Reperfusion therapy

A detailed clinical history, past medical and surgical history, medications, allergies, laboratory work-up, physical examination, and NIHSS should be obtained as quickly as possible for assessment of inclusion and exclusion criteria for lAT. Table 4.1 lists the criteria for catheter-based reperfusion therapy currently in place at the Massachusetts General Hospital (Table 4.1 see also www.acutestroke.com for updated criteria). 

Mohna CA, Saver JL. Extending reperfusion therapy for acute ischemic stroke emerging pharmacological, mechanical, and imaging strategies. Stroke 2005 36 2311-2320. 

Early reperfusion therapy with either primary percutaneous coronary intervention or administration of a fibrinolytic agent within 3 hours of symptom onset is the recommended therapy for patients presenting with ST-segment elevation acute coronary syndrome. 

In patients with ST-segment elevation (STE) ACS, in-hospital death rates are approximately 7% for patients who are treated with fibrinolytics and 16% for patients who do not receive reperfusion therapy. In patients with non-ST-segment elevation (NSTE) MI, in-hospital mortality is less than 5%. In-hospital and 1-year mortality rates are higher for women and elderly patients. In the first year following MI, 38% of women and 25% of men will die, most from recurrent infarction.1 At 1 year, rates of mortality and reinfarction are similar between STE and NSTE MI. 

Initiate reperfusion therapy in appropriate candidates (fibrinolysis or primary PCI)... 

Obtain serial troponin and CK MB as confirmatory results not needed before reperfusion therapy is initiated multilead continuous ST-segment monitoring... 

Is reperfusion therapy with fibrinolysis indicated at this time ... 

Pharmacotherapy for early treatment of ACS is outlined in Fig. 5-3. According to the ACC/AHA ST-segment elevation ACS practice guidelines, in addition to reperfusion therapy, early pharmacotherapy of STE should include intranasal oxygen... 

Twenty to 40 percent of patients presenting with STE ACS receive fibrinolysis compared with 7% receiving primary PCI.26,27 Therefore, many patients do not receive early reperfusion therapy. The primary reason for lack of reperfusion therapy is that most patients present more than 12 hours after the time of symptom onset.27 The percentage of eligible patients who receive reperfusion therapy is a quality indicator of care in... 

Landmark clinical trials have established the role of early P-blocker therapy in reducing MI mortality, reinfarction, and arrhythmias. Most of these trials were performed in the 1970s and 1980s before routine use of early reperfusion therapy.40,41 However, data regarding the acute benefit of P-blockers in MI... 

Ischemic stroke patients presenting within hours of symptom onset should be evaluated for reperfusion therapy. 

Christian TF, Behrenbeck T, Pellikka PA, Huber KC, Chesebro JH, Gibbons RJ. Mismatch of left ventricular function and infarct size demonstrated by technetium-99m isonitrile imaging after reperfusion therapy for acute myocardial infarction identification of myocardial stunning and hyperkinesia. J Am Coll Cardiol 1990 16 1632-1638... 

Table 4 Randomized clinical trials of platelet glycoprotein llb/llla inhibitors during reperfusion therapy for acute ST-elevation myocardial infarction...

Topol EJ, Reperfusion therapy for acute myocardial infarction with fibrinolytic therapy or combination reduced fibrinolytic therapy and platelet glycoprotein llb/llla inhibition the GUSTO V randomized trial. Lancet 2001 357 1 905,... 

Sabatine MS, McCabe CH, Gibson CM, Cannon CP Design and rationale of Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction (CLARITY-TIMI) 28trial. Am HeartJ 2005 149 227-233. 

Two major forms of reperfusion therapy are available fibrinolytic therapy and primary coronary intervention. This review mainly addresses the former. 

Ross AM, Molhoek B Lundergan C, et al. Randomized comparison of enoxaparin, a low molecular weight heparin, with unfractionated heparin adjunctive to tissue plasminogen activator thrombolysis and aspirin second trial of Heparin and Aspirin Reperfusion Therapy (HART II). Circulation 2001 104 648-652. 

Stone GW, Cox D, Gracia E, et al. Normal flow (TIMID) before mechanical reperfusion therapy is an independent determinant of survival in acute myocardial infarction results from the primary angioplasty in myocardial infarction trials. Circulation 2002 104 636-641. 

Sabatine MS, Cannon CR Gibson CM. Clopidogrel as adjunctive reperfusion therapy (CLARITY)-thrombolysis in myocardial infarction (TIM I) 28 investigators. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics the PCI-CLARITY study. JAMA 2005 294(10) 1224-1232. 

Topol, E. J. (1998). Toward a new frontier in myocardial reperfusion therapy. Emerging platelet preeminence. Circulation 97, 211-218. 

With the development of thrombolytic therapies (NINDS Stroke-Trial 1995 Hack e et al. 1995) there is a high demand for new methods which provide detailed information on the infarcted parenchyma, especially for those methods which enable characterization of tissue that is potentially salvageable by reperfusion therapy. Since the concentration of key metabolites may play a pivotal role, MR spectroscopy may have an impact on treatment decisions. 

No preclinical studies of neuroprotectives plus hypothermia in permanent occlusion stroke models without thrombolysis have been reported. This is of particular importance because these permanent ischemia models may better simulate the events that occur clinically in the vast majority of stroke patients who do not receive reperfusion therapy with a thrombolytic agent. Such studies will be necessary before proceeding with clinical trials in stroke patients. 

The fourth group is those who present to the emergency department at any time after the onset of chest pain with clear ECG evidence of AMI. In this group, detection with serum biomarkers of myocardial injury is not necessary initially. Many of these patients may qualify for reperfusion therapy at a time before blood markers of cardiac injury have increased, and therapy should not be withheld if these criteria are met. Subsequently, specific and sensitive myocardial markers could be employed to monitor the success of reperfusion during the 60- to 90-minute period after therapy. Rapid assays providing early serial values followed by interpretation of the markers patterns of appearance are often helpful in determining subsequent management. 

Mechanisms of hemorrhagic transformation after tissue plasminogen activator reperfusion therapy for ischemic stroke. Stroke 35 2726-2730... 

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