Prognostic role of plasminogen-activator-inhibitor-1 levels in treatment with streptokinase of patients with acute myocardial infarction

Association between plasminogen activator inhibitor-1 and cardiovascular events: a systematic review and meta-analysis

Background

Small studies have implicated plasminogen activator inhibitor-1 (PAI-1) as a predictor of cardiovascular events; however, these findings have been inconsistent.

We sought out to examine the potential role of PAI-1 as a marker for major adverse cardiovascular events (MACE).

Methods

We systematically reviewed all indexed studies examining the association between PAI-1 and MACE (defined as death, myocardial infarction, or cerebrovascular accident) or restenosis. EMBASE, Web of Science, Medline, and the Cochrane Library were searched through October 2016 to identify relevant studies, supplemented by letters to authors and review of citations. Studies reporting the results of PAI-1 antigen and/or activity levels in association with MACE in human subjects were included.

Results

Of 5961 articles screened, we identified 38 articles published between 1991 to 2016 that reported PAI-1 levels in 11,557 patients. In studies that examined PAI-1 antigen and activity levels, 15.1% and 29.6% of patients experienced MACE, respectively. Patients with MACE had higher PAI-1 antigen levels with a mean difference of 6.11 ng/mL (95% CI, 3.27-8.96). This finding was similar among patients with and without known coronary artery disease. Comparatively, studies that stratified by PAI-1 activity levels were not associated with MACE. In contrast, studies of coronary restenosis suggest PAI-1 antigen and activity levels are negatively associated with MACE.

Conclusions

Elevated plasma PAI-1 antigen levels are associated with MACE. Definitive studies are needed to ascertain if PAI-1 acts simply as a marker of risk or if it is indeed a bona fide therapeutic target.

Electronic supplementary material

The online version of this article (10.1186/s12959-018-0166-4) contains supplementary material, which is available to authorized users.

Serum levels of thrombotic markers in patients with acute myocardial infarction

Tissue plasminogen activator (TPA) and plasminogen activator inhibitor-1 (PAI-1) have pro- and anti-fibrinolytic activities respectively. The net fibrinolytic activity is mainly determined by the balance between TPA and PAI-1 levels. Considering the important role of these markers in thrombotic pathway, we determined the levels of TPA and PAI-1 in sera of 50 AMI patients, 100 patients with associated risk factors (dyslipidemia and high blood pressure) and 100 healthy controls. The findings showed significantly high levels of TPA and PAI-1 in AMI patients as compared to control subjects. Both these markers were only non-significantly increased in the risk group. There was no correlation between body mass index and these markers however TPA and PAI-1 were significantly correlated with age and systolic blood pressure, respectively. In conclusion, a combination of these markers could provide a useful tool to assess the prognosis of AMI.

Clinical and biochemical predictors affect the choice and the short-term outcomes of different thrombolytic agents in acute myocardial infarction

BACKGROUND

The presence of plasminogen activator inhibitor-1, angiotensin-converting enzyme and others may play a role in unsuccessful recanalization after thrombolytic therapy.

OBJECTIVES

To find out the clinical and biochemical predictors that may affect the choice and short-term outcomes following different thrombolytic agents in acute myocardial infarction.

METHODOLOGY

Angiotensin-converting enzyme and plasminogen activator inhibitor-1 plasma levels of 184 patients with acute myocardial infarction, treated with streptokinase, metalyze or reteplase, were determined. Failure of thrombolysis was assessed by noninvasive reperfusion criteria. Prolonged hospitalization, impaired left ventricular ejection fraction and reinfarction were considered as short-term outcomes.

RESULTS

Patients who received streptokinase developed higher incidence of >50% resolution of ST-segment elevation (82.5 vs. 64.7%, P-value<0.05, in comparison with metalyze and 82.5 vs. 55.7%, P-value 0.001, in comparison with reteplase) than those who received other thrombolytic agents. High plasma angiotensin-converting enzyme was associated with prolonged hospitalization (55, 63 and 94%, P<0.02) following streptokinase, metalyze and reteplase, respectively. High plasma plasminogen activator inhibitor-1 is associated with impaired left ventricular ejection fraction (55.3, 76.7 and 68.5%, P<0.09), ST resolution<50% (13.2, 36.7 and 37.5%, P=0.03), ST resolution>50% (86.8, 63.3 and 62.5%, P=0.03) following streptokinase, metalyze and reteplase, respectively.

CONCLUSIONS

Rapid determination of pretreatment angiotensin-converting enzyme and plasminogen activator inhibitor-1 plasma levels in patients with acute myocardial infarction may influence the choice and outcomes of the thrombolytic agents. The presence of a high plasma level of either angiotensin-converting enzyme or plasminogen activator inhibitor-1 is significantly associated with adverse short-term outcomes after treatment with reteplase or metalyze.

The effect of high plasma levels of angiotensin-converting enzyme (ACE) and plasminogen activator inhibitor (PAI-1) on the reperfusion after thrombolytic therapy in patients presented with acute myocardial infarction

The resistance to thrombolytic agents and delays in reperfusion occur in more than 30% after acute myocardial infarction. This may play an important role in the unsuccessful recanalization after thrombolytic therapy. The aim of this study is to assess the clinical and biochemical markers of reperfusion after different types of thrombolytic therapy and to find out the relationship between PAI-1 and ACE serum levels and the short-term outcome. Pretreatment ACE and PAI-1 plasma levels of 184 patients with acute myocardial infarction, treated with thrombolytic therapy were determined. Failure of thrombolysis was considered when reperfusion was delayed as assessed by noninvasive reperfusion criteria, reinfarction, and impaired left ventricular function. High plasma level of ACE (> 50 U/L), PAI-1 (> 43 ng/ml) and both was found in 57, 108 and 32 patients respectively. Subjects with high ACE plasma levels were characterized by impaired LV systolic function (79.0% vs. 75.0%), new Q-wave (88.4% vs. 74.2%), less reperfusion arrhythmia (19.3% vs. 22.8%) and prolonged hospitalization (70% vs. 66%) but no statistical significance was observed. High enzymes levels of PAI-1 were observed with higher incidence of anterior myocardial infarction (50.0% vs. 41.0%), lesser ST segment resolution (65.6% vs. 58.8%), reinfarction (6.3% vs. 5.9%), and impaired LV systolic function (90.6% vs. 76.0%), and prolonged hospitalization (70.4% vs. 63.4). There was a statistically significant difference between thrombolytic agents in the presence of high ACE regarding hospital overstay (p = 0.02). While the presence of high PAI-1 was significantly affect the degree of ST-segment resolution (p = 0.03).

CONCLUSION

High plasma ACE and/or PAI-1 plays a considerable role in the higher incidence of unsuccessful reperfusion and impaired left ventricular function after thrombolytic therapy. A rapid diagnostic tool that enables physician of detecting those enzymes before giving thrombolytic therapy may change the strategy of treatment to offer another effective revascularization method.

Plasminogen activator inhibitor-1 in patients with atrial arrhythmias during acute myocardial infarction, treated with streptokinase

Atrial arrhythmias (AA), especially atrial fibrillation (AF), during acute myocardial infarction (AMI) are often associated with increased mortality and heart failure. Impaired fibrinolysis with elevated plasminogen activator inhibitor-1 (PAI-1) activity is associated with resistance to fibrinolytic therapy in AMI patients, but it is also found in patients with AF. Our aim was a prospective study of the role of pre-treatment PAI-1 levels for the presence of AA in AMI patients and the influence of AA on in-hospital mortality. In 116 AMI patients, treated with streptokinase, pre-treatment PAI-1 levels were estimated by the chromogenic method (normal levels, 0.3-3.5 U/ml) and in-hospital AA were assessed as atrial fibrillation, flutter and/or tachycardias. Between patients with and without AA, a significant difference was observed in mean pre-treatment PAI-1 levels, in several in-hospital complications and mortality (24 versus 4.4%; P < 0.01; odds ratio, 6.45; 95% confidence interval, 1.66-25.0). The PAI-1 level > 7 U/ml was the most significant independent pre-treatment risk factor for AA (P < 0.05; odds ratio, 3.5; 95% confidence interval, 1.15-10.6). We conclude that AA were a significant risk for in-hospital mortality of AMI patients, treated with streptokinase. A pre-treatment PAI-1 level > 7 U/ml was the most significant pre-treatment risk for AA in these patients.

Failed reperfusion after thrombolytic therapy: recognition and management

BACKGROUND

Failed reperfusion after thrombolysis occurs in as many as 30% of patients with acute myocardial infarction (MI). Furthermore, some patients have incomplete tissue perfusion despite reperfusion of the infarct-related artery. Close assessment of the efficacy of thrombolytic administration in people with evolving acute MI is necessary, particularly with regard to myocardial perfusion status, because some patients may benefit from incremental pharmacologic or invasive reperfusion strategies.

PURPOSE AND METHOD

This article reviews a number of strategies to assess infarct-related artery patency and myocardial tissue perfusion. These include coronary angiography, continuous ST-segment monitoring, serial electrocardiography, obtaining serial serum biochemical markers of myocardial necrosis, monitoring for reperfusion arrhythmias, and assessment of changes in chest pain intensity.

CONCLUSION

The early detection of failed reperfusion is critical if incremental strategies to enhance myocardial salvage are to be considered. Continuous ST-segment monitoring is a relatively inexpensive, reliable, and accurate tool for assessing real-time myocardial perfusion.