Identification and management of patients with failed thrombolysis after acute myocardial infarction

Clinical outcome after thrombolytic therapy for acute myocardial infarction is closely related to restoration of flow in the infarct-related artery. Because thrombolytic therapy does not achieve coronary artery patency in 15% to 50% of patients, the early identification and treatment of patients with failed thrombolysis may lead to improved clinical outcomes. Unfortunately, the noninvasive identification of patients with failed thrombolysis continues to be problematic. Reduction in chest pain, decrease in ST-segment elevation, and presence of arrhythmias, although suggestive of reperfusion, are not diagnostic. Biochemical markers may hold promise for improved early identification of failed thrombolysis. In the setting of failed thrombolysis, clinical outcome may be improved by "rescue" percutaneous transluminal coronary angioplasty (PTCA) of the infarct-related artery. Several studies suggest that successful rescue PTCA is associated with high technical success rates and improved clinical outcomes. However, these same studies also suggest that patients with failed rescue PTCA may have higher mortality rates than patients who are treated conservatively. On the basis of current data, if failed thrombolysis is suspected, rescue PTCA should be considered, particularly in patients with anterior myocardial infarction and early presentation. Further investigations are needed to study the role of adjunctive methods such as stenting, glycoprotein IIb/IIIa inhibition, and intraaortic balloon counterpulsation in the setting of rescue PTCA. Because of the relative lack of prospective data in this area, additional studies are urgently needed to help improve the ability to identify and manage patients with failed thrombolysis after acute myocardial infarction.