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Usefulness of a Pericardial Friction Rub After Thrombolytic Therapy During Acute Myocardial Infarction in Predicting Amount of Myocardial Damage

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Usefulness of a Pericardial Friction Rub After Thrombolytic Therapy During Acute Myocardial Infarction in Predicting Amount of Myocardial Damage Usefulness of a Pericardial Friction Rub After Thrombolytic Therapy During Acute Myocardial Infarction in Predicting Amount of Myocardial Damage Thomas C. Wail, MD, Robert M. Califf, MD, Lynn Harrelson-Woodlief, MS, Daniel B. Mark, MD, MPH, Michael Honan, MD, Charles W. Abbotsmith, MD, Richard Candela, MD, Eric Berrios, RN, Harry R. Phillips, MD, Eric J. Topol, MD, and the TAMI Study Group eforethe era of thrombolytic therapy, pericarditis in To evaluate the clinical incidence and outcomes of acute myocardial infarction (AMI) was reported patients with pericarditis after thrombolytic thera- B to occur in approximately 7 to 20% of patients.1-6 py, 810 patients were prospectively studied during Based on clinical and pathologic studies, the presenceof acute myocardial infarction (AMI). Pericarditis was extensive transmural necrosiswas believed to be a pre- defined as the presence of a pericardial friction rub requisite for the development of pericardial inflamma- during the hospital course. Only 5% of patients de- tion.7 Hospital and long-term mortality has been report- veloped a rub during AMI, a low percent compared ed to be higher in conservatively treated patients with with that in the prethrombolytic era. A pericardial evidence of pericarditis after AMI.3-5 By achieving ear- friction rub more often occurred in the setting of an ly reperfusion, the use of thrombolytic therapy may pre- anterior wall AMI. Patients wlth, compared to vent progression to transmural necrosis,thereby reduc- those without, a pericardial friction rub had lower ing the risk of developing pericarditis.8 Once an in- ejection fractions (45 vs 51%, p = 0.002); worse flammatory reaction has developed,the risk of the de- regional left ventricular function (-3.2 vs 2.7, stan- velopment of hemorrhagic pericardial tamponade may dard deviatlon per chord); higher in-hospital mor- be increased.9Although pericarditis has been previous- tality (15 vs 6%, p = 0.056); a higher frequency of ly reported to occur less frequently in patients given power failure (83 vs 57%); a higher frequency of thrombolytic therapy in the setting of AMI,l”-12 the fre- anterior wall location of the AMI (53% of cases, p quency and clinical outcomes of pericarditis after this = 0.002); and a higher frequency of 3-vessel dis- treatment has not been systematically studied. This ease. Therefore, although the frequency of a peri- study reports, the cumulative Thrombolysis and Angio- cardial friction rub was low (5%) compared with plasty in Myocardial Infarction (TAMI) study’s experi- that in the prethrombolytic era, its occurrence de- ence with pericarditis in the setting of thrombolytic in- notes more extensive myocardial damage with a tervention. worse clinical outcome. Perhaps with successful re- perfusion of the infarct-related vessel, transmural METHODS myocardial necrosis is prevented and with it the de- Patients: Patients with AM1 complicated by peri- velopment of pericarditis. Cardiac tamponade did carditis were identified in the TAM1 trials 1 through 3 not occur clinically in any patient who developed ‘a and in the Urokinase Pilot Study at Duke University pericardial friction rub. Medical Center. Pericarditis was strictly defined as the (Am J Cardiol 1990;66:1418-1421) presenceof a pericardial friction rub on auscultation on physical examination at any time during the patient’s hospitalization. The patients were examined at least dai- ly by the attending physician and study nurses. As previously described, patients with AM1 were prospectively enrolled in trials of intravenous thrombo- lytic therapy if they met the standard treatment crite- ria.13-16Briefly, inclusion criteria included: (1) symp- From the Division of Cardiology, Department of Medicine, Duke Uni- toms consistent with an AM1 for 30 minutes’ duration versity Medical Center, Durham, North Carolina; The University of without response to sublingual nitroglycerin, (2) ST- Michigan Medical Center, Ann Arbor, Michigan; Riverside Methodist Hospital, Columbus, Ohio; and Christ Hospital, Cincinnati, Ohio. This segment elevation of > 1 mm in 2 2 contiguous electro- study was supported in part by Research Grant HS05635 from the cardiographic leads, (3) onset of chest discomfort within Agency for Health Care Policy and Research, Rockville, Maryland, 6 hours of the time of thrombolytic therapy administra- and Research Grant HL36587 from the National Heart, Lung, and tion, and (4) age <76 years. Usual exclusion criteria Blood Institute, Bethesda, Maryland. Manuscript received May 10, 1990; revised manuscript received and accepted August 1, 1990. included: (1) no bleeding diathesis, (2) absenceof car- Address for reprints: Thomas C. Wall, MD, Duke University Medi- diogenic shock, and (3) no prior coronary artery bypass cal Center, Box 3484, Durham, North Carolina 27710. surgery. 1418 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 66 LE 111 Baseline Clinical Characteristics Pericardial Rub No Pericardial Rub (n=40) (n = 770) Age (years)” 56 (46-65) 57 (49-65) Men/women 36/4 614/156 Weight (kg)* 84 (72-93) 82 (73-91) Coronary risk factors + (%) Systemic hypertension 43 42 Diabetes mellitus 8 16 Hypercholesterolemia 5 13 Cerebrovascular disease 3 2 Peripheral vascular disease 5 5 Family history of premature 43 46 TABLE II Pericardial Rub and Thrombolytic Therapy coronary artery disease Cigarette smoking 60 64 * Figures shown are median (25th to 75th percentiles). + = risk factors obtaned from admissian history. Definitions have been previously 111 published.20 1 ;iasei Yjg TABLE IV Baseline Angiographic Data Pericardial Rub No Pericardial Rub (n=40) (n = 770) TAMI = Thrombolysls and Angioplasty in Myocardlal Infarction trial. AMI location (%) Anterior 23 (57) 308 (40) Inferior 17 (43) 462 (60) ThePapsutCcregimens: The 4 thrombolytic therapy Infarct-related artery (%) trials with their respective pharmacologic intervemions Left main 1 (2) I(O.5) are displayed in Table I.13-i6 As previously reported, af- Left anterior descending 20 (50) 288 (37) ter immediate catheterization, all patients were treated Left circumflex 3 (8) lOl(13) with standard therapy including lidocaine, oxygen, mor- Right 14 (35) 358 (47) Graft 1 (2) 4 (0.5) phine as neededfor pain and nitrates either topically or Undetermined 1 (2) 18(2) intravenously. Aspirin, 325 mg/day, was also adminis- No. of coronary arteries tered along with a continuous infusion of intravenous narrowed 50% in heparin to maintain the partial thromboplastin time at 2 diameter (%) 0 4(10) 59 (8) times the control value. This infusion was continued un- 1 16(40) 362 (47) til repeat catheterization at 7 to 10 days. Beta blockers 2 7 (17) 217 (28) were not added to the medical regimen unless clinically 3 12 (30) 126 (16) indicated for systemic hypertension, supraventricular Left main 1 (3) 6(l) tachyarrhythmias or noncardiac disorders (e.g., mi- TIMI grade 90 minutes consensus (%) graine headaches).Patients were also treated with calci- Patent 28 (72) 539 (72) um antagonists 3 times a day. Other medications, in- Occluded 11 (28) 208 (28) cluding antiarrhythmic agents, were used at the discre- 0 7 (18) 158 (21) tion of the clinician. No other antiplatelet agents such 1 4(10) 50 (7) 2 503) 156 (21) as dipyridamole were used routinely. 3 23 (59) 383 (51) ata analysis: Case report forms were completed by AMI = acute myocardral Infarction; TIMI = Thrombolysis in Myocardial Infarction the clinical research nurse coordinators and reviewed by trial. the principal investigator at each site before submission to the Duke Data Coordinating Center. The data were verilied independently by study monitors from review of examined, 40 (4.9%) had evidence of clinical pericardi- the clinical records. tis during the hospitalization. The variability among the Throughout the clinical trials reviewed in this report, different phases of the thrombolytic studies was not a consistentdatabase was maintained to allow for assur- substantial. ance about variable definition and recording of events. Baseline characteristics for patients with or without Values for continuous variables are presented as mean a pericardial rub did not differ with regard to gender, t- 1 standard deviation (SD) and for discrete variables demographics and standard cardiac risk factors (Table values are presented as percentages.For discrete vari- III). Of the 40 cases,23 (58%) had a rub detected with- ables, comparisonswere made by the chi-square test or in 48 hours of initial presentation. the Fisher’s exact test and by t tests for continuous vari- Patients with anterior wall AMI had a higher inci- ables. All p values presentedare Zsided. dence of a pericardial friction rub than those with infe- rior AM1 (Table IV). Similarly, the left anterior de- scending coronary artery was more often the infarct- The frequencies of pericardial friction rub for the related artery in the pericarditis group. Patients who different studies are listed in Table II. Of 8 10 patients developed a friction rub had more severe coronary dis- THE AMERICAN JOURNAL OF CARDIOLOGY DECEMBER 15, 1990 ease than those who did not (33% with 3-vesselor left higher in patients with (15%) compared with those main diseaseversus 17%). No difference was apparent without clinical pericarditis (6%) (p = 0.056). In pa- in acute catheterization Thrombolysis in Myocardial In- tients with a rub who died, power failure tended to be farction study flow grades between those with or with- the predominant mechanism (83%), whereasin patients out clinical pericarditis. without a rub, the cause of death was more evenly dis- Patients with clinical pericarditis had a significantly tributed between power failure (57%) and other factors, lower global ejection fraction at the time of acute ven- mostly arrhythmia. No patient in either group devel- triculography (Figure 1): Median global ejection frac- oped a hemodynamically significant pericardial effusion tion was 45% for those with and 51% for those without or cardiac tamponade by bedside clinical evaluation. (p = 0.002). Infarct zone function measured in SDS per This negative finding has an upper 95% confidencelimit chord was significantly worse at the time of catheteriza- of approximately 0.4%.
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