Acute myocardial infarction treated with intracoronary streptokinase: A report of the society for cardiac angiography

The effects of the rate of intravenous infusion of streptokinase and the duration of symptoms on the time interval to reperfusion in patients with acute myocardial infarction.

“…Our finding that at slow infusion rates of streptokinase, the duration of chest pain was a determinant of the reperfusion time, suggests that the age of the thrombus influenced the results of thrombolytic therapy. This is in accordance with clinical studies using streptokinase in which the duration of symptoms before initiation of treatment was shown to be a determinant of both the rate of successful reperfusion'6 [29][30][31] and the rapidity of thrombolysis,29 32 and is also consistent with experimental studies showing that older thrombi are more resistant to lysis. 33 34 This age-related resistance of the thrombus to lysis may be due to an increased degree of fibrin cross-linking within the thrombus,> a decrease in plasminogen content of the thrombus due to its retraction27 or thrombus growth with time.7 The finding that the age of the thrombus was a factor only in patients who received streptokinase at slow infusion rates is consistent with the experimental data reported by McDonagh et al 38 who found the presence of fibrin cross-linking to be a determinant of the rate of thrombolysis at low concentrations of urokinase, but not at high concentrations.…”

Treatment Strategies in Cardiogenic Shock Complicating Acute Myocardial Infarction

“…Supporting this view is the finding that the degree of reperfusion following intracoronary streptokinase is markedly reduced (43%) in patients with cardiogenic shock when compared to acute MI patients without cardiogenic shock (70%) [21]. In cardiogenic shock patients without reperfusion, the mortality was 84%, while effective thrombolysis and thus reperfusion reduced the mortality to 42% [21]. Based on these and other results from observational human studies [22,23], trials examining the effect of thrombolytics B intra-aortic balloon pump, so-called augmented thrombolysis, are warranted.…”

“…In animal studies, the extent of reperfusion can be noticeably increased by augmenting the systemic blood pressure either with vasopressor agents or the use of an intra-aortic balloon pump [19,20]. Supporting this view is the finding that the degree of reperfusion following intracoronary streptokinase is markedly reduced (43%) in patients with cardiogenic shock when compared to acute MI patients without cardiogenic shock (70%) [21]. In cardiogenic shock patients without reperfusion, the mortality was 84%, while effective thrombolysis and thus reperfusion reduced the mortality to 42% [21].…”

“…The difference is not significant, but suggests a small and relevant effect of thrombolytics in high-risk patients with acute MI. The effect may indeed be small, GISSI [18] Angio registry [21] SHOCK registry [1] Cardiogenic Shock Heart Drug 2001;1:176-181 [3] 78 69 n = 55, randomized SHOCK trial (30 days) [7] 56 46 n = 302, randomized SHOCK trial ! 75 years (6 months) 65 45 subgroup analysis and more recent (non-placebo-controlled) studies [13,17] have shown an unchanged high mortality (160%), regardless of the chosen thrombolytic drug.…”

The Coronary Artery Bypass Surgery – Angioplasty Interface

“…First, the results of clinical investigations began to emphasize the impor tance of the supply (coronary blood flow) side of the myocardial oxygen supply-demand re lationship. This followed growing concern that extensive attempts to improve morbid ity and mortality by reducing myocardial ox ygen demand had largely failed [3][4][5], Sec ond, numerous epidemiological studies high lighted the prognostic significance of obstruc tive coronary disease and the relationship between progression of coronary stenosis, myocardial infarction, impaired left ventric ular function and coronary mortality [6][7][8][9][10], Third, results of randomized trials compar ing surgical revascularization and medical therapy confirmed the superiority of surgical revascularization in relieving symptoms [11,12], improving functional status [13,14] and, in subsets of patients, improving prognosis [11,12,[15][16][17][18][19], Despite improvements in surgical and anesthesia techniques, many physicians and patients found the prospect of surgery daunt ing. The attendant mortality, morbidity, and discomfort; metabolic consequences of extra corporeal circulation; physical and psycho logical invalidism; and loss of employment were perceived as suboptimal for treatment for localized obstruction of the coronary cir culation.…”