Identify patients who have not achieved the desired objective of an open artery following thrombolytic administration.

Clinical signs of reperfusion following thrombolytic administration, include the following:

• Resolution of chest discomfort, within 90 minutes
• At least 50% resolution of ECG changes, within 90 minutes
• Early CK washout
• Reperfusion arrhythmias (i.e., bradyarrhythmias or accelerated idioventricular rhythm)

If a patient's symptoms and/or ECG changes do not resolve within 90 minutes, the patient should be referred to cardiology and considered for salvage angioplasty, especially if an anterior wall MI exists.

DISCUSSION

The original Thrombolysis in MI Trial (TIMI, 1987) evaluated artery patency by coronary angiography, between 30 and 90 minutes following thrombolytic administration. This study found that peak incidence of restoration of normal blood flow (TIMI grade 3) was at 90 minutes, following thrombolysis. Clinical markers of early reperfusion include resolution of chest discomfort, resolution of ECG changes, and reperfusion arrhythmias, including accelerated idioventricular rhythm and/or bradyarrhythmias, and early CK washout. These markers are not very sensitive for detecting artery patency following thrombolytic administration (Califf et al., 1988).

If a patient fails to manifest evidence of reperfusion, consideration should be given to rescue percutaneous revascularization, especially if the infarction involves the anterior wall (Goldman & Eisenberg, 2000). If angioplasty capability is not available at the presenting facility, transfer to another facility with angioplasty capability may be considered (Ross et al., 1998; Vermeer et al., 1999).