Combination thrombolytic therapy: A comparison of simultaneous and sequential regimens of tissue plasminogen activator and urokinase

摘要

Coronary angioplasty following unsuccessful tissue plasminogen activator (t-PA) therapy for acute myocardial infarction has been associated with a high incidence of subsequent reocclusion of the infarct-related artery, and a relatively high in-hospital mortality. In contrast, the combination of t-PA and urokinase, when given intravenously prior to coronary angiography, appears to be associated with a low incidence of post-rescue angioplasty reocclusion. In order to determine whether intraprocedural urokinase, given at the time of rescue coronary angioplasty for falled t-PA therapy, improves long-term patency of the infarct vessel to the same extent as preangiographic, combination t-PA/urokinase therapy, three thrombolytic treatment strategies were retrospectively compared. The first group included 86 patients undergoing rescue angioplasty after t-PA monotherapy (t-PA alone). The clinical and anglographic outcomes of these patients were compared with those of 24 patients who received intravenous or intracoronary urokinase during rescue angioplasty following unsuccessful t-PA therapy (sequential t-PA/urokinase therapy), and with those of 34 patients undergoing rescue coronary angioplasty following unsuccessful therapy with the combination of intravenous t-PA and urokinase (simultaneous therapy). There was no difference in postangioplasty patency rate of the infarct-related artery between the three groups. However, the sequential t-PA/urokinase regimen was associated with a subsequent reocclusion rate that was lower than the rate that occurred in the t-PA monotherapy group but higher than the rate in the simultaneous t-PA/urokinase group (13 versus 29 versus 2%, respectively; p = 0.003). In-hospital mortality in the sequential therapy group was 13% compared with 12% in the t-PA monotherapy group and 0% in the simultaneous t-PA/urokinase group (p = 0.10). There was no significant difference between the groups in the incidence of bleeding or in the need for emergency coronary artery bypass graft surgery. We conclude that the addition of intracoronary or intravenous urokinase at the time of rescue coronary angioplasty may improve the long-term patency of the infarct-related artery following intravenous t-PA therapy, but that the initial, preangiographic administration of combined t-PA and urokinase appears to be a preferable treatment regimen for patients in whom rescue coronary angioplasty appears likely.