Thrombolytic therapy for acute myocardial infarction: what dose should be used?

Most of the concern about dosing of t-PA as presented in the literature is related to the lower weight groups and the increased incidence of bleeding in this patient population. Not much is known or written about what doses of t-PA should be used in the grossly obese patient with an MI. In the patient described briefly at the beginning of this editorial, the usual accelerated dose regimen was used. Although the patient's symptoms resolved quickly, ST-segment elevation never returned to baseline. Creatine kinase-MB and troponin I rose and fell slowly. He had an uneventful course in the hospital but my impression is that he did not reperfuse his myocardium. Unfortunately, because of his weight, we were unable to evaluate this patient with either coronary angiography or echocardiography. As I think more about this case, I am of the opinion that the patient was underdosed with 100 mg of t-PA. If I had it to do over again, I would use a higher dose of t-PA. I would be interested to hear how others would have treated the patient.