Evaluation of the effectiveness of intracoronary streptokinase infusion in acute myocardial infarction: Postprocedure management and hospital course in 204 patients

128

The effect of thrombolysis in acute myocardial infarction on enzymatic infarct size, left ventricular function, and early mortality was studied in subsets of patients in a randomized trial. Early thrombolytic therapy with intracoronary streptokinase (152 patients) or with intracoronary streptokinase preceded by intravenous streptokinase (117 patients) was compared with conventional treatment (264 patients). All 533 patients were admitted to the coronary care unit within 4 hr after onset of symptoms indicative of acute myocardial infarction. Four hundred eighty-eight patients were eligible for this detailed analysis, and 245 of these were allocated to thrombolytic therapy and 243 to conventional treatment. Early angiographic examinations were performed in 212 patients allocated to thrombolytic therapy. Patency of the infarct-related artery was achieved in 181 patients (85%). Enzymatic infarct size, as measured from cumulative a-hydroxybutyrate dehydrogenase release, was smaller in patients allocated to thrombolytic therapy (median 760 vs 1170 U/liter in control patients, p = .0001). Left ventricular ejection fraction measured by radionuclide angiography before discharge from the hospital was higher after thrombolytic therapy (median 50% vs 43% in control patients, p = .0001). Three month mortality was lower in patients allocated to thrombolytic therapy (6% vs 14% in the control group, p = .006). With the use of multivariate regression analysis, infarct size limitation, improvement in left ventricular ejection fraction, and three month mortality were predicted by sum of the ST segment elevation, time from onset of symptoms to admission, and Killip class at admission. Thrombolysis was most effective in patients admitted within 2 hr after onset of symptoms and in patients with a sum of ST segment elevation of 1.2 mV or more. On the other hand, no beneficial effects of streptokinase on enzymatic infarct size, left ventricular function, or mortality were observed in the subset of patients with a sum of ST segment elevation of less than 1.2 mV who were admitted between 2 and 4 hr after onset of symptoms. Circulation 74, No. 6, 1379No. 6, -1389No. 6, , 1986 IN APPROXIMATELY 80% to 90% of patients with acute myocardial infarction, intracoronary infusion of streptokinase given in the first hours after onset of chest pain leads to thrombolysis and recanalization of the occluded coronary artery. 1-3From the Working Group on Thrombolytic Therapy in Acute Myocardial Infarction of the Netherlands Interuniversity Cardiology Institute. Participating centers and collaborators are listed before the references.

Section: Patient Selection and Methodsmentioning

confidence: 90%

“…[1][2][3] angiographically proven obstruction, without major complications. The high patency rate after thrombolysis was associated with limitation of infarct size, higher left ventricular ejection fraction (LVEF), and improved survival in comparison with these variables in conventionally treated patients.…”

mentioning

confidence: 88%

Which patients benefit most from early thrombolytic therapy with intracoronary streptokinase?

Vermeer¹,

Simoons²,

Bär³

et al. 1986

128

“…"17 18 Bleeding is usually a multifactorial process involving vascular integrity, platelet action, and the coagulation system. While there is indication that major bleeding is more common with reduced fibrinogen levels, factors such as heparin anticoagulation, length of time before removal of arterial catheter, and the patient's ability to protect arterial puncture site are obvious additional variables.…”

Section: Discussionmentioning

confidence: 99%

Intracoronary thrombolysis in patients with acute myocardial infarction: comparison of the efficacy of urokinase with streptokinase.

Tennant¹,

Dixon²,

Venable³

et al. 1984

125

The efficacy of intracoronary urokinase and streptokinase were compared in 80 patients with acute myocardial infarction in a prospective, randomized, double-blind study. Urokinase was infused into the occluded coronary artery at 6000 U/min, and streptokinase was infused at 2000 U/min. 756 MethodsThis was a randomized, double-blind, parallel study of the efficacy of intracoronary urokinase (Abbokinase; Abbott Pharmaceuticals) and streptokinase (Streptase; Hoechst-Roussel Pharmaceuticals, Inc.) in treating patients with acute myocardial infarction.Patients were eligible for inclusion in the study under the following conditions: (1) typical symptoms of myocardial infarction occurred less than 12 hr before infusion, (2) electrocardiogram showed short-term changes of myocardial infarction, (3) no specific contraindication to thrombolytic therapy existed, and (4) angiographic demonstration of a completely occluded vessel related to the infarct. After informed consent was obtained, the hospital pharmacy randomized the patient to receive either urokinase or streptokinase. Unlabeled thrombolytic solution, containing either streptokinase at a concentration of 500 IU/ml or urokinase at a concentration of 1500 U/ml, was supplied by the pharmacy. All medical personnel and the clinical investigators outside the pharmacy were blinded as to the thrombolytic drug used. Baseline coagulation studies before catheterization included measurements of serum fibrinogen, fibrin split products, thrombin time, prothrombin time, partial thromboplastin time, and plasminogen levels. In the catheterization laboratory, left ventricular and coronary angiography were performed. Heparin was given without knowledge of the treatment group in bolus doses ranging from 2500 U to 10,000 U. The thrombolytic solution was then infused into the occluded infarct-related vessel at a rate of 4 ml/min (

“…14. [21][22][23][24][25][26][27][28][29] This difference could not be explained by skewing of the known pretreatment clinical or laboratory risk factors, such as the delay before treatment or unusual resistance to SK, and could be ASuccessful treatment in 12 patients includes six who responded to initial infusions of low-(n = 2) or standard-dose SK (n = 4) plus six who responded to retreatment at standard dose after failure at low-dose SK.…”

Section: Discussionmentioning

confidence: 99%

Relationship of the lytic state to successful reperfusion with standard- and low-dose intracoronary streptokinase.

Rothbard¹,

Fitzpatrick²,

Francis³

et al. 1985

The influence of a systemic lytic state on reperfusion obtained after intracoronary streptokinase (SK) therapy has been evaluated in 15 patients with acute myocardial infarction and complete coronary occlusion. Coronary angiographic studies and measurements of blood fibrinolytic parameters were repeated at 15 min intervals during the infusion of a standard dose of SK and were compared with the results with approximately one-tenth the standard dose. Successful reperfusion was obtained in only 20% (2/10) of patients receiving the low dose, compared with a 75% to 80% success rate in patients receiving the standard dose as initial treatment (4/5) or as follow-up treatment of patients in whom low-dose therapy failed (6/8 THE RATIONALE for regional thrombolytic treatment of coronary arterial thrombosis is that a high local concentration of plasminogen activator can induce maximal thrombolysis with minimal systemic effect in the blood and a low incidence of hemorrhagic complication. Implicit in this approach are the assumptions that the activator is relatively restricted to the region of the thrombus and that its concentration in the blood is below a critical threshold that would affect plasma coagulation. However, greater therapeutic efficacy and decreased risk of bleeding have not been proved by comparative trial of systemic vs regional treatment, 562 nor has the exact dose of activator required to achieve a restricted local effect been determined by a dose-response study. Furthermore, the available studies do not clearly demonstrate superior results with local infusions. Early studies with streptokinase (SK) have used both regional perfusions into the coronary ostial and intravenous administration2 in patients with acute myocardial infarction. These studies suggested efficacy of both local and systemic infusion, albeit without the benefit of angiographic documentation. The dramatic demonstration by Rentrop et al.3 4 of coronary arterial reperfusion after intracoronary administration of SK stimulated others to adopt such an approach.5-10 However, the intracoronary SK dosage was high, equivalent to that used intravenously for the treatment of deep vein thrombosis, pulmonary embolism, or peripheral arterial occlusion," 12 suggesting that regional localization of SK may not have been accomplished in the reported successes.