Acute myocardial infarction after intravenous thrombolysis for acute ischemic stroke: case series and systematic review

Background and objectives: Intravenous thrombolysis (IV–rtPA) has been suggested as a potential cause of myocardial infarction (MI) after acute ischemic stroke (AIS), with randomized clinical trials showing a higher number of cardiac events within the thrombolysis group. We assessed the prevalence and MI mechanisms after IV–rtPA for AIS. Methods: Retrospective review of consecutive AIS patients admitted to six stroke units and systematic literature review searching for AIS patients who suffered a MI less than 24 h after IV–rtPA. In those with available coronary angiography, MI etiology was defined as atherosclerotic or embolic. Patients’ characteristics were compared between groups. Results: Fifty-two patients were included. Thirty-two patients (61.5%) derived from hospital cases, after reviewing 6958 patients treated with IV–rtPA [0.5% (95% CI 0.38–0.54) of total hospital cases]. After coronary angiography (n = 25, 48.1%), 14 (54%) patients were considered to have an atherosclerotic MI, and 11 (46%) due to coronary embolism. Patients with an embolic MI more frequently had a cardioembolic AIS (72.7% vs 28.6%; p-value = 0.047) and an intracardiac thrombus (27.3% vs 0.0%; p-value = 0.044). Although not statistically significant, patients with an embolic MI had apparent lower time intervals between starting IV–rtPA infusion and MI occurrence [2 h (0.2–3.0) vs 3 h (1.0–15.0); p-value = 0.134]. Conclusions: MI within the first 24 h after IV–rtPA for AIS is an infrequent event, and more frequently non-embolic. However, the prevalence of embolic MI was superior to what is found in the general population with MI. There was an association between the pathophysiology of AIS and MI. The low number of events and publication bias may have limited our conclusions.