Large-Scale Trials of Thrombolytic Therapy for Acute Myocardial Infarction: GISSI-2, ISIS-3, and GUSTO-1

Editorials15 September 1993Large-Scale Trials of Thrombolytic Therapy for Acute Myocardial Infarction: GISSI-2, ISIS-3, and GUSTO-1Paul M. Ridker, MD, Christopher O'Donnell, MD, Victor J. Marder, MD, and Charles H. Hennekens, MDPaul M. Ridker, MDBrigham and Women's Hospital, Boston, MA 02215-1204. University of Rochester, Rochester, NY 14642. Harvard Medical School, Boston, MA 02215., Christopher O'Donnell, MDBrigham and Women's Hospital, Boston, MA 02215-1204. University of Rochester, Rochester, NY 14642. Harvard Medical School, Boston, MA 02215., Victor J. Marder, MDBrigham and Women's Hospital, Boston, MA 02215-1204. University of Rochester, Rochester, NY 14642. Harvard Medical School, Boston, MA 02215., and Charles H. Hennekens, MDBrigham and Women's Hospital, Boston, MA 02215-1204. University of Rochester, Rochester, NY 14642. Harvard Medical School, Boston, MA 02215.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-119-6-199309150-00017 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail With the release of the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator to Treat Occluded Arteries [1]) study results, data are now available from three large-scale randomized trials that directly compared the thrombolytic agents most commonly used in the United States (Table 1). When examined both individually and together, these three trials show, at most, small absolute differences among agents, in terms of both lives saved and major complications (including hemorrhagic stroke). All three trials also indicate that the choice of thrombolytic agent is less important for patient survival than the delay time to initiation of treatment. This ...References1. GUSTO trial results. American Federation of Clinical Research. Clin Res. 1993; 41:207-8. Google Scholar2. Gruppo Italiano per lo Studio dell Streptochinasi nell'Infarcto Miocardico (GISSI). GISSI-2: A factorial randomised trial of alteplase versus streptokinase and heparin versus no heparin among 12 490 patients with acute myocardial infarction. Lancet. 1990; 336:65-71. Google Scholar3. The International Study Group. In-hospital mortality and clinical course of 20 891 patients with suspected acute myocardial infarction randomised between alteplase and streptokinase with or without heparin. Lancet. 1990; 336:71-5. Google Scholar4. ISIS-3 (Third International Study of Infarct Survival Collaborative Group). ISIS-3: a randomised comparison of streptokinase vs tissue plasminogen activator vs anistreplase and of aspirin and heparin vs heparin alone among 41 299 cases of suspected acute myocardial infarction. Lancet. 1992; 339:753-70. Google Scholar5. Ridker PM, Hebert P, Fuster V, Hennekens CH. Are both aspirin and heparin justified as adjuncts to thrombolytic therapy for acute myocardial infarction? Lancet. 1993; 341:1574-7. Google Scholar6. Ridker PM, Manson JE, Goldhaber SZ, Hennekens CH, Buring JE. Comparison of delay times to hospital presentation for physicians and non-physicians with acute myocardial infarction. Am J Cardiol. 1992; 70:10-3. Google Scholar7. Kereiakes DJ, Topol EJ, George BS, Abbottsmith CW, Stack RS, Candela RJ, et al. Emergency coronary artery bypass surgery preserves global and regional left ventricular function after intravenous tissue plasminogen activator therapy for acute myocardial infarction. J Am Coll Cardiol. 1988; 11:899-907. Google Scholar8. Kereiakes DJ, Weaver WD, Anderson JL, Feldman T, Gibler B, Aufderhide T, et al. Time delays in the diagnosis and treatment of acute myocardial infarction: a tale of eight cities. Report from the Pre-hospital Study Group and the Cincinnati Heart Project. Am Heart J. 1990; 120:773-80. Google Scholar9. Fibrinolytic Therapies Trialists: Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet. 1993; (In press). Google Scholar10. Pfeffer MA, Moye LA, Braunwald E, Basta L, Brown EJ, Cuddy TE, et al. Selection bias in the use of thrombolytic therapy in acute myocardial infarction. JAMA. 1991; 266:528-32. Google Scholar Author, Article, and Disclosure InformationAuthors: Paul M. Ridker, MD; Christopher O'Donnell, MD; Victor J. Marder, MD; Charles H. Hennekens, MDAffiliations: Brigham and Women's Hospital, Boston, MA 02215-1204. University of Rochester, Rochester, NY 14642. Harvard Medical School, Boston, MA 02215.Corresponding Author: Paul M. Ridker, MD, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Avenue East, Boston, MA 02215-1204. 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The current state of the art and prospects for improvementFibrinolytic therapy in patients with ST-elevation myocardial infarctionReferencesPharmacologic Options for Treatment of Ischemic DiseaseAccelerated streptokinase in ST-elevation myocardial infarction — a romanian (ASK–ROMANIA) multicenter registryPharmacologic Options for Treatment of Ischemic DiseaseGuidelines for the management of acute coronary syndromes 2006Thrombolytic therapy for acute myocardial infarction in unsuspected infective endocarditisDiagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Statement for Health Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart AssociationDiagnosis, Treatment, and Long-Term Management of Kawasaki DiseaseAcute coronary syndromesSafety considerations for new vaccine developmentDo potential patients prefer tissue plasminogen activator (TPA) over streptokinase (SK)?THROMBOLYTIC THERAPYConcomitant Use of Intraaortic Balloon Counterpulsation and Streptokinase in Acute Anterior Myocardial InfarctionThe GUSTO TrialsThrombolytic Therapy: A Review of Its Use in Acute Myocardial InfarctionCoronary Revascularization Surgery After Myocardial Infarction: Impact of Bypass Surgery on Survival After ThrombolysisSystemic lytic state is not a predictor of coronary reperfusion in acute myocardial infarctionAge and Thrombolytic TherapyStreptokinase versus Alteplase in Acute Myocardial InfarctionPharmacological and invasive therapy for acute myocardial infarctionInfluences on the Quality of Published Drug StudiesThrombolytic TherapyAcute Myocardial Infarction Treatments in 58 Italian Hospitals: A Drug Utilization SurveyThe demise of the randomized controlled trialA cost-effectiveness model of thrombolytic therapy for acute myocardial infarctionAntithrombotic therapy for acute myocardial infarctionCurrent issues concerning thrombolytic therapy for acute myocardial infarctionLessons we have learned from the GUSTO trialAcute Myocardial InfarctionCost Effectiveness of Tissue Plasminogen ActivatorThrombolytic therapy for acute myocardial infarctionApplying lessons from randomized trials to community practiceMedical Therapy of Acute Myocardial Infarction: Part I. Role of Thrombolytic and Antithrombotic TherapyDirect comparison of aspirin plus hirudin aspirin plus heparin, and aspirin alone among 12,000 patients with acute myocardial infarction not receiving thrombolysis: Rationale and design of the First American Study of Infarct Survival (ASIS-1)Thrombolysis in Acute Myocardial Infarction: t-PA for Everyone?Beyond Thrombolysis: Other Effects of Thrombolytic DrugsThe Gusto Trial: Is the Open-Artery Hypothesis Proven? 15 September 1993Volume 119, Issue 6Page: 530-532KeywordsAcute myocardial infarctionAspirinDeath ratesEmergency departmentHemorrhagic strokeHeparinMortalityRandomized trialsStrokeTissue plasminogen activator ePublished: 15 August 2000 Issue Published: 15 September 1993 Copyright & PermissionsCopyright © 1993 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...