Controversy: Using ReoPro with thrombolytics
When a 46-year-old man presents to the ED with chest pain, the initial electrocardiogram (ECG) shows a ST-segment elevation in the inferior leads. After the ED physician consults with the cardiologist, a decision is made to transfer the patient to another facility for definitive cardiac catheterization.
Because it’s estimated that 90 minutes would pass before the procedure is started, combination therapy (ReoPro and half-dose of Retavase) is given to the patient in the ED prior to transfer. By the time the patient arrives at the catheterization lab, the chest pain has decreased, ST-segment elevation has decreased, and the patient is hemodynamically stable.
The patient successfully underwent angioplasty and stenting of the right coronary artery, was transferred to the cardiac step-down unit, and was discharged home the following day without complications.
The above scenario illustrates recently changed practice, which includes the use of IIb/IIIa inhibitors in combination therapy with half-dose thrombolytics in the acute myocardial infarction (AMI) patient, says Janet Williams, RN, MSN, CCRN, clinical trials nurse coordinator for the department of emergency medicine at the University of Cincinnati.
ReoPro, which is manufactured by Eli Lilly & Co. in Indianapolis, is being used as part of the AMI protocol at four EDs affiliated with the Health Alliance of Greater Cincinnati: the University Hospital, the Christ Hospital, the Jewish Hospital, and Fort Hamilton Hospital. The study combines two blood-thinning drugs to provide the fastest treatment for heart attack victims. (See box, below, to learn what the AMI protocol includes.)
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Here are steps of AMI protocol Here is what the acute myocardial infarction (AMI) protocol for use of ReoPro (Eli Lilly & Co., Indianapolis) at four EDs affiliated with the Health Alliance of Greater Cincinnati includes:
Source: Lindner Clinical Trial Center, Cincinnati. |
An indication for combo therapy
Williams offers the following indication for combination therapy: The patient who presents to an ED with an AMI, and there is a delay in transferring this patient to the catheterization laboratory for primary angioplasty and stenting. Delay may be due to one of the following factors:
- definitive care transfer time from one facility to another;
- during the day when the catheterization team is busy finishing up other cases;
- on nights and weekends when the patient needs to remain in the ED until the on-call catheterization team arrives.
"This combination is controversial because of the view that primary angioplasty remains the gold standard for care of these patients," she explains. Combination therapy may be warranted when there will be a time delay in transportation to the catheterization lab for primary angioplasty and stenting, says Williams.
This patient will benefit from receiving thrombolytics until transfer to the cardiac catheterization laboratory can occur, she says. "The dosing of thrombolytics in combination therapy’ is decreased in half," Williams explains. "This half dose benefits the patient because the decrease in dose decreases the potential side effects that could occur following thrombolytic infusion."
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