Activated partial thromboplastin time and outcome after thrombolytic therapy for acute myocardial infarction: results from the GUSTO-I trial.
BACKGROUND
Although intravenous heparin is commonly used after thrombolytic therapy, few reports have addressed the relationship between the degree of anticoagulation and clinical outcomes. We examined the activated partial thromboplastin time (aPTT) in 29,656 patients in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial and analyzed the relationship between the aPTT and both baseline patient characteristics and clinical outcomes.


RESULTS
Intravenous heparin was administered as a 5000-U bolus followed by an initial infusion of 1000 U/h, with dose adjustment to achieve a target aPTT of 60 to 85 seconds. aPTTs were collected 6, 12, and 24 hours after thrombolytic administration. Higher aPTT at 24 hours was strongly related to lower patient weight (P < .00001) as well as older age, female sex, and lack of cigarette smoking (all PT< .0001). At 12 hours, the aPTT associated with the lowest 30-day mortality, stroke, and bleeding rates was 50 to 70 seconds. There was an unexpected direct relationship between the aPTT and the risk of subsequent reinfarction. There was a clustering of reinfarction in the first 10 hours after discontinuation of intravenous heparin.


CONCLUSIONS
Although the relationship between aPTT and clinical outcome was confounded to some degree by the influence of baseline prognostic characteristics, aPTTs higher than 70 seconds were found to be associated with higher likelihood of mortality, stroke, bleeding, and reinfarction. These findings suggest that until proven otherwise, we should consider the aPTT range of 50 to 70 seconds as optimal with intravenous heparin after thrombolytic therapy.
Granger
C B
CB
Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
Hirsch
J
J
Califf
R M
RM
Col
J
J
White
H D
HD
Betriu
A
A
Woodlief
L H
LH
Lee
K L
KL
Bovill
E G
EG
Simes
R J
RJ
Topol
E J
EJ
D000328:Adult; D000367:Age Factors; D000368:Aged; D001835:Body Weight; D002561:Cerebrovascular Disorders / Q000209:etiology; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D010314:Partial Thromboplastin Time; D011379:Prognosis; D011897:Random Allocation; D012008:Recurrence; D012737:Sex Factors; D012907:Smoking / Q000009:adverse effects; D013300:Streptokinase / Q000008:administration & dosage; D015912:Thrombolytic Therapy; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage; D016896:Treatment Outcome
D006493:Heparin; D013300:Streptokinase; D010959:Tissue Plasminogen Activator