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Reconsidering the Safety of Intravenous Thrombolysis for Ischemic Stroke After Recent Myocardial Infarction

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Intravenous tissue-type plasminogen activator (IV-rtPA) for acute ischemic stroke may be given to patients with recent or concurrent myocardial infarction (MI), but consideration should be given to the type of MI and time elapsed between the events, according to study results published in Stroke.

While previously the American Heart Association/American Stroke Association guidelines considered MI within the preceding 3 months an absolute contraindication to IV-rtPA use, more recent guidelines consider this option reasonable. In this study the researchers assessed the safety of IV-rtPA in patients with acute ischemic stroke and a recent MI through a retrospective review of consecutive patients with acute ischemic stroke admitted to 2 tertiary university hospitals, and a systematic literature review of patients with acute stroke and history of MI in the previous 3 months.

The study cohort included 102 patients, with 47 patients derived from literature review and 56 patients derived from hospital cases (median age 64; 68% male). Of these, 47 patients (46%, mean age 68; 66% male) were treated with IV-rtPA, including 25 (53.2%) with concurrent acute ischemic stroke and MI and 23 (48.9%) with acute ischemic stroke and ST-segment-elevation myocardial infarction (STEMI). Of the remaining 55 patients who did not receive IV-rtPA (mean age 62; 69.1% male), 12 (21.8%, P =.002) had concurrent acute ischemic stroke and MI and 36 (65.5%, P =.110) had STEMI.

In the group of patients treated with IV-rtPA, 7 patients (14.9%) developed any cardiac complication, including 4 cases (8.5%) of cardiac rupture/tamponade; in all cases, STEMI was diagnosed in the week preceding the ischemic stroke. In the group of patients not treated with IV-rtPA, any cardiac complication was reported in 10 patients (18.2%, P =.79), with 1 case (1.8%) of wall rupture/cardiac tamponade (P =.18).

There were no differences between the groups in thrombus embolization, in-hospital myocardial infarction recurrence, life-threatening arrhythmias, symptomatic intracranial hemorrhage, or in-hospital death.

Of the 10 patients with STEMI in the week preceding stroke who also received IV-rtPA treatment, 6 (60%) had at least 1 cardiac complication, and 4 (40%) had cardiac rupture/tamponade. Cardiac complications were not documented following IV-rtPA in patients with non-STEMI.

The study had several limitations, including a small sample size and potential for publication bias as all cases of cardiac wall rupture or tamponade were derived from the literature search. Further, selection bias may account for the lower frequency of STEMI and non-concurrent events in the IV-rtPA group, pointing to a more cautious approach to treating these patients.

“In patients with [acute ischemic stroke] and recent or concurrent MI, type of MI and the time elapsed between the 2 events should be taken in[to] consideration while deciding to deliver IV-tPA,” the researchers concluded. They go on to note that, “although recent NSTEMI or concurrent events were not associated with cardiac complications, STEMI in the week preceding stroke should prompt caution.”

Reference

Marto JP, Kauppila LA, Jorge C, et al. Intravenous thrombolysis for acute ischemic stroke after recent myocardial infarction [published online August 22, 2019]. Stroke. doi:10.1161/STROKEAHA.119.025630 

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