỡ / chèn ép tim liên quan hoặc giả định, tất cả đều có STEMI trong tuần trước đột quỵ. Biến chứng này xảy ra ở 1 (1,8%) bệnh nhân trong nhóm không được điều trị (P = 0,178). Không có sự khác biệt về thuyên tắc huyết khối (1 [2,1%) so với 2 [3,6]; P = 1.000) và loạn nhịp tim đe dọa tính mạng (3 [6,4%) so với 7 [12,7]; P = 0,335). Không có bệnh nhân không mắc bệnh STEMI nào dùng IV – rtPA có biến chứng tim. Kết luận — Ở bệnh nhân AIS và NMCT gần đây hoặc đồng thời, loại MI và thời gian trôi qua giữa 2 sự kiện nên được cân nhắc khi quyết định cung cấp IV – rtPA. Mặc dù các biến cố không phải STEMI gần đây hoặc xảy ra đồng thời có vẻ an toàn, nhưng STEMI trong tuần trước đột quỵ cần được lưu ý ngay. Số lượng thấp các sự kiện và sự thiên lệch về công bố có thể có trong kết luận của chúng tôi
Trang 1After myocardial infarction (MI), there is an increased risk
of acute ischemic stroke (AIS).1,2 However, how to
man-age an AIS after recent MI, namely if IV–rtPA (intravenous
tissue-type plasminogen activator) should be performed, is a
question that remains to be answered Clinical trials that led to
the approval of intravenous alteplase in AIS excluded patients
with acute MI or presumed post-MI complications.3–5 The
most feared complications of treating these patients with IV–
rtPA are myocardial rupture, cardiac tamponade after post-MI
pericarditis, and embolization of ventricular thrombus Also,
patients with acute MI are usually treated with double
anti-platelet treatment and anticoagulants that may increase the
risk of hemorrhagic transformation of ischemic brain tissue
A survey of stroke clinicians’ practice regarding throm-bolysis prescription outside formal inclusion criteria6 dis-closed that one-third would consider performing thrombolysis after recent non–ST-segment–elevation myocardial infarc-tion (NSTEMI), whereas only 25% would do so after recent ST-segment–elevation myocardial infarction (STEMI) American Heart Association/ American Stroke Association guidelines initially considered recent MI (preceding 3 months)
as an absolute contraindication to treatment with IV–rtPA.7
In 2013, recent MI was considered as a relative contraindica-tion,8 and in both 2016 American Heart Association/ American Stroke Association Scientific Statement and 2018 guidelines, IV–rtPA was considered reasonable.9,10 The strength given
Background and Purpose—The safety of IV–rtPA (intravenous tissue-type plasminogen activator) for acute ischemic stroke
(AIS) treatment after recent myocardial infarction (MI) is still a matter of debate We studied the safety of delivering IV–rtPA to AIS patients with a MI within the preceding 3 months
Methods—Retrospective review of consecutive AIS admitted to 2 tertiary university hospitals’ and systematic literature review for AIS patients with history of MI in the previous 3 months Patients were divided into 2 groups: treated or not treated with standard IV–rtPA dose for AIS Cardiac complications (cardiac rupture/tamponade, intracardiac thrombus embolization, or life-threatening arrhythmias) were compared between groups and assessed by type of MI (non–ST-segment–elevation myocardial infarction [STEMI], or STEMI) and time elapsed between vascular events
Results—One hundred and two patients were included; 46 (45.1%) were derived from literature review Median age (interquartile range) was 64 (53–75) years old, and 69 (67.6%) were men Forty-seven (46.1%) received IV–rtPA In the treated group, 25 (53.2%) and 23 (48.9%) patients had, respectively, concurrent AIS and MI and STEMI, in comparison
with 12 (21.8%; P=0.002) and 36 (65.5%; P=0.110) patients in the nontreated Four (8.5%) IV–rtPA–treated patients
died from confirmed or presumed cardiac rupture/ tamponade, all with a STEMI in the week preceding stroke This
complication occurred in 1 (1.8%) patients in the nontreated group (P=0.178) There were no differences in thrombus embolization (1 [2.1%) versus 2 [3.6]; P=1.000) and life-threatening arrhythmias (3 [6.4%) versus 7 [12.7]; P=0.335)
No non-STEMI patients receiving IV–rtPA had cardiac complications
Conclusions—In patients with AIS and recent or concurrent MI, MI type and the time elapsed between the 2 events should
be taken into consideration when deciding to deliver IV–rtPA Although recent non-STEMI or concurrent events seem safe, STEMI in the week preceding stroke should prompt caution The low number of events and publication bias may
have influenced our conclusions (Stroke 2019;50:00-00 DOI: 10.1161/STROKEAHA.119.025630.)
Key Words: heart ◼ hospital ◼ myocardial infarction ◼ stroke ◼ systematic review
◼ therapeutics ◼ tissue-type plasminogen activator
Received March 17, 2019; final revision received June 30, 2019; accepted July 10, 2019.
From the Department of Neurology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal (J.P.M., S.C., M.V.-B.); CEDOC – Nova Medical School, Universidade Nova de Lisboa, Portugal (J.P.M., S.C., M.V.-B.); Stroke Unit, Department of Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal (L.A.K., T.P.-e.-M., C.F.); Department of Cardiology, Hospital de Santa Maria, University of Lisboa, Portugal (C.J.); and Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Portugal (T.P.-e.-M., C.F.).
The online-only Data Supplement is available with this article at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.119.025630.
Correspondence to Ana Catarina Fonseca, MD, PhD, Serviço de Neurologia, Hospital de Santa Maria, Avenida Professor Egas Moniz, 1649-035 Lisboa, Portugal Email acfonseca@medicina.ulisboa.pt
© 2019 American Heart Association, Inc.
Intravenous Thrombolysis for Acute Ischemic Stroke
After Recent Myocardial Infarction
Case Series and Systematic Review
João Pedro Marto, MD; Linda Azevedo Kauppila, MD; Cláudia Jorge, MD; Sofia Calado, MD; Miguel Viana-Baptista, MD, PhD; Teresa Pinho-e-Melo, MD; Ana Catarina Fonseca, MD, PhD
DOI: 10.1161/STROKEAHA.119.025630
Stroke is available at https://www.ahajournals.org/journal/str
Trang 2to these latest recommendations depends on MI
character-istics and is based on expert’s opinion European Stroke
Organization guidelines give no indication on how to manage
these patients.11
With only seldom case reports available, evidence
sup-porting or contradicting IV–rtPA treatment in AIS after
re-cent MI is scarce We studied the safety of IV–rtPA in stroke
patients with an MI within the preceding 3 months by
per-forming a hospital case series analysis and a systematic
lit-erature review
Methods
Study Design and Patient Selection
This article adheres to the American Heart Association Journals’
implementation of the Transparency and Openness Promotion
Guidelines Anonymized data supporting the findings of this study
will be available on reasonable request.
We retrospectively reviewed a database of consecutive AIS
admitted to 2 tertiary university hospitals’ stroke units (from January
2004 to December 2018 in Centro Hospitalar Lisboa Norte and
from January 2010 to December 2018 in Centro Hospitalar Lisboa
Ocidental) and performed a systematic literature review searching for
AIS patients with a history of MI in the previous 3 months Patients
were divided into 2 groups: treated with IV–rtPA (standard dose
for AIS - 0.9 mg/kg) and those without IV–rtPA treatment (control
group) Patients with MI during or after IV–rtPA treatment were not
considered For the purpose of the systematic review, the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
guide-lines were followed 12 The present study was approved by local
eth-ics committees.
Stroke and MI Definition
Stroke was defined as a new syndrome of rapidly developing clinical
symptoms or signs of focal disturbance of cerebral function, lasting
longer than 24 hours and with no apparent cause other than vascular
origin, regardless of whether infarction was evident on cerebral
im-aging 13 MI was considered if there was a rise or fall of cardiac
bi-omarker values (preferably cardiac troponin), with at least 1 value
above the 99th percentile upper reference limit, and with at least
one of the following: symptoms of ischemia; new or presumed new
significant ST-segment–T wave changes or new left bundle branch
block; and development of pathological Q waves 14 For STEMI, the
following criteria were considered: new ST-elevation at the J point in
at least 2 contiguous leads of ≥2.5 mm in men <40 years, ≥2 mm in
men ≥40 years, or ≥1.5 mm in women in leads V2–V3 or of ≥1 mm
in other contiguous chest or limb leads 15 New or presumably new
left bundle branch block has been considered a STEMI equivalent 15
Postmortem histopathologic evidence of MI was also considered for
MI diagnosis MI was considered concurrent with AIS if patients
were diagnosed with both entities within the first hours of hospital
admission and before acute stroke treatment.
Studied Variables and Outcomes
The following variables were collected: age and sex, vascular risk
factors (hypertension, diabetes mellitus, atrial fibrillation,
dyslipid-emia, smoking), stroke location (anterior versus posterior circulation;
in anterior circulation left versus right cerebral hemisphere), stroke
severity at admission by the National Institutes of Health Stroke
Scale, time elapsed between MI and AIS (in days), IV–rtPA
treat-ment for AIS, endovascular treattreat-ment (EVT) for AIS, awareness of
recent MI history at the time of IV–rtPA treatment and MI
electro-cardiographic features regarding subtype (STEMI versus NSTEMI),
prestroke antithrombotic medication, echocardiography findings,
antithrombotic medication after AIS, and MI treatment with
percu-taneous coronary intervention (PCI) Regarding outcomes, the
occur-rence of cardiac complication (myocardial wall rupture or cardiac
tamponade, intracardiac thrombus embolization, or arrhythmias), in-hospital MI recurrence, hemorrhagic transformation according to ECASS-II (European Cooperative Acute Stroke Study-II), 16 and in-hospital death, were registered.
Systematic Review
A systematic search using combinations of keywords was performed
in Pubmed and EMBASE from January 1980 to September 1, 2018 Crossed-reference and free research of scientific publications was added No time limitation filter was applied The following MeSH terms were used: “Myocardial Infarction”; “Inferior Wall Myocardial Infarction”; “Anterior Wall Myocardial Infarction”; “Stroke”;
“Stroke, Lacunar”; “Infarction, Posterior Cerebral Artery”; “Brain Stem Infarctions”; “Infarction, Middle Cerebral Artery”; “Infarction, Anterior Cerebral Artery”; “Pericardial Effusion”; “Heart Rupture”; and, “Heart Rupture, Post-Infarction.”
As referred above, in order for an article to be considered eligible and included, it was mandatory that the patient(s) had AIS and evi-dence of an MI occurring in the preceding 3 months Study selection and data collection were performed by 2 independent authors (Drs Marto and Kauppila), and disagreements were solved by a third in-dependent party (Dr Fonseca) Reports retrieved were screened for potential eligibility by title and abstract analysis, and after a first se-lection, full text of potentially eligible studies was screened for ap-propriateness for inclusion The variables and outcomes retrieved were the described above Detailed search strategy description is presented in the online-only Data Supplement Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart summa-rizing study selection is shown in Figure.
Statistical Analysis
Baseline variables and outcomes were compared between the IV– rtPA–treated and nontreated groups using the χ 2 , Fisher exact and
Mann-Whitney U tests as appropriate Additionally, a stratified
anal-ysis according to MI type and time elapsed since the index event was performed Because of the small number of patients studied and fre-quency of certain outcome events, adjusted regression modeling was not conducted Statistical analysis was performed with IBM SPSS Statistics, Version 23.0.
Results
One hundred and two patients were included; 56 patients (54.9%) were derived from the hospital cases Median age (in-terquartile range) of included patients was 64 (53–75) years old, and 69 (67.6%) were men Included patients’ characteris-tics are presented in Table 1
Forty-seven (46.1%) patients were treated with IV–rtPA Treated patients were older, had fewer posterior circulation strokes, and a lower frequency of pretreatment with anticoag-ulant therapy (Table 1)
Patients with IV–rtPA treatment had more frequently con-current AIS and MI events and less frequently STEMI In the latter, the difference did not achieve statistical significance (Table 1) Regarding outcomes, 3 patients died due to car-diac rupture, all with a STEMI in the week preceding stroke One patient died after cardiogenic shock, with the authors considering that it could be attributable to cardiac rupture Additionally, one patient had a nonfatal pericardial effusion Both of these formerly mentioned patients had a STEMI, 1
to 7 days before stroke onset Among these 5 cases, 4 were treated with IV–rtPA, whereas the patient from the non–IV– rtPA group received EVT with intraarterial urokinase (6 hours after a STEMI and 5.5 hours after stroke onset) No statisti-cally significant differences were registered between patients
Trang 3with or without IV–rtPA regarding wall rupture/ cardiac
tam-ponade (Table 2)
Echocardiography results were available in 84 patients
Among the 17 (20.1%) patients with documented
intracar-diac thrombus, 1 patient, not treated with IV–rtPA, had a
new coronary embolism There were 2 additional cases
of thrombi embolization in patients that had a preceding
unremarkable echocardiogram These resulted in new
em-bolic strokes in a previously unaffected territory Both
were STEMI literature cases, one of which had received
IV–rtPA
Two patients had ventricular fibrillation, both were
STEMI literature cases, and 1 had been treated with IV-rtPA
Additionally, 8 patients had other major heart rhythm
distur-bances: 2 with pulseless electrical activity and 6 died of
car-diac arrest of unknown cause (Table 2) Two received IV–rtPA
treatment, 1 with a STEMI 2 days before and 1 with a STEMI
concurrent with stroke
Among the 10 patients with a STEMI in the week
preced-ing stroke who also received IV–rtPA treatment, 6 (60%) had
at least 1 cardiac complication, and 4 (40%) had cardiac
rup-ture/ tamponade No patient with NSTEMI had cardiac
com-plications after thrombolysis
Thirty-two (31.4%) patients underwent percutaneous
coronary angioplasty Treatment rates were higher in those
without IV–rtPA treatment (Table 1) No patient treated with
PCI had cardiac rupture/ tamponade
Among the 34 patients with documented poststroke
antithrombotic therapy after IV–rtPA treatment, 16 were
treated with 1 antiplatelet, 11 with dual antiplatelets, and 7
with anticoagulation (2 with 1 additional antiplatelet, 4 with
2 additional antiplatelets) Twenty-seven patients started
antithrombotic therapy 24 hours after thrombolysis, four <24 hours, and three >48 hours
Among patients with IV–rtPA and with follow-up im-aging, 2 (4.9%) experienced symptomatic intracranial hem-orrhage, fatal in 1, none with previous antithrombotic therapy
No differences were registered between patients with or without IV–rtPA regarding symptomatic intracranial hemor-rhage (Table 2)
Table 3 presents a summary of all complications in IV– rtPA treated patients
In total, 20 (19.6%) patients died during hospitalization, with no differences between treatment groups Three patients died after documented cardiac rupture, 2 due to cardiogenic shock, 2 with pulseless electrical activity, 6 after cardiac arrest
of unknown cause, 1 after ventricular fibrillation, 1 after re-current MI, 1 after symptomatic intracranial hemorrhage (after IV–rtPA), 2 after malignant cerebral infarction, and 2 due to aspiration pneumonia
Discussion
In this study, all cases of cardiac wall rupture or tamponade
as a complication of IV–rtPA occurred in patients that had a STEMI, 1 to 7 days before stroke onset The only case of car-diac rupture in the group without IV–rtPA had been treated with intraarterial thrombolysis, after a recent STEMI
These findings support the most recent American Heart Association/ American Stroke Association guidelines, where although it is considered reasonable to treat AIS patients with recent MI, the strength given to the recommendations depends
on MI type and on time elapsed between both events.10
In MI, higher rates of cardiac complications (wall rupture, cardiac tamponade, and presence of ventricular thrombus) were
Figure Preferred Reporting Items for
System-atic Reviews and Meta-Analyses flowchart.
Trang 4documented in transmural infarctions.17–20 Histopathologic studies consider transmural infarction as a prerequisite for cardiac rupture,18 which may justify the safer profile found in NSTEMI patients Risk of myocardial wall rupture and
post-MI pericarditis seem to be related to both size and transmural extension of the MI, justifying higher rates of life-threatening complications in STEMI, and in particular, in large left ante-rior descending artery infarcts The same principle applies for the presence of ventricular thrombus because larger infarcts more likely cause myocardial dyskinesia and impair ventric-ular ejection fraction, promoting local blood stasis
Cardiac complications tend to peak 2 to 14 days after
MI,21,22 so early, but not concurrent MI, may also prompt caution In our study, most complications occurred when thrombolysis was given within the first days after MI; how-ever, <15% of patients received thrombolysis later than 2 weeks after MI, and therefore, there may be a selection bias Myocardium fibrosis and scarring are completed 7 weeks after
MI, so the definition of recent MI for thrombolysis treatment could theoretically be shortened to 7 weeks.23
Our results showed a higher frequency of wall rupture/car-diac tamponade in the IV–rtPA group, although not statistically
Table 1 Baseline Characteristics and Treatment Comparison Between Patients
With or Without IV–rtPA Treatment
Treated With IV–rtPA (n=47)
Without IV–rtPA (n=55) P Value Demographics
Age, y 68 (60–77) 62 (47–72) 0.014
Male sex 31 (66.0) 38 (69.1) 0.83
Vascular risk factors*
Hypertension 29 (65.9) 32 (69.6) 0.82
Diabetes mellitus 15 (34.1) 16 (32.6) 1.00
Atrial fibrillation 11 (25.0) 10 (21.7) 0.81
Dyslipidemia 16 (36.4) 18 (39.1) 0.83
Smoking 10 (22.7) 16 (34.8) 0.25
Stroke characteristics
Anterior circulation† 42 (93.3) 41 (75.9) 0.027
Admission NIHSS‡ 14(10–18) 11 (4–22) 0.11
Prestroke antithrombotic therapy§
Single antiplatelet 12 (27.3) 3 (6.0) 0.010
Dual antiplatelets 6 (13.6) 16 (32.0)
Anticoagulation# 7 (15.9) 13 (26.0)
Myocardial infarction
Concurrent events 25 (53.2) 12 (21.8) 0.002
Time between events, d‖ 4 (1–20) 4 (1–21) 0.82
STEMI 23 (48.9) 36 (65.5) 0.11
Echocardiogram‡
Unremarkable 8 (22.2) 18 (37.5) 0.22
Hypokinesia 15 (41.7) 11 (22.9)
Akinesia 7 (19.4) 8 (16.7)
Intracardiac thrombus 6 (16.7) 11 (22.9)
Treatment
Poststroke antithrombotic therapy¶
Single antiplatelet 16 (47.1) 8 (20.5) 0.029
Dual antiplatelets 11 (32.4) 11 (28.2)
Isolated anticoagulation 2 (5.9) 13 (33.3)
Anticoagulation + 1 antiplatelet 2 (5.9) 3 (7.7)
Anticoagulation + dual
antiplatelets
3 (8.8) 4 (10.3)
Endovascular stroke treatment 0 (0.0) 11 (20.0) 0.001
Percutaneous coronary intervention 7 (14.9) 25 (45.5) 0.001
Age, admission NIHSS, and time between events are reported as median values
and interquartile range All the other variables are reported as absolute numbers and
percentages IV–rtPA indicates intravenous thrombolysis; NIHSS, National Institutes
of Health Stroke Scale; and STEMI, ST-segment–elevation myocardial infarction.
*Missing in 12 patients.
†Missing in 3 patients.
‡Missing in 18 patients.
§Missing in 8 patients.
‖Without concurrent events.
¶Missing in 29 patients.
#Eight patients also under antiplatelets.
Table 2 Outcome Comparison Between Patients With or Without IV–rtPA Treatment
Treated With IV–rtPA (n=47)
Without IV–rtPA (n=55) P Value Any cardiac complication 7 (14.9) 10 (18.2) 0.79 Wall rupture/ cardiac tamponade* 4 (8.5) 1 (1.8) 0.18 Arrhythmia (total) 3 (6.4) 7 (12.7) 0.34 Ventricular fibrillation 1 1 0.34 Pulseless electrical activity 1 1
Cardiac arrest of unknown cause
Embolization 1 (2.1) 2 (3.6) 1.00 In-hospital myocardial infarction
recurrence
1 (2.1) 1 (1.8) 1.00
Hemorrhagic transformation†
No 27 (65.9) 30 (69.8) 0.77 H1 5 (12.2) 6 (14.0) H2 3 (7.3) 3 (7.0) P1 5 (12.2) 2 (4.7) P2 1 (2.4) 2 (4.7) Symptomatic intracranial
hemorrhage†
2 (4.9) 2 (4.5) 1.00
In-hospital death 7 (14.9) 13 (23.6) 0.32 Hemorrhagic transformation and symptomatic intracranial hemorrhage according to the ECASS-II classification ECASS-II indicates European Cooperative Acute Stroke Study-II; and IV–rtPA indicates intravenous thrombolysis.
*Confirmed and fatal in 3 One with presumed wall rupture/cardiac tamponade after dying from cardiogenic shock One with nonfatal pericardial effusion In the non–rtPA group, the patient died from wall rupture after receiving intraarterial urokinase treatment.
†Missing in 18 patients.
Trang 5significant, which can be due to the small number of included
patients In addition, higher mean age and a lower frequency
of PCI in the IV–rtPA group may have contributed to these
results.17,24 The low number of events5 precludes a multivariate
logistic regression model adjusting for potential confounders
Thrombus embolization events were rare and had a
sim-ilar frequency in both groups, which seems to be in line
with the last American Heart Association/ American Stroke
Association guidelines statement that may be reasonable to
perform IV–rtPA in patients with stroke and intracardiac
thrombus.10
There were no differences between groups regarding the
occurrence of arrhythmias The acute stress response triggered
by the cerebral ischemic event, natural history of MI, and its
location, maybe partially responsible for this complication
After MI, patients are given antithrombotic regimens
that may increase the risk of hemorrhagic complications
after thrombolysis Although therapeutic anticoagulation is a
formal contraindication,10 dual antiplatelet therapy has raised
concerns.25,26 Recent published data27 and recommendations10
do not support withholding thrombolysis due to dual
antiplate-let therapy, although regimens with potent P2Y12 inhibitors
(prasugrel or ticagrelor) may need further study In our study,
the rate of radiological and symptomatic hemorrhagic
trans-formation was lower than reported in the ECASS-II trial,16 and
no differences were verified between patients with or without
IV–rtPA treatment No patients were pretreated with potent
P2Y12 inhibitors previous to IV–rtPA treatment
In the era of EVT, patients unqualified for IV–rtPA due
to medical complications can receive primary mechanical
thrombectomy It has been shown that mechanical
thrombec-tomy has good results in patients with contraindications for
IV–rtPA,28,29 but not all patients fulfill criteria for EVT (eg,
proximal vessel occlusion), and there is no clear evidence that primary EVT has the same results as bridging therapy.30,31 Nevertheless, in patients with AIS after recent STEMI (not concurrent), and large vessel occlusion, primary mechanical thrombectomy may be considered
For patients with concurrent AIS and MI, a combined treatment has been proposed.9,32,33 Because IV–rtPA is the only approved treatment for both vascular events, it can be perceived as the best solution A viable option is to give the es-tablished dose of alteplase for stroke and, if indicated, proceed with PCI.9 If PCI is performed, procedural decisions (stenting versus balloon angioplasty or type of stent), as well as anti-thrombotic regimen, can be tailored in each patient according
to the risk of ischemic hemorrhagic transformation In patients fulfilling criteria, EVT and PCI can be combined.32 While de-ciding to give IV–rtPA for AIS and recent MI, the physician should be aware of clinical signs that may suggest increased probability of cardiac complications (eg, pericardial rub) or consider using urgent transthoracic echocardiography.33 Our study has limitations The low number of included patients limits our ability to perform adjusted analysis and, therefore, our conclusions Also, because all cases of con-firmed or suspected cardiac wall rupture or tamponade were derived from the literature search, publication bias, with po-tential overestimation of these cardiac complications, cannot
be excluded Nevertheless, this bias is inherent to a systematic review of case reports The lower frequency of STEMI and nonconcurrent events in the IV–rtPA group may indicate a se-lection bias, reflecting the higher caution of stroke physician
in treating these patients
Conclusions
In patients with AIS and recent or concurrent MI, type of MI and the time elapsed between the 2 events should be taken in consideration while deciding to deliver IV–rtPA Although re-cent NSTEMI or concurrent events were not associated with cardiac complications, STEMI in the week preceding stroke should prompt caution The low number of events and publi-cation bias may have influenced our conclusions
Disclosures
Dr Viana-Baptista reports personal fees from Sanofi-Genzyme Portugal, Daiichi Sankyo, and Boehringer Ingelheim outside the sub-mitted work The other authors report no conflicts.
References
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after myocardial infarction Ann Intern Med 2005;143:785–792 doi:
10.7326/0003-4819-143-11-200512060-00006
3 Clark WM, Wissman S, Albers GW, Jhamandas JH, Madden KP, Hamilton S Recombinant tissue-type plasminogen activator (Alteplase) for ischemic stroke 3 to 5 hours after symptom onset The ATLANTIS study: a randomized controlled trial Alteplase thrombolysis for acute
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Table 3 Summary of Cardiac Complications According to Type of Myocardial
Infarction and Time Elapsed Between Both Events, in IV–rtPA Treated Patients
Type and
Location of
Myocardial
Infarction
Timing Cardiac Complications
Wall Rupture/
Cardiac Tamponade Arrhythmia Embolization NSTEMI Concurrent
1–7 d
>7 d STEMI Concurrent 1*
1–7 d 4† 2‡§ 1‡
>7 d Hemorrhagic transformation (P1/P2) and sICH according to the ECASS-II
classification ECASS-II indicates European Cooperative Acute Stroke
Study-II; IV–rtPA, intravenous thrombolysis; NSTEMI, non–ST-segment–elevation
myocardial infarction; sICH, symptomatic intracranial hemorrhage; and STEMI,
ST-segment–elevation myocardial infarction.
*One patient with inferior STEMI died after cardiac arrest of unknown cause.
†Confirmed and fatal in 2 left anterior STEMI One patient with inferior STEMI
and presumed wall rupture/ cardiac tamponade after dying from cardiogenic
shock One patient with inferior STEMI with nonfatal pericardial effusion.
‡One patient with inferior STEMI had both arrhythmia (ventricular fibrillation)
and embolization complications.
§One patient with inferior STEMI had pulseless electrical activity.
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