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Despite early treatment with thrombolytic agents for acute myocardial infarction, a significant portion of patients fail to achieve a patent infarct artery. To study the various factors related to achieving patency in the infarct vessel, 201 patients who received streptokinase within six hours of symptoms were studied. All patients underwent cardiac catheterization during the same hospitalization at 5.40 +/- 3.26 days after admission. Forty-five (22.4%) patients were found to have an occluded infarct artery (group 1) and 156 (77.6%) had a patent infarct vessel (group 2). There was no difference in the time from onset of symptoms to receiving streptokinase between the two groups. The two groups were similar to each other with regard to age, gender, history of myocardial infarction or angina, and major risk factors for coronary disease. Coagulation parameters before and after streptokinase therapy, reflecting the lytic state, were similar in both groups. The left ventricular end diastolic pressure was significantly higher and the left ventricular ejection fraction was significantly lower in group 1 than in group 2. These observations suggest that despite early initiation of thrombolytic therapy in patients with acute myocardial infarction, a significant portion of patients fail to achieve a patent infarct artery. This failure cannot be explained by the observed clinical parameters or the lytic state after streptokinase.

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The data registry of all patients admitted between 1982 and 1990 to the Coronary Care Unit at Hamad General Hospital with the diagnosis of documented acute myocardial infarction is reviewed. We report a total of 2,515 patients (86.6% men and 13.4% women) with a mean age of 51 years (range 18-99). Of these, 62% were smokers, 29% had diabetes, and 20% had hypertension. The hospital mortality rate was 10%. The most significant factors associated with higher mortality were older age, female gender, and anteroseptal infarction. The age of 23% of the patients was 40 years or younger. Comparison between these younger patients (Group I) and those over 40 years (Group II) demonstrated that Group I had lower mortality (3.6%) than Group II (12%) (p < 0.001). Group I patients were predominantly men (96.8%), of Asian nationalities (71%), and usually smokers (78%). The observation that myocardial infarction occurs frequently in young Asian men needs further evaluation to identify specific risk factors.

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There are differences in the risk factor profile and coronary anatomy of young patients who develop coronary artery disease compared with those of older ones. There is an absence of data in published reports regarding the response to thrombolytic therapy and the outcome of acute myocardial infarction in young patients. Sixty-two patients aged < 35 years (group 1) were compared with 58 aged > 55 years (group 2) who presented with acute myocardial infarction and were treated with intravenous streptokinase. Group 1 had a significantly higher incidence of smoking (p = 0.0009) and a lower incidence of diabetes mellitus (p = 0.002) than did group 2. Fifty-eight patients in group 1 and 40 in group 2 were studied by angiography at a similar time (5 to 6 days) after admission. Patients in group 1 had a better left ventricular ejection fraction (55 +/- 13% vs 49 +/- 13%; p = 0.03), but similar patency rates of the infarct vessel (74 vs 73%) compared with those of group 2. Group 1 also had a higher incidence of insignificant disease (22.5 vs 2.5%; p = 0.008) and a lower incidence of 3-vessel disease (10 vs 37.5%; p = 0.004). This suggests that there are differences in the risk factor profiles and coronary anatomy of young patients compared with those of older ones. Despite similar benefits from thrombolytic therapy in the form of a patient infarct vessel, there may be differences in the long-term outcome among these patients.

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The authors reviewed their experience with 245 patients who were treated with intravenous streptokinase for acute myocardial infarction at an average time of less than three hours from the onset of chest pain. Of these, 148 patients were from the Indian subcontinent (Group 1) and the remaining (Group 2) were predominantly from an Arabic background. Group 1 patients were younger and had lower serum cholesterol and fibrinogen levels than the Group 2 patients. Group 1 patients had a lower incidence of previous myocardial infarction (p = 0.0006) and antecedent angina pectoris (p = 0.017). A patency rate of 77.5% was seen in all patients studied at 5.37 +/- 2.96 days after admission and was similar in both the groups. Group 1 patients had a lesser extent of coronary artery disease (p = 0.01) manifested as a higher incidence of single-vessel disease (p = 0.06) and a lower incidence (p = 0.06) of three-vessel obstruction. The overall mortality for the initial hospitalization was 2.18% and showed no difference between the two groups. Patients from the Indian subcontinent presenting with acute myocardial infarction appear to be a unique population in that they are younger, have a somewhat lower cardiac risk profile, and have less extensive coronary artery disease than their Arabic counterparts.

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The clinical features of patients treated with streptokinase for chest pain and anterior ST-segment elevation who subsequently develop non-Q-wave infarction are unknown. Of the 75 consecutive patients who initially presented with chest pain and ST-segment elevation in the anterior leads (V1-V6, I, aVL) and were treated with intravenous streptokinase (time from symptoms to treatment averaged less than 3 hours), 32 (43%) developed a non-Q-wave and 43 (57%) a Q-wave myocardial infarction. Twenty seven of 32 patients (84%) from the non-Q-wave group and 39 of 43 (91%) from the Q-wave group were studied by angiography at 5.16 +/- 2.88 days after the onset of myocardial infarction. Left ventricular end-diastolic pressure was 13 +/- 6 vs 20 +/- 7 mm Hg (p less than 0.001), left ventricular ejection fraction was 60 +/- 8 vs 49 +/- 14% (p less than 0.001) and the infarct vessel patency rate was 85 vs 72% (p = 0.44) in patients with a non-Q versus a Q-wave infarction, respectively. In summary, when patients presenting with chest pain and ST-segment elevation are treated with streptokinase, a significant portion of these symptoms will evolve into a non-Q-wave infarction. Patients with a non-Q-wave infarction will have a better preserved left ventricular function than patients who develop a Q-wave infarction. This suggests the need for equal distribution of such patients in randomized trials of thrombolytic therapy for acute myocardial infarction to avoid misinterpreting data between groups.

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