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. 1997 Jan;14(1):2–9. doi: 10.1136/emj.14.1.2

Thrombolysis after acute myocardial infarction.

P A Nee 1
PMCID: PMC1342833  PMID: 9023613

Abstract

Appropriate use of a thrombolytic agent may save 20 to 30 lives per 1000 treatments. Thrombolysis should be considered in all patients presenting with cardiac chest pain lasting more than 30 minutes for up to 12 hours after symptom onset. ECG criteria include ST elevation of at least 1 mm in limb leads and/or at least 2 mm in two or more adjacent chest leads or left bundle branch block. There is no upper age limit. All patients should also receive oral aspirin and subcutaneous (intravenous with rt-PA) heparin. Other adjuvant treatments have been reviewed previously in this journal. Streptokinase is the drug of choice except where there is persistent hypotension, previous streptokinase or APSAC at any time, known allergy to streptokinase, or a recent proven streptococcal infection. In these circumstances the patient should receive rt-PA. Additional indications for rt-PA, based on subset analysis by the GUSTO investigators, include patients with ALL of the following: age less than 75 years, presentation within four hours of symptom onset, and ECG evidence of anterior acute myocardial infarction. Treatment should be initiated as soon as possible. The greatest benefit is observed in patients treated early, pain to treat intervals of less than one hour make possible mortality reductions of nearly 50%. "When" matters more than "where": fast tracking to the CCU is one option but A&E initiated thrombolysis is feasible and timely. Prehospital thrombolysis is appropriate in certain geographical situations. The development of practical guidelines for thrombolysis represents the most comprehensive example of evidence based medicine. Streptokinase was first shown to influence outcome in acute myocardial infarction nearly 40 years ago. More recently alternative regimes have been evaluated in several prospective randomised controlled trials yielding pooled data on nearly 60,000 patients. However, systematic review of cumulative data reveals a statistically significant mortality gain for intravenous streptokinase over placebo which could have been identified as early as 1971-at least 15 years before it became generally used in clinical practice.

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Selected References

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  1. Birkhead J. S. Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London. BMJ. 1992 Aug 22;305(6851):445–448. doi: 10.1136/bmj.305.6851.445. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Braunwald E. Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction, and improved survival. Should the paradigm be expanded? Circulation. 1989 Feb;79(2):441–444. doi: 10.1161/01.cir.79.2.441. [DOI] [PubMed] [Google Scholar]
  3. Channer K. S. Deciding who should have thrombolysis. BMJ. 1993 Oct 30;307(6912):1146–1146. doi: 10.1136/bmj.307.6912.1146. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Chesebro J. H., Knatterud G., Roberts R., Borer J., Cohen L. S., Dalen J., Dodge H. T., Francis C. K., Hillis D., Ludbrook P. Thrombolysis in Myocardial Infarction (TIMI) Trial, Phase I: A comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987 Jul;76(1):142–154. doi: 10.1161/01.cir.76.1.142. [DOI] [PubMed] [Google Scholar]
  5. DeWood M. A., Spores J., Notske R., Mouser L. T., Burroughs R., Golden M. S., Lang H. T. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med. 1980 Oct 16;303(16):897–902. doi: 10.1056/NEJM198010163031601. [DOI] [PubMed] [Google Scholar]
  6. Eisenberg M. S. Reducing the door-to-drug interval for thrombolytic therapy. Acad Emerg Med. 1995 Jul;2(7):579–580. doi: 10.1111/j.1553-2712.1995.tb03592.x. [DOI] [PubMed] [Google Scholar]
  7. Elliott J. M., Cross D. B., Cederholm-Williams S. A., White H. D. Neutralizing antibodies to streptokinase four years after intravenous thrombolytic therapy. Am J Cardiol. 1993 Mar 15;71(8):640–645. doi: 10.1016/0002-9149(93)91003-z. [DOI] [PubMed] [Google Scholar]
  8. Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group. BMJ. 1992 Sep 5;305(6853):548–553. doi: 10.1136/bmj.305.6853.548. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Krumholz H. M., Pasternak R. C., Weinstein M. C., Friesinger G. C., Ridker P. M., Tosteson A. N., Goldman L. Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction. N Engl J Med. 1992 Jul 2;327(1):7–13. doi: 10.1056/NEJM199207023270102. [DOI] [PubMed] [Google Scholar]
  10. Lee K. L., Califf R. M., Simes J., Van de Werf F., Topol E. J. Holding GUSTO up to the light. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries. Ann Intern Med. 1994 May 15;120(10):876–885. doi: 10.7326/0003-4819-120-10-199405150-00009. [DOI] [PubMed] [Google Scholar]
  11. Maggioni A. P., Maseri A., Fresco C., Franzosi M. G., Mauri F., Santoro E., Tognoni G. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-2). N Engl J Med. 1993 Nov 11;329(20):1442–1448. doi: 10.1056/NEJM199311113292002. [DOI] [PubMed] [Google Scholar]
  12. Muller D. W., Topol E. J. Selection of patients with acute myocardial infarction for thrombolytic therapy. Ann Intern Med. 1990 Dec 15;113(12):949–960. doi: 10.7326/0003-4819-113-12-949. [DOI] [PubMed] [Google Scholar]
  13. Nee P. A., Gray A. J., Martin M. A. Audit of thrombolysis initiated in an accident and emergency department. Qual Health Care. 1994 Mar;3(1):29–33. doi: 10.1136/qshc.3.1.29. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. O'Donnell M. Battle of the clotbusters. BMJ. 1991 May 25;302(6787):1259–1261. doi: 10.1136/bmj.302.6787.1259. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Pell A. C., Miller H. C. Delays in admission of patients with acute myocardial infarction to coronary care: implications for thrombolysis. Health Bull (Edinb) 1990 Sep;48(5):225–231. [PubMed] [Google Scholar]
  17. Pell A. C., Miller H. C., Robertson C. E., Fox K. A. Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis. BMJ. 1992 Jan 11;304(6819):83–87. doi: 10.1136/bmj.304.6819.83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Rawles J. Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian Region Early Anistreplase Trial (GREAT). J Am Coll Cardiol. 1994 Jan;23(1):1–5. doi: 10.1016/0735-1097(94)90494-4. [DOI] [PubMed] [Google Scholar]
  19. Rentrop K. P., Blanke H., Karsch K. R., Wiegand V., Köstering H., Oster H., Leitz K. Acute myocardial infarction: intracoronary application of nitroglycerin and streptokinase. Clin Cardiol. 1979 Oct;2(5):354–363. doi: 10.1002/clc.4960020507. [DOI] [PubMed] [Google Scholar]
  20. Rijken D. C., Collen D. Purification and characterization of the plasminogen activator secreted by human melanoma cells in culture. J Biol Chem. 1981 Jul 10;256(13):7035–7041. [PubMed] [Google Scholar]
  21. Scholz K. H., Tebbe U., Herrmann C., Wojcik J., Lingen R., Chemnitius J. M., Brune S., Kreuzer H. Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction. Am J Cardiol. 1992 Mar 15;69(8):724–728. doi: 10.1016/0002-9149(92)90494-j. [DOI] [PubMed] [Google Scholar]
  22. Schröder R., Biamino G., von Leitner E. R., Linderer T., Brüggemann T., Heitz J., Vöhringer H. F., Wegscheider K. Intravenous short-term infusion of streptokinase in acute myocardial infarction. Circulation. 1983 Mar;67(3):536–548. doi: 10.1161/01.cir.67.3.536. [DOI] [PubMed] [Google Scholar]
  23. Sherry S. The origin of thrombolytic therapy. J Am Coll Cardiol. 1989 Oct;14(4):1085–1092. doi: 10.1016/0735-1097(89)90493-2. [DOI] [PubMed] [Google Scholar]
  24. Smith R. A., Dupe R. J., English P. D., Green J. Fibrinolysis with acyl-enzymes: a new approach to thrombolytic therapy. Nature. 1981 Apr 9;290(5806):505–508. doi: 10.1038/290505a0. [DOI] [PubMed] [Google Scholar]
  25. Tenaglia A. N., Califf R. M., Candela R. J., Kereiakes D. J., Berrios E., Young S. Y., Stack R. S., Topol E. J. Thrombolytic therapy in patients requiring cardiopulmonary resuscitation. Am J Cardiol. 1991 Oct 15;68(10):1015–1019. doi: 10.1016/0002-9149(91)90488-7. [DOI] [PubMed] [Google Scholar]
  26. Thornton J. G., Onwude J. L. Pre-eclampsia: discordance among identical twins. BMJ. 1991 Nov 16;303(6812):1241–1242. doi: 10.1136/bmj.303.6812.1241. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Vincent R. Advances in the early diagnosis and management of acute myocardial infarction. J Accid Emerg Med. 1996 Mar;13(2):74–79. doi: 10.1136/emj.13.2.74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Weaver W. D., Cerqueira M., Hallstrom A. P., Litwin P. E., Martin J. S., Kudenchuk P. J., Eisenberg M. Prehospital-initiated vs hospital-initiated thrombolytic therapy. The Myocardial Infarction Triage and Intervention Trial. JAMA. 1993 Sep 8;270(10):1211–1216. [PubMed] [Google Scholar]
  29. Weaver W. D., Eisenberg M. S., Martin J. S., Litwin P. E., Shaeffer S. M., Ho M. T., Kudenchuk P., Hallstrom A. P., Cerqueira M. D., Copass M. K. Myocardial Infarction Triage and Intervention Project--phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coll Cardiol. 1990 Apr;15(5):925–931. doi: 10.1016/0735-1097(90)90218-e. [DOI] [PubMed] [Google Scholar]
  30. Weston C. F., Avery P. Thrombolysis following pre-hospital cardiopulmonary resuscitation. Int J Cardiol. 1992 Nov;37(2):195–198. doi: 10.1016/0167-5273(92)90208-k. [DOI] [PubMed] [Google Scholar]
  31. Weston C. F., Penny W. J., Julian D. G. Guidelines for the early management of patients with myocardial infarction. British Heart Foundation Working Group. BMJ. 1994 Mar 19;308(6931):767–771. doi: 10.1136/bmj.308.6931.767. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Wilcox R. G., von der Lippe G., Olsson C. G., Jensen G., Skene A. M., Hampton J. R. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction. Anglo-Scandinavian Study of Early Thrombolysis (ASSET). Lancet. 1988 Sep 3;2(8610):525–530. doi: 10.1016/s0140-6736(88)92656-6. [DOI] [PubMed] [Google Scholar]

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