Of 57 patients with acute myocardial infarction (AMI) treated with rt-PA, we observed 2 major bleeding complications, both in patients who had been treated with anti-inflammatory drugs prior to admission. The thrombolytic protocol included: lOmg rt-PA in bolus and continuous infusion of 110 mg over 6 hr 5,000 iu heparin in bolus and continuous infusion of 25,000 iu/ 24hr, and aspirin 250 mg/24hr. The first patient, a 64 year old woman had been taking indomethacin 25 mg × 3 daily, during 3 weeks prior to the AMI. Rt-PA protocol was initiated with relief of chest pain and disappearance of ST elevation, but at 2 hr rt, sciatic pain developed. Treatment was continued accor ding to protocol in spite of the pain, but on the 3rd day hemoglobin decreased to 7.8%. Abdominal CT scan disclosed retroperitoneal hemorrhage. All anticoagulant medications were stopped, and 4 units of blood were transfused. The retro-peritoneal mass dissolved gradually. The second patient, a 68 year old male was treated by diclofenac 100 mg for 5 days prior to admission for AMI, and consequently aspirin was removed from the rt-PA protocol. However, 2 hr after completion of the 6 hr rt-PA infusion, gross hematuria and a “coffee ground” vomiting developed. Heparin infusion was discontinued and antacid treatment initiated, resulting in cessation of bleeding within a few hrs. In both patients the anticipated prolongation of APTT (heparin) and about 30% decrease in fibrinogen level were observed as the sole abnormality, and thus we related the bleeding episodes to the anti-aggregating effect of indomethacin and diclofenac respectively. We suggest that the use of anti-inflammatory drugs prior to administration of rt-PA protocol can be hazardous, and that special prudence (possibly protocol modification) is warranted.
Use of nonsteroidal anti-inflammatory drugs and the risk of first-time acute myocardial infarction