Thrombolytic agents: a clinician's perspective

Clinicians and researchers often have different perspectives: Clinicians deal with patients as individuals; researchers deal with them as members of groups whose characteristics can be defined statistically. Clinicians should be cautious and skeptical about new therapies, therefore, because the applicability of group-successful treatment to individual subjects is not always appropriate. In deciding whether to use the new thrombolytic therapy in acute myocardial infarction, clinicians should consider the factors that limit as well as those that support its use. As a clinician, I ultimately favor its use because intracoronary thrombosis is almost ubiquitous in acute infarction, and thrombolytic therapy addresses this basic problem. Fortunately, acute infarction is an evolutionary process, giving us time to take action. Since the extent of necrotic myocardium determines prognosis, and reperfusion can limit infarction size, salvaging myocardium should improve the outcome. Thrombolytic therapy can usually be administered quickly, easily, and safely. It requires minimal laboratory monitoring but careful clinical monitoring. Signs of successful therapy are easily recognized clinically, as are the signs of reocclusion if it occurs. The problem of the best treatment to follow thrombolytic therapy remains unsolved. But the thrombolytic component of overall management of a patient with acute myocardial infarction is worthwhile.