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November 1, 1999Journal of accident & emergency medicineOpen Access

Thrombolysis in acute myocardial infarction: analysis of studies comparing accelerated t-PA and streptokinase.

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Why the study?

Does accelerated t-PA reduce 30 day mortality compared to streptokinase in patients with acute myocardial infarction?

Population

64,387 patients with acute myocardial infarction from 4 prospective, randomised clinical trials.

Comparison

Accelerated infusion t-PA with concomitant use… vs Streptokinase 1.5 million units given over one…

Design

Meta-analysis

Follow-up

30 days

Authors

BSBM SmithBankstown Lidcombe Hospital

Discussion

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Implication

Does not support routine accelerated t-PA preference given stroke risk; leaves open net benefit after multiplicity adjustment in meta-analysis.

Key Points

  • To compare the outcomes of accelerated t-PA and streptokinase in treating acute myocardial infarction.
  • Review of prospective randomized clinical trials from Medline and other sources.
  • Included trials had over 1000 patients with acute myocardial infarction.
  • Compared accelerated t-PA infusion and streptokinase administration with aspirin and heparin.
  • Accelerated t-PA showed a marginal 30-day mortality advantage of 6.6% compared to 7.3% for streptokinase (p = 0.02).
  • The relative risk of 0.918 (95% CI 0.854 to 0.986) indicates a potential benefit, primarily from the GUSTO I study.
  • t-PA was associated with an increased incidence of stroke.

Structured PICO

Does accelerated t-PA reduce 30 day mortality compared to streptokinase in patients with acute myocardial infarction?

P
Population
64,387 patients with acute myocardial infarction from 4 prospective, randomised clinical trials (GUSTO I, GUSTO IIb Angioplasty Substudy, GUSTO III, and COBALT).
I
Intervention
Accelerated infusion t-PA (alteplase) with concomitant use of aspirin and heparin
C
Comparator
Streptokinase 1.5 million units given over one hour with concomitant use of aspirin and heparin
O
Outcome
30 day mortalityhard clinical

Accelerated t-PA provides a marginal, borderline significant 30-day mortality benefit over streptokinase in acute MI, but carries an increased risk of stroke.

Cite This Study

BM Smith (1999) studied this question.

synapsesocial.com/papers/6a1def94ef3fa0b4c0ef9766https://doi.org/10.1136/emj.16.6.407
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Also Consider

Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context:

  1. 1Variations in patient management and outcomes for acute myocardial infarction in the United States and other countries. Results from the GUSTO trial. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries1995 · 115 citations
  2. 2A randomized controlled trial of intravenous tissue plasminogen activator and early intravenous heparin in acute myocardial infarction.1989 · 275 citations
  3. 3Hirudin in Acute Myocardial Infarction1996 · 488 citations
  4. 4Recombinant hirudin for unstable angina pectoris. A multicenter, randomized angiographic trial.1994 · 162 citations
  5. 5A Comparison of Recombinant Hirudin with Heparin for the Treatment of Acute Coronary Syndromes1996 · 664 citations