I think Jonathan's analysis is superb. However I do have one question for
the bright MRCPers on the List! I've never understood the logic underpinning
the premise that coagulopathy is a contra-indication to thrombolysis - it
just doesn't make sense to me. Fibrinolytics disrupt the final common
pathway of the coagulation sequence, and do so to a fairly impressive
degree. It shouldn't make a difference then if there exists a problem higher
up the sequence (which is usually a subclinical problem) or even if there
exists a problem at the same part of the cascade. In other words, if you've
got a dodgy blood vessel in your GI tract or your brain, it's gonna blow
anyway following thrombolysis, regardless of the presence or otherwise of a
pre-existing coagulopathy. And conversely if your blood vessels are sound,
they'll remain intact despite thrombolysis on top of a pre-existing
coagulopathy, won't they? Perhaps this simply represents yet more of the
"just to be on the safe side" attitude so ubiquitous in medicine these days.
Can anyone shed some light?
Perhaps John should have asked; what would you do if your v-W patient was 45
years old, otherwise healthy, and presented with a large anterior MI?
Adrian Fogarty
----- Original Message -----
From: "Jonathan Benger"
> So, for what it's worth, I probably wouldn't thrombolyse this lady, all
> other things being equal.
>
> The number needed to treat in inferor MI is a staggering 120,(1) and this
> data is based on several large clinical trials of thrombolysis which tend
to
> recruit younger men with minimal or no co-morbidity. The risk of
> intracerebral haemorrhage is increased by advancing age, female sex,
> hypertension, low body weight (an arguement for reducing the dose of
> thrombolysis), previous anticoagulation and a history of cerebrovascular
> disease(2), so this patient appears to have a risk considerably in excess
of
> that reported in the clinical trials. This, coupled with observational
> evidence in real patient populations that thrombolytic therapy may not
yield
> the expected benefits in patients older than 75 years, and may even be
> harmful,(3) would make me very cautious.
>
> As in all cases I would make a final decision based on a range of factors
> and in consultation with the patient wherever possible. It's one thing to
> know what the evidence is, but much more important to know how this
applies
> to the patient in front of you.(4) Perhaps urgent angioplasty would
provide
> the benefits of early reperfusion with less risk?
>
> Jonathan Benger.
> SpR, Bristol.
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