Recurrent ischemia after thrombolysis: importance of associated clinical findings. GUSTO-I Investigators. Global Utilization of Streptokinase and t-PA [tissue-plasminogen activator] for Occluded Coronary Arteries.
OBJECTIVE
We sought to assess the incidence and clinical relevance of examination data to recurrent ischemia within an international randomized trial.


BACKGROUND
Ischemic symptoms commonly recur after thrombolysis for acute myocardial infarction.


METHODS
Patients (n = 40,848) were prospectively evaluated for recurrent angina and transient electrocardiographic (ECG) or hemodynamic changes. Five groups were developed: Group 1, patients with no signs or symptoms of recurrent ischemia; Group 2, patients with angina only; Group 3, patients with angina and ST segment changes; Group 4, patients with angina and hemodynamic abnormalities; and Group 5, patients with angina, ST segment changes and hemodynamic abnormalities. Baseline clinical and outcome variables were compared among the five groups.


RESULTS
Group 1 comprised 32,717 patients, and Groups 2 to 5 comprised 20% of patients (4,488 in Group 2; 3,021 in Group 3; 337 in Group 4; and 285 in Group 5). Patients with recurrent ischemia were more often female, had more cardiovascular risk factors and less often received intravenous heparin. Significantly more extensive and more severe coronary disease, antianginal treatment, angioplasty and coronary bypass surgery were observed as a function of ischemic severity. The 30-day reinfarction rate was 1.6% in Group 1, 6.5% in Group 2, 21.7% in Group 3, 13.1% in Group 4 and 36.5% in Group 5 (p < 0.0001); in contrast, the 30-day mortality rate was significantly lower (p < 0.0001) in Groups 1, 2 and 3 (6.6%, 5.4% and 7.7%, respectively) than in Groups 4 and 5 (21.8% and 29.1%).


CONCLUSIONS
Postinfarction angina greatly increases the risk of reinfarction, especially when accompanied by transient ECG changes. However, mortality is markedly increased only in the presence of concomitant hemodynamic abnormalities.
Betriu
A
A
Hospital Clinic, University of Barcelona, Spain. betriu001@msn.com
Califf
R M
RM
Bosch
X
X
Guerci
A
A
Stebbins
A L
AL
Barbagelata
N A
NA
Aylward
P E
PE
Vahanian
A
A
Van de Werf
F
F
Topol
E J
EJ
D000368:Aged; D017023:Coronary Angiography; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000188:drug therapy* / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D015996:Survival Rate; D015912:Thrombolytic Therapy