Incidence of left ventricular thrombi formation after thrombolytic therapy with recombinant tissue plasminogen activator, heparin, and aspirin in patients with acute myocardial infarction

Cardio-cerebral infarction: a narrative review of pathophysiology, treatment challenges, and prognostic implications

Cardio-cerebral infarction (CCI) is a rare clinical syndrome characterized by the simultaneous or sequential occurrence of acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Despite its complex pathogenesis and more severe prognosis compared to isolated AMI or AIS, no consensus has been established regarding its definition, classification, epidemiology, treatment protocols, or prognostic management. Current research is largely confined to case reports or small case series, and there are no unified diagnostic or treatment guidelines, nor any expert consensus. Consequently, clinicians often rely on single-disease guidelines for AMI or AIS, or personal experience, when managing CCI cases. This approach complicates treatment decisions and may result in missed opportunities for optimal interventions, thereby adversely affecting long-term patient outcomes. This narrative review aimed to systematically summarize the definition, classification, epidemiological features, pathogenesis and therapeutic strategies, and prognostic aspects of CCI while thoroughly examining the progress and limitations of existing studies to guide future research and clinical practice. By offering a detailed analysis of reperfusion strategies, antiplatelet therapy, and anticoagulation in CCI patients, this review highlights the safety and efficacy differences among current treatments and explores methods for optimizing individualized management to improve clinical outcomes. Furthermore, this article aimed to enhance clinicians' understanding of CCI, provide evidence-based recommendations for patient care, and outline directions for future research. Ultimately, by refining diagnostic and therapeutic strategies, we aimed to reduce CCI-related mortality and improve long-term prognoses for affected patients.

Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.

Left ventricular thrombosis: new perspectives on an old problem

Left ventricular thrombosis (LVT) is a major risk factor for systemic thromboembolism and might complicate both the acute and the chronic phase of ischaemic heart disease after myocardial infarction and, less frequently, non-ischaemic cardiomyopathies. The pathophysiology of thrombus formation is complex and involves the three aspects of Virchow's triad: blood stasis, prothrombotic state, and tissue injury. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. Of note, anticoagulation therapy with heparin and vitamin K antagonists decreases the risk of embolic stroke though exposing patients to an undeniable risk of bleeding complications. Although limited data on the off-label use of direct oral anticoagulants have reported safety and efficacy for LVT resolution, yet more evidence is needed to justify their use in clinical practice.

Incidence, diagnostic methods, and evolution of left ventricular thrombus in patients with anterior myocardial infarction and low left ventricular ejection fraction: a prospective multicenter study

BACKGROUND AND OBJECTIVES

We aimed to assess the incidence and evolution of left ventricular (LV) thrombi in a high-risk population of patients with LV systolic dysfunction after anterior myocardial infarction (ant-MI). We also compared the accuracy of transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging with contrast-delayed enhancement (CMR-DE) in detecting LV thrombi.

METHODS

We prospectively included 100 consecutive patients with LV ejection fraction (LVEF) <45% at the first TTE performed <7 days after ant-MI. A second evaluation with TTE and CMR-DE (by blinded examiners) was performed at 30 days. A third TTE and assessment of clinical status were performed between 6 and 12 months after ant-MI.

RESULTS

Patients (males 71%; mean age 59.1 ± 12.1 years; mean LVEF 33.5% ± 6.0%) were included at a median of 5.5 days (interquartile range 25th-75th percentile 4.25-6.0 days) after ant-MI. Thrombi were detected among 26 (26%) patients at a median of 12.0 days after ant-MI (7 patients at 1-7 days after MI; 15 at 8-30 days; and 4 after day 30). Sensitivity and specificity for LV thrombi detection were 94.7% and 98.5%, respectively, for TTE as compared with CMR-DE. Most thrombi (n = 24; 92.3%) disappeared after triple antithrombotic therapy (vitamin K antagonist in addition to dual antiplatelet therapy).

CONCLUSION

Left ventricular thrombus is a frequent complication after ant-MI with systolic dysfunction. When a search for thrombus is prespecified, the accuracy of TTE is high as compared with CMR-DE. The best antithrombotic strategy is not known.

Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era

BACKGROUND

Rapid reperfusion has been shown to decrease mortality and improve left ventricular (LV) function. Previous studies have reported that LV thrombus (LVT) is a major complication of ST-segment elevation acute anterior wall myocardial infarction (AMI). There are little data on LVT in the current primary percutaneous coronary intervention (PPCI) era. We sought to demonstrate the incidence of LVT after AMI in patients treated with PPCI compared with those treated with thrombolysis or with conservative management.

METHODS

In a 6-year period, 642 patients with anterior wall AMI and echocardiography were treated with PPCI (n = 297), thrombolysis (n = 128), or conservative treatment (n = 217). Left ventricular thrombus was defined as an echodense mass adjacent to an abnormally contracting myocardial segment.

RESULTS

The rate of LVT among anterior wall AMI was 6.2%. Predictors for LVT were reduced ejection fraction (adjusted relative risk 0.71, 95% CI 0.52-0.96) and severe mitral regurgitation (adjusted relative risk 2.48, 95% CI 1.0-6.44). There was no statistical difference in LVT rate according to treatment: 21 (7.1%) of 297 patients in the PPCI group, 10 (7.8%) of 128 patients in the thrombolytic group, and 9 (4.1%) of 217 patients in the conservative group (P = .28). Those in the thrombolytic group were characterized by shorter duration from symptom onset and were generally also treated with heparin/low-molecular weight heparin.

CONCLUSIONS

This is the largest report to evaluate the incidence of LVT formation after AMI. In the current era of rapid reperfusion by PPCI, the rate of thrombus formation is similar to that reported in the past and not different than for patients currently treated conservatively or with thrombolysis.

Peak C-reactive protein concentration correlates with left ventricular thrombus formation diagnosed by contrast echocardiographic left ventricular opacification in patients with a first anterior acute myocardial infarction

BACKGROUND

Wall motion abnormality in the apical legion of the left ventricle (LV) with stagnant flow alone is not sufficient to identify patients at high risk for LV thrombus formation among those with first anterior acute myocardial infarction (AMI). The aim of this study was to identify the determinants of LV thrombus formation using contrast echocardiography.

METHODS AND RESULTS

In 75 patients with first anterior AMI, standard and contrast echocardiography was performed to detect LV thrombus. Although LV thrombus was found in 10 patients (13%) using standard echocardiography, it was found in 15 patients (20%) using contrast echocardiography. Apical stagnant flow was observed in 14 patients (93%) with LV thrombus. In addition, patients with LV thrombus had a higher peak C-reactive protein (CRP) concentration (18.2+/-4.3 vs 7.9+/-5.5 mg/dl, p<0.0001). In multivariate analysis, only peak CRP concentration was identified as an independent predictor of LV thrombus (p=0.02, odds ratio: 1.400, confidence interval: 1.040-1.884). The receiver-operating characteristics (ROC) analysis revealed the best cutoff value of a peak CRP concentration >10.7 mg/dl to identify patients with LV thrombus (sensivity 0.93, specificity 0.75, area under ROC curve 0.91).

CONCLUSIONS

The peak CRP concentration is a useful marker of patients with first anterior AMI who are at high risk for LV thrombus.

Incidence and Prevention of Ischemic Stroke following Myocardial Infarction: Review of Current Literature

Myocardial infarction is the leading cause of death today. With the fast progress in pharmacotherapy and revascularization technology, outcomes following a myocardial infarction have become very favorable. While most of the complications from a myocardial infarction can be adequately managed, thus leading to reduced mortality, stroke following a myocardial infarction remains a challenge even today, and can lead to potentially devastating complications. We discuss the incidence, pathophysiology, and management options of non-hemorrhagic stroke following a myocardial infarction.

Treatment of left ventricular thrombi with a low molecular weight heparin

BACKGROUND

Once a diagnosis of left ventricular thrombus has been established, the classical attitude consists in the administration of unfractionated heparin relayed by oral anticoagulation therapy. However, the use of unfractionated heparins in this indication was only assessed in an open, non-randomized study with no control group, including 23 patients. On the other hand, although low molecular weight heparins are routinely used in some departments, there are no studies available concerning these agents in this indication. The aim of this study was to evaluate the feasibility of low molecular weight heparin therapy in patients with left ventricular thrombi.

METHODS

The study was a prospective, non-randomized, open-label trial. All patients with a new left ventricular thrombus diagnosed between September 2000 and September 2003 received enoxaparine 100 IU/kg twice daily for a mean duration of 13 days. A relay treatment with fluindione was initiated on day 5. The left ventricular thrombus outcome was followed for 3 weeks by bi-weekly transthoracic echocardiography.

RESULTS

26 left ventricular thrombi were diagnosed over the 3-year study period: 19 in post-infarct patients with a history of anterior myocardial infarction and 7 in patients with dilated cardiomyopathy. The mean thrombus area decreased from 2.30+/-0.32 to 0.36+/-0.11 cm2 (p<0.0001). Nineteen thrombi out of twenty-six (73%) disappeared during the treatment period. No thrombocytopenia or hemorrhagic events were observed. One transient ischemic attack was reported.

CONCLUSION

This preliminary study suggests that low molecular weight heparins are well tolerated and efficient in terms of left ventricular thrombi disappearance or size reduction.

Prevalence of early left ventricular thrombus after primary coronary intervention for acute myocardial infarction

The prevalence of left ventricular (LV) thrombus after acute myocardial infarction (AMI) has been reported high at 20-60%. Current reperfusion therapies such as thrombolysis have shown a trend toward reducing the incidence of LV thrombosis. However, the prevalence of LV thrombus after primary percutaneous coronary intervention (PCI) for AMI has not been systematically studied. At Massachusetts General Hospital 71 consecutive patients who underwent primary PCI for acute ST elevation MI were reviewed for the prevalence of LV thrombus evaluated by echocardiography. Echocardiography was performed within 5 days of infarction. PCI was successful in all patients. The time delay from symptom onset to intervention was 191 minutes. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved in more than 80% of cases. Only 3 patients (4%) had echocardiographic evidence of LV thrombus. All 3 patients had anterior infarctions. The incidence among patients with anterior MI was 10% (3 of 30 patients). The prevalence of LV thrombus in patients treated with primary PCI for AMI is low (4%).

Role of echocardiography in systemic arterial embolism. A review with recommendations

The ability of echocardiography to diagnose sources of embolism and the role of the examination in the prediction of thromboembolism are reviewed. In addition, the yield of transthoracic (TTE) and transoesophageal echocardiography (TEE) is analysed in patients with suspected embolism and guidelines are proposed for performing echocardiography in this setting. In general, echocardiography is reliable for diagnosing sources of embolism and this applies in particular to TEE in the case of atrial, valvular, and aortic abnormalities. However, the method is useful for predicting embolism in a few cases only. There is a substantial risk in the event of mobile or protruding thrombi, but screening for these and other markers of thromboembolism seems to be unproductive in most groups of risk patients. Yet, in the presence of atrial fibrillation, echocardiography may be helpful in defining patients with an otherwise normal heart and low risk of embolism--and in defining the relatively rare patient with a clinically low-risk profile but moderate-to-severe left ventricular systolic dysfunction and a high risk of embolism. TEE-guided conversion of atrial fibrillation without weeks of preceding anticoagulation may prove useful, after further investigation. The risk of embolism in relation to the size and mobility of valvular vegetations has remained controversial. In patients with suspected recent embolism, TTE results in less than 5% new therapeutic consequences. In those with a normal TTE, the yield of TEE seems to be equally low. We therefore recommend a selective strategy: TTE and TEE can be omitted when a cardiac source of embolism appears from the clinical setting and in most patients with an obvious predisposition to cerebrovascular disease. However, in the latter cases TTE should be performed if indicated by the clinical situation, e.g. in the presence of fever and murmur. TTE is also recommended when there are no obvious markers of primary vascular disease. To preclude very rare sources of embolism (e.g. atrial thrombi despite sinus rhythm), supplementary TEE is recommended in younger patients in whom primary vascular disease is very unlikely. The diagnosis by TEE of common conditions such as atrial septal aneurysms and patent foramen ovale cannot, however, be taken as proof of the mechanism of a systemic arterial occlusive event; thus it is difficult to change therapy on the basis of such diagnoses.

Ischemic cerebral infarction after rt-PA and heparin therapy for acute myocardial infarction. The TIMI-II pilot and randomized clinical trial combined experience

BACKGROUND AND PURPOSE

Ischemic cerebral infarction (CI) is a serious complication of acute myocardial infarction (MI). Little information exists on CI after thrombolytic therapy for MI.

METHODS

Of 3924 MI patients treated with recombinant tissue plasminogen activator (rt-PA) and heparin, 29 (0.7%) developed CI after treatment. All CI patients had detailed neurological evaluations, and 27 (93%) had CT scans centrally reviewed.

RESULTS

Age range was 40 to 74 years (mean, 60 years); 25 patients (86%) were men, and 22 (76%) were white. The electrocardiographic location of MI was anterior in 22 (76%) and nonanterior in 7 (24%). Five CIs occurred within 6 hours, 4 between 6 to 24 hours, 8 during the remainder of the first week, 10 during the second week, and 2 others distributed over the 4 weeks after study entry. Six of 29 CIs did not involve the cerebral cortex; 9 patients (31%) had multiple CIs. Of 28 CIs thought to be embolic in origin, 17 showed strong evidence for at least one cardiac abnormality (mural clot, wall-motion abnormality, aneurysm, or atrial fibrillation) known to be associated more specifically with embolism than MI. Eight of 27 CIs (30%) with CT scans had hemorrhagic transformation of varying degrees; 5 were symptomatic.

CONCLUSIONS

The time of occurrence and sites of CI after rt-PA and heparin therapy for acute MI are similar to those reported during the prethrombolytic era.

Left ventricular thrombosis after anterior myocardial infarction with and without thrombolytic treatment

OBJECTIVES

To examine the incidence of left ventricular thrombus in patients with anterior myocardial infarction, with and without streptokinase treatment. To identify predictors of thrombus development.

DESIGN

Consecutive patients prospectively studied during the hospitalized period. Echocardiography was performed within 3 days of admission and before discharge.

SETTING

Umeå University Hospital, a teaching hospital in Northern Sweden.

SUBJECTS

Ninety-nine patients with anterior myocardial infarction of whom 74 were treated with streptokinase.

MAIN OUTCOME MEASURES

Left ventricular thrombus and left ventricular segmental myocardial function.

RESULTS

During the hospital stay, a thrombus developed in 46% (95% confidence interval [CI], 35-57%) of the patients in the thrombolysis group and in 40% (95% CI, 21-59%) of the patients in the non-thrombolysis group. No difference in left ventricular segmental myocardial function was found between the thrombolysis and non-thrombolysis groups at hospital discharge. No embolic events were observed. The occurrence of a left ventricular thrombus at hospital discharge was significantly associated with previous myocardial infarction, peak enzyme levels, left ventricular global and segmental dysfunction and an increased dose of peroral diuretics or use of parenteral diuretics. In a multiple logistic regression model, left ventricular segmental dysfunction was the most important predictor of left ventricular thrombus.

CONCLUSION

Thrombolytic treatment with streptokinase does not prevent the development of a left ventricular thrombus but the risk of embolic complications is low. The left ventricular segmental myocardial score can be used to assess the risk of thrombus development, also, after thrombolysis.

Improved echocardiographic detection and characterization of left ventricular apical thrombi with a 5.0 MHz short-focus transducer

Transthoracic echocardiography is a frequently used technique for detecting ventricular thrombi. This study compares the usefulness of a 5.0 MHz short focal length transducer (5-short) with standard frequency (2.5 or 3.5 MHz) transducers for the detection of left ventricular thrombi. In addition, the effect of body habitus on study quality was evaluated. A consecutive series of 101 patients sent for echocardiographic imaging with the diagnosis of myocardial infarction, dilated cardiomyopathy, or recent suspected embolic event were imaged in the apical four-chamber, apical long-axis, and apical two-chamber views with a standard transducer and also with the 5-short. Out of this group, 16 apical thrombi were identified, six with the 5-short only, three with standard transducers only, and seven by both techniques. The areas of the seven thrombi detected by both transducers were consistently larger when measured on 5-short images compared with standard transducer images (4.6 +/- 2.3 vs 3.7 +/- 2.3 cm2, p = 0.02). In the three studies positive only with the standard transducers, the 5-short demonstrated only prominent trabeculae but no thrombus. The studies positive only with the 5-short had significantly smaller calculated thrombi areas than those visualized by the standard transducers (1.6 +/- 1.2 vs 4.2 +/- 2.1 cm2, p = 0.02). No thrombus was detected by either technique in a normally contracting left ventricular apex. There were significantly fewer studies having near-field artifact when performed by the 5-short compared with those performed with standard transducers (14/101 vs 40/101, p = 0.00004).(ABSTRACT TRUNCATED AT 250 WORDS)

Ischemic stroke and intracranial hemorrhage following thrombolytic therapy for acute myocardial infarction: a risk-benefit analysis

Stroke is a potentially serious complication of acute myocardial infarction (AMI). In the prethrombolytic era, most strokes were attributed to cerebral embolism. On the basis of available information, the occurrence of stroke in the thrombolytic era appears to be less than in the prethrombolytic era. In the thrombolytic era, the occurrence of various forms of intracranial hemorrhage has increasingly been documented in addition to cerebral embolism, with intriguing features. In general, however, the delineation of specific stroke subtypes has been imprecise and must take into account factors that are unique to this setting. Age is a risk factor for both ischemic and hemorrhagic stroke. Potential risk factors for intracranial hemorrhage include hypertension, dosage of fibrinolytic agents, and prior neurologic disease. Potential causes of intracranial hemorrhage include combined fibrinolytic/adjunctive therapies, various cerebrovascular lesions, and head trauma. Existing data suggest that mortality related to stroke complicating AMI is on the decline as well. More research is needed in order to quantify precisely the occurrence and proportions of stroke subtypes, risk factors, and causes in order to define mechanisms and preventive measures.