Predictors of early morbidity and mortality after thrombolytic therapy of acute myocardial infarction. Analyses of patient subgroups in the Thrombolysis in Myocardial Infarction (TIMI) trial, phase II.

Abstract

The strong independent correlation of pulmonary edema/cardiogenic shock with death suggests that thrombolysis is not sufficient to improve survival in these patients. The higher mortality in patients with versus without prior AMI in the conservative strategy suggests that early catheterization and revascularization of these patients might be beneficial. Conversely, the higher mortality in diabetes without prior AMI in the invasive than in the conservative strategy suggests that early aggressive management might not be suitable in this subgroup except for clinical indications. Reinfarction was not predictable by clinical variables except by history of angina. The finding that "not current smoker" was an independent correlate with reinfarction was unexpected.

The smoker’s paradox after successful fibrinolysis: reduced risk of reocclusion but no improved long-term cardiac outcome

“…In previous studies after fibrinolysis the paradoxical beneficial short-term outcome of smokers has been attributed to more favorable clinical and angiographic baseline characteristics and a better response to fibrinolytic therapy [4][5][6][8][9][10][11]. Consistent with the latter observation we found a rate of current smokers in patients after successful fibrinolysis which is considerably higher than reported in the overall fibrinolysis population in contemporary megatrials: 64% vs. 44% [22,24].…”

“…In one study current smoking was independently associated with a lower risk of reinfarction 42 days after fibrinolysis [4]. Despite the independently reduced risk of reocclusion in smokers in our study, the risk of reinfarction at 3 months did not differ from non-smokers.…”

“…At baseline angiography smokers had less extensive coronary artery disease with a higher rate of single vessel disease, less severe residual infarct related stenoses, and more smooth infarct lesions. Whereas in previous trials smokers most often had infarctions related to the right coronary artery [4,5,8], left coronary artery infarctions predominated in smokers in our study. Besides a different timing of angiography (24 h vs. 90 min), this may be explained by the inclusion of only patients with a patent infarct artery.…”

“…Several studies have reported lower reinfarction rates in smokers as compared to non-smokers [4,5,26,31,32]. In one study current smoking was independently associated with a lower risk of reinfarction 42 days after fibrinolysis [4].…”

“…However, after acute myocardial infarction short-term clinical outcome in smokers is more favorable than in non-smokers. In patients treated with fibrinolysis for acute myocardial infarction this so-called ''smoker's paradox'' has been attributed to more favorable clinical and angiographic baseline characteristics in smokers [4][5][6]. Several studies reported higher rates of good early antegrade epicardial flow (Thrombolysis In Myocardial Infarction (TIMI) 3 flow) in smokers [7], suggesting a better response to fibrinolysis [5,6,[8][9][10][11].…”