4 research outputs found
Risk Factors for In-hospital Nonhemorrhagic Stroke in Patients With Acute Myocardial Infarction Treated With Thrombolysis: Results from GUSTO-I
BACKGROUND: Nonhemorrhagic stroke occurs in 0.1% to 1.3% of patients with
acute myocardial infarction who are treated with thrombolysis, with
substantial associated mortality and morbidity. Little is known about the
risk factors for its occurrence. METHODS AND RESULTS: We studied the 247
patients with nonhemorrhagic stroke who were randomly assigned to one of
four thrombolytic regimens within 6 hours of symptom onset in the GUSTO-I
trial. We assessed the univariable and multivariable baseline risk factors
for nonhemorrhagic stroke and created a scoring nomogram from the baseline
multivariable modeling. We used time-dependent Cox modeling to determine
multivariable in-hospital predictors of nonhemorrhagic stroke. Baseline
and in-hospital predictors were then combined to determine the overall
predictors of nonhemorrhagic stroke. Of the 247 patients, 42 (17%) died
and another 98 (40%) were disabled by 30-day follow-up. Older age was the
most important baseline clinical predictor of nonhemorrhagic stroke,
followed by higher heart rate, history of stroke or transient ischemic
attack, diabetes, previous angina, and history of hypertension. These
factors remained statistically significant predictors in the combined
model, along with worse Killip class, coronary angiography, bypass
surgery, and atrial fibrillation/flutter. CONCLUSIONS: Nonhemorrhagic
stroke is a serious event in patients with acute myocardial infarction who
are treated with thrombolytic, antithrombin, and antiplatelet therapy. We
developed a simple nomogram that can predict the risk of nonhemorrhagic
stroke on the basis of baseline clinical characteristics. Prophylactic
anticoagulation may be an important treatment strategy for patients with
high probability for nonhemorrhagic stroke, but further study is needed
Incidence and predictors of bleeding after contemporary thrombolytic therapy for myocardial infarction
BACKGROUND: Although the benefit of thrombolytic therapy in reducing mortality in acute myocardial infarction is well established, the types of bleeding and risk factors for bleeding are less well described in large trials. METHODS AND RESULTS: We analyzed the baseline characteristics, outcomes, and incidence of bleeding by location, severity, and treatment assignment among 41,021 patients in the GUSTO-I trial of thrombolysis for acute myocardial infarction. Of the 40,903 patients for whom there were complete data, 1.2% suffered severe bleeding and 11.4% experienced moderate hemorrhage at a variety of sites. The most common sources of bleeding were procedure related. The thrombolytic regimen was strongly related to the incidence of bleeding; comparatively more bleeding was seen with the therapies of streptokinase plus intravenous heparin and the streptokinase and tissue plasminogen activator plus intravenous heparin combination. In multivariate analysis, the four most powerful independent predictors of hemorrhage were older age, lighter body weight, female sex, and African ancestry; they remained the most important predictors of bleeding when multivariate analysis was performed on patients who did not undergo invasive procedures. The presence of serious hemorrhage was associated with other undesirable outcomes (recurrent events, left ventricular dysfunction, arrhythmia, or stroke). CONCLUSIONS: Important predictors of bleeding in this population are increased age, lighter weight, female sex, African ancestry, and experiencing invasive procedures. Other nonhemorrhagic adverse clinical outcomes were associated with moderate and severe bleeding, which was in turn associated with increased length of hospital stay and mortality at 30 days
Effects of stroke on medical resource use and costs in acute myocardial infarction. GUSTO I Investigators. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries Study
BACKGROUND: Stroke occurs concurrently with myocardial infarction (MI) in
approximately 30 000 US patients each year. This number is expected to
rise with the increasing use of thrombolytic therapy for MI. However, no
data exist for the economic effect of stroke in the setting of acute MI
(AMI). The purpose of this prospective study was to assess the effect of
stroke on medical resource use and costs in AMI patients in the United
States. METHODS AND RESULTS: Medical resource use and cost data were
prospectively collected for 2566 randomly selected US GUSTO I patients
(from 23 105 patients) and for the 321 US GUSTO I patients who developed
non-bypass surgery-related stroke during the baseline hospitalization.
Follow-up was for 1 year. All costs are expressed in 1993 US dollars.
During the baseline hospitalization, stroke was associated with a
reduction in cardiac procedure rates and an increase in length of stay,
despite a hospital mortality rate of 37%. Together with stroke-related
procedural costs of 29 242 versus 22 400 versus
15 092 higher
than for no-stroke patients. Hemorrhagic stroke patients had a much higher
hospital mortality rate than non-hemorrhagic stroke patients (53% versus
15%, P<0.001), which was associated with approximately $7200 lower mean
baseline hospitali
An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction
BACKGROUND: The relative efficacy of streptokinase and tissue plasminogen activator and the roles of intravenous as compared with subcutaneous heparin as adjunctive therapy in acute myocardial infarction are unresolved questions. The current trial was designed to compare new, aggressive thrombolytic strategies with standard thrombolytic regimens in the treatment of acute myocardial infarction. Our hypothesis was that newer thrombolytic strategies that produce earlier and sustained reperfusion would improve survival. METHODS: In 15 countries and 1081 hospitals, 41,021 patients with evolving myocardial infarction were randomly assigned to four different thrombolytic strategies, consisting of the use of streptokinase and subcutaneous heparin, streptokinase and intravenous heparin, accelerated tissue plasminogen activator (t-PA) and intravenous heparin, or a combination of streptokinase plus t-PA with intravenous heparin. ("Accelerated" refers to the administration of t-PA over a period of 1 1/2 hours--with two thirds of the dose given in the first 30 minutes--rather than the conventional period of 3 hours.) The primary end point was 30-day mortality. RESULTS: The mortality rates in the four treatment groups were as follows: streptokinase and subcutaneous heparin, 7.2 percent; streptokinase and intravenous heparin, 7.4 percent; accelerated t-PA and intravenous heparin, 6.3 percent, and the combination of both thrombolytic agents with intravenous heparin, 7.0 percent. This represented a 14 percent reduction (95 percent confidence interval, 5.9 to 21.3 percent) in mortality for accelerated t-PA as compared with the two streptokinase-only strategies (P = 0.001). The rates of hemorrhagic stroke were 0.49 percent, 0.54 percent, 0.72 percent, and 0.94 percent in the four groups, respectively, which represented a significant excess of hemorrhagic strokes for accelerated t-PA (P = 0.03) and for the combination strategy (P < 0.001), as compared with streptokinase only. A combined end point of death or disabling stroke was significantly lower in the accelerated-tPA group than in the streptokinase-only groups (6.9 percent vs. 7.8 percent, P = 0.006). CONCLUSIONS: The findings of this large-scale trial indicate that accelerated t-PA given with intravenous heparin provides a survival benefit over previous standard thrombolytic regimen