Acute myocardial infarction following intravenous tissue plasminogen activator for acute ischemic stroke: An unknown danger

Abstract

Thrombolysis with intravenous tissue (IV) plasminogen activator (tPA) is considered for patients with acute ischemic stroke falling within the described inclusion criteria defined by The National Institute of Neurological Disorders and Stroke (NINDS) rtPA trial. Complications of IV thrombolysis with tPA are commonly related to hemorrhage, anaphylaxis, or arterial occlusion. We describe two cases of acute myocardial infarction (MI) following IV tPA infusion for acute stroke. One of the patients had underlying ischemic heart disease (IHD) while the other did not have any prior IHD. Both had presented with acute ischemic stroke within the window period of thrombolysis and had no contraindications for thrombolysis. Both the patients succumbed due to myocardial infarction and cardiovascular collapse due to new onset arrhythmias. Acute MI immediately following IV tPA for stroke is a rare but serious complication. The disruption of intracardiac thrombus and subsequent embolization to coronary arteries may be an important mechanism in the occurrence of MI after administration of tPA for acute ischemic stroke. As both the patients succumbed before the arrangement for coronary angiography, the demonstration of intracardiac or intracoronary thrombus was not possible. But clinically, the presence of chest pain with elevated troponin levels and ST segment elevation pointed to MI. We suspect that fragmentation and lysis of intracardiac thrombus may result in MI after use of tPA for acute ischemic stroke, though the remote possibility of simultaneous occurrence of two atherosclerotic events MI and stroke exists.

Does intravenous administration of recombinant tissue plasminogen activator for ischemic stroke can cause inferior myocardial infarction?

“… 12 , 13 In fact rTPA can degrade the clot to small fragments with subsequent embolization to coronary arteries leading to MI. 9 …”

“… 8 Several conditions such as aortic dissection, large vessel arteritis and endocarditis can induce myocardial infarction and ischemic stroke, simultaneously. 9 , 10 In addition, some drugs like amphetamines and cocaine may lead to concurrent occurrence of myocardial infarction and ischemic stroke. 11 …”

“…An indication of acute myocardial infarction after administration of rTPA for ischemic stroke is increasingly reported. 7 , 9 , 10 In this study, we described a patient with previous cardiovascular risk factors who was complicated with acute myocardial infarction following prescription of rTPA for an acute ischemic stroke.…”

Spontaneous coronary thrombosis following thrombolytic therapy for acute cardiovascular accident and stroke: a case study

“…Symptomatic events such as acute myocardial infarction (MI) after CVA rarely occur and are often the result of an underlying cardiac embolic source for both events such as a left ventricular thrombus. Patients treated with systemic thrombolysis for an acute CVA may be at risk for subsequent MI, perhaps due to disruption of an existing LV thrombus [4–6]. In this report, we present a case of an individual, without prior MI or LV thrombus, who developed spontaneous coronary thrombosis following tissue plasminogen activator (tPA) administration and discuss the mechanisms of MI following acute CVA.…”

ST-elevation myocardial infarction or neurogenic-stunned myocardium — Diagnostic and treatment dilemma following acute ischemic stroke

“…One of the patients did not have prior ischemic heart disease. The disruption of intracardiac thrombus and subsequent embolization to coronary arteries may be an important mechanism involved [9].…”