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ACCELERATED t-PA VS. STREPTOKINASE FOR MI.
The intravenous thrombolytics streptokinase and tissue plasminogen activator (t-PA) had equivalent benefits for patients with acute myocardial infarction in the GISSI-2 and ISIS-3 trials (see Journal Watch accession numbers 900731001 and 920417001). Now, the international GUSTO trial finds that an accelerated t-PA regimen (given over 1.5 hours rather than the conventional 3 hours, and with two-thirds of the dose in the first half hour) is somewhat better than streptokinase.
The study randomized 41,021 patients with acute MI to one of four regimens: streptokinase and subcutaneous heparin, streptokinase and IV heparin, accelerated t-PA and IV heparin, or both streptokinase and t-PA plus IV heparin. All patients had presented within 6 hours of the onset of symptoms.
Mortality at 30 days was significantly reduced in the t- PA-plus-heparin group as compared with the streptokinase groups (6.3 vs. 7.3 percent), amounting to 10 more patients alive at 30 days per 1000 patients treated. The t-PA group had an excess of 2 hemorrhagic strokes, and an excess of 3 strokes of all kinds, per 1000 patients treated. (In this regard, the group given both t-PA and streptokinase did worse than the group given t-PA alone).
Comment: This study convincingly shows that the accelerated t-PA regimen, as compared with streptokinase, improves short-term survival with a very small increased risk for stroke. It remains to be seen whether longer-term survival will be superior and whether the regimen will be cost-effective, given the higher cost of t-PA.
— ALK
Published in Journal Watch General Medicine September 17, 1993
Citation(s):
Fuster V. Coronary thrombolysis -- a perspective for the practicing physician. N Engl J Med 1993 Sep 2 329 723-725.
- Original article (Subscription may be required)
- Medline abstract (Free)
GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993 Sep 2 329 673-682.
- Original article (Subscription may be required)
- Medline abstract (Free)