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Current issues concerning thrombolytic therapy for acute myocardial infarction
C H Hennekens1, C J O'Donnell, P M Ridker
1Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
Insights
Thrombolytic agents and aspirin significantly reduce mortality in acute myocardial infarction. Early and widespread use of these treatments, especially streptokinase, saves lives and has fewer side effects like stroke.
Area of Science:
- Cardiology
- Emergency Medicine
- Pharmacology
Background:
- Acute myocardial infarction (AMI) treatment relies on reperfusion strategies.
- Thrombolytic agents are crucial for restoring blood flow in AMI.
- Comparative data on different thrombolytics and adjunct therapies are essential.
Purpose of the Study:
- To compare the risks and benefits of thrombolytic agents in acute myocardial infarction.
- To interpret findings from major randomized trials like GISSI-2, ISIS-3, and GUSTO-1.
- To clarify the efficacy and safety profiles of tissue-type plasminogen activator (t-PA), streptokinase, and APSAC.
Main Methods:
- Analysis of data from three large-scale randomized trials (GISSI-2, ISIS-3, GUSTO-1).
- Direct comparison of thrombolytic agents and aspirin in patients with acute myocardial infarction.
- Evaluation of mortality rates, stroke incidence, and cerebral hemorrhages.
Main Results:
- Thrombolytic agents (t-PA, streptokinase, APSAC) reduce mortality in AMI.
- Thrombolytic therapy within 12 hours reduces mortality by ~20%; aspirin within 24 hours reduces it by ~23%.
- Streptokinase shows significantly fewer strokes and cerebral hemorrhages compared to t-PA or APSAC.
Conclusions:
- Early and widespread use of thrombolytic therapy and aspirin can save numerous lives.
- Streptokinase appears safer regarding cerebrovascular events than t-PA or APSAC.
- The mortality benefit of accelerated t-PA remains less conclusive compared to its safety profile.
Abstract:
Data are now available from three large-scale randomized trials that directly compare the risks and benefits of thrombolytic agents in acute myocardial infarction. In the interpretation of results from the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2) trial and its International Extension, the Third International Study of Infarct Survival (ISIS-3), and the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, there are areas of both agreement and controversy. It is generally agreed that the agents most commonly used in the United States--tissue-type plasminogen activator (t-PA), streptokinase and anisoylated plasminogen streptokinase activator complex (APSAC)--all reduce mortality when given to patients with acute evolving myocardial infarction. Further, it is clear that thrombolytic therapy given to such patients presenting up to 12 h after onset of symptoms reduces the mortality rate by approximately 20%, that aspirin therapy for patients presenting up to 24 h reduces the mortality rate by approximately 23% and that the benefits of thrombolytic therapy and aspirin are additive. Finally, and of most importance, the earlier administration as well as the more widespread use of thrombolytic therapy and aspirin would save many more lives. The totality of evidence clearly indicates that streptokinase produces significantly fewer strokes and cerebral hemorrhages than either t-PA or APSAC. Whether or not accelerated t-PA has a small advantage for mortality is less conclusive.(ABSTRACT TRUNCATED AT 250 WORDS)