Prospective randomized trial of intravenous and intracoronary streptokinase in acute myocardial infarction.

Abstract

To evaluate the relative thrombolytic efficacy and complications of intracoronary vs high-dose, short-term intravenous streptokinase infusion in patients with acute myocardial infarction, we performed baseline coronary arteriography and then randomly allocated 51 patients with acute myocardial infarction to receive either intracoronary (n = 25) or intravenous (n = 26) streptokinase. Patients getting the drug by the intracoronary route received 240,000 IU of streptokinase into the infarct-related artery over 1 hr, whereas those getting the drug by the intravenous route received either 500,000 IU of streptokinase over 15 min (n = 10) or I million IU of streptokinase over 45 min (n = 16). Angiographically observed thrombolysis occurred in 76% (19/25) of the patients receiving intracoronary streptokinase, in 10% (1/10) of the patients receiving 500,000 IU of streptokinase intravenously, and in 44% (7/16) of the patients receiving 1 million IU of streptokinase intravenously. Among patients in whom thrombolysis was observed, mean elapsed time from onset of streptokinase infusion until lysis was 31 ± 18 min in patients receiving intracoronary streptokinase and 38 + 20 min in those receiving intravenous streptokinase (p = NS). Among patients in whom intravenous streptokinase "failed," intracoronary streptokinase in combination with intracoronary guidewire manipulation recanalized only 7% (1/15). Fibrinogen levels within 6 hr after streptokinase were significantly lower in the patients receiving intravenous streptokinase (39 ± 17 mg/dl) than the levels in those receiving intracoronary streptokinase (88 + 70 mg/dl) (p < .05) but were similar 24 hr after streptokinase in the two groups. Bleeding requiring transfusion occurred in one patient in each group. Thus, in this prospective randomized trial of intracoronary vs intravenous streptokinase, hemorrhagic complications were few, although both regimens produced a systemic lytic state. Although the thrombolytic efficacy of intracoronary streptokinase was superior to that of high-dose, short-term intravenous streptokinase, the higher-dose intravenous regimen (1 million IU over 45 min) achieved thrombolysis in a significant minority (44%) of patients and might be useful therapy for patients not having access to emergency catheterization.Circulation 68, No. 5, 1051No. 5, -1061No. 5, , 1983 RECENTLY, intracoronary streptokinase has achieved considerable popularity as a means for recanalizing acutely thrombosed coronary arteries in patients with evolving acute myocardial infarction. 1 Unfortunately, emergency coronary arteriography and intracoronary streptokinase infusion require sophisticated equipment and a specially trained operator and

Coronary thrombolysis with intravenously administered human tissue-type plasminogen activator produced by recombinant DNA technology.

“…Others have reported that streptokinase administered systemically is less effective than that by the intracoronary route. 5 6 We have previously shown6 that intravenous administration of t-PA isolated from culture fluid of melanoma cells7 results in prompt coronary thrombolysis in dogs without systemic activation of the fibrinolytic system. This agent converts plasminogen to plasmin essentially only when the zymogen is bound to fibrin.…”

Prevention of coronary artery reocclusion and reduction in late coronary artery stenosis after thrombolytic therapy in patients with acute myocardial infarction. A randomized study of maintenance infusion of recombinant human tissue-type plasminogen activator.

“…Patients with patent infarct-related arteries at 90 minutes of infusion were randomized to receive either heparin alone (1,000 units/hr) or a maintenance infusion of 0.8 mg/kg rt-PA given during 4 hours with a continuous infusion of heparin. Repeat coronary angiography was performed 60 minutes after the start of the randomized maintenance infusion (at 150 minutes), or it was performed earlier if acute reocclusion was suspected on the basis of either chest pain or electrocardiographic STsegment elevation.…”

“…[1][2][3][4][5][6] Recombinant tissue-type plasminogen activator (rt-PA) has been shown to be a more effective thrombolytic agent than streptokinase7-9 and to produce less extensive systemic fibrinogenolysis. '0 In multicenter trials, intravenous rt-PA has been associated with coronary reocclusion rates of 10% to 30% despite heparin anticoagulation.…”

Intravenous versus intracoronary streptokinase in acute myocardial infarction

“…Nine studies were reviewed (Alderman et al, 1984;Anderson et al, 1984;Blunda ef al., 1984;Geft et al, 1983;Rogers et al, 1983Rogers et al, , 1984Saltups el al., 1984;Taylor et al, 1984;Valentine et al, 1985), three of which were abstracts; two of these abstracts were presented at the American College of Cardiology meeting in March 1984, the third was presented at the 56th Annual Scientific Session of the American Heart Association in October 1983. The following are compared between ICSK and IVSK groups: (1) Duration from onset of symptoms to the initiation of treatment.…”

“…Only in four studies was angiography performed prior to and during treatment with IVSK (Alderman et al, 1984;Blunda et al, 1984;Rogers et al, 1983;Saltups et al, 1984). The rest of the trials did not document the infarct-related vessel prior to the initiation of IVSK therapy.…”