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New developments in thrombolytic therapy
1Center for Thrombosis and Vascular Research, University of Leuven, Belgium.
Insights
Thrombolytic agents like streptokinase and recombinant tissue-type plasminogen activator (rt-PA) treat cardiovascular disease by dissolving blood clots. While rt-PA is more effective, both have similar side effects, and further trials are needed to confirm mortality benefits.
Area of Science:
- Cardiovascular Medicine
- Hematology
- Pharmacology
Background:
- Thrombotic cardiovascular diseases are a leading cause of death and disability.
- Thrombolytic agents activate plasminogen to plasmin, dissolving fibrin clots.
- Plasmin can degrade hemostatic components, increasing bleeding risk.
Purpose of the Study:
- To review current thrombolytic agents for acute myocardial infarction.
- To compare the efficacy and safety of different thrombolytic therapies.
- To assess the potential role of thrombolysis in routine cardiovascular care.
Main Methods:
- Review of clinical studies on thrombolytic agents.
- Comparison of efficacy, fibrin-specificity, and side effect profiles.
- Analysis of cost-effectiveness and clinical outcomes.
Main Results:
- Recombinant tissue-type plasminogen activator (rt-PA) is more effective and fibrin-specific than streptokinase.
- Streptokinase recanalizes 40-45% of coronary arteries, reducing mortality by 25%.
- rt-PA achieves 65-70% reperfusion but at a higher cost; side effects are similar.
Conclusions:
- Thrombolytic therapy is likely to become routine for acute myocardial infarction.
- rt-PA offers higher efficacy, but cost-effectiveness and mortality benefits require further study.
- Both streptokinase and rt-PA are available for clinical use.
Abstract:
Thrombotic complications of cardiovascular disease are a main cause of death and disability and, consequently, thrombolysis could favorably influence the outcome of such life-threatening diseases as myocardial infarction, cerebrovascular thrombosis and venous thromboembolism. Thrombolytic agents are plasminogen activators that convert plasminogen, the inactive proenzyme of the fibrinolytic system in blood, to the proteolytic enzyme plasmin. Plasmin dissolves the fibrin of a blood clot, but may also degrade normal components of the hemostatic system and predispose to bleeding. Currently, five thrombolytic agents are either approved for clinical use or under clinical investigation in patients with acute myocardial infarction. These include streptokinase, urokinase, recombinant tissue-type plasminogen activator (rt-PA), anisoylated plasminogen streptokinase activator complex (APSAC) and single chain urokinase-type plasminogen activator (scu-PA, prourokinase). The first generation thrombolytic agents, streptokinase (and probably also urokinase), are only moderately efficacious and their administration is associated with extensive systemic fibrinogen breakdown. In comparative studies performed in patients with acute myocardial infarction, recombinant tissue-type plasminogen activator (rt-PA) is a more effective and fibrin-specific thrombolytic agent than streptokinase. The acylated plasminogen streptokinase activator complex (APSAC) has a profile of thrombolytic efficacy and fibrin-specificity that is similar or somewhat better than that of streptokinase, but has the advantage that it can be administered by bolus injection. Single chain urokinase-type plasminogen activator is more fibrin-specific than urokinase. Comparative data on the efficacy and safety of this agent are limited as it is in the early stage of clinical investigation. Reduction of infarct size, preservation of ventricular function and/or reduction in mortality has been observed with streptokinase, rt-PA and APSAC. Therefore, thrombolytic therapy will probably become routine therapy for early acute myocardial infarction. In patients with acute myocardial infarction, intravenous streptokinase recanalizes 40-45 percent of occluded coronary arteries and reduces mortality by 25 percent; it costs approximately $200 for a therapeutic dose of 1,500,000 units. Recombinant tissue-type plasminogen activator (rt-PA) is more potent for coronary arterial thrombolysis, producing both more rapid and more frequent (65-70 percent) reperfusion, but it costs over $1,000 for a therapeutic dose of 100 mg. Side effects (mainly bleeding) and the incidence of reocclusion associated with the use of streptokinase and rt-PA are not markedly different. Whether the higher efficacy of rt-PA will translate into a comparably larger reduction of mortality remains to be determined in large comparative clinical trials. Both agents are available for clinical use.(ABSTRACT TRUNCATED AT 400 WORDS)