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April 14, 1989, Vol 261, No. 14 >
ARTICLE | April 14, 1989

Coronary Thrombolysis— It's Worth the Risk FREE

Alan J. Tiefenbrunn, MD; Philip A. Ludbrook, MB, BS, FRACP
[+] Author Affiliations

Reprint requests to the Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8086, St Louis, MO 63110 (Dr Tiefenbrunn).


JAMA. 1989;261(14):2107-2108. doi:10.1001/jama.1989.03420140109036
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References

ALTHOUGH the concept of coronary thrombolysis for the treatment of acute evolving myocardial infarction has been extant for over three decades,1 it is only in the last few years that profound benefits have been consistently documented in large numbers of patients, reflected by improved left ventricular function,2-5 decreased incidence and severity of congestive heart failure,5 decreased incidence of late fatal arrhythmias,6 and improved short-7-10 and long-term11,12 mortality. However, as with any medical or surgical treatment, pharmacologic activation of the fibrinolytic system entails a risk—in its case, the primary risk being that of bleeding. This risk is not a "side effect" but a direct consequence of the desired action when lytic agents are administered, ie, fibrin degradation and clot dissolution. Unfortunately, plasmin activation cannot be confined presently to pathological deposits of fibrin, and protective thrombi also will be disrupted. Nevertheless, spontaneous bleeding (gastrointestinal, genitourinary, retroperitoneal,

REFERENCES

1 +
Fletcher AP, Alkjaersig N, Smyrniotis FE, Sherry S.  The treatment of patients suffering from early myocardial infarction with massive and prolonged streptokinase therapy . Trans Assoc Am Phys. 1958;;71:287-296.
2 +
Ritchie JL, Cerqueria M, Maynard C, Davis K, Kennedy JW.  Ventricular function and infarction size: the western Washington intravenous streptokinase in myocardial infarction trial . J Am Coll Cardiol. 1988;;11:689-697.
3 +
O'Rourke M, Baron D, Keogh A, et al.  Limitation of myocardial infarction by early infusion of recombinant tissue-type plasminogen activator . Circulation . 1988;;77:1311-1315.
4 +
National Heart Foundation of Australia Coronary Thrombolysis Group.  Coronary thrombolysis and myocardial salvage by tissue plasminogen activator given up to 4 hours after onset of myocardial infarction . Lancet . 1988;;1:203-207.
5 +
Guerci AD, Gerstenblith G, Brinker JA, et al.  A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty . N Engl J Med. 1987;;317:1613-1618.
6 +
Sager PT, Perlmutter RA, Rosenfeld LE, McPherson CA, Wackers FJ, Batsford WP.  Electrophysiologic effects of thrombolytic therapy in patients with a transmural anterior myocardial infarction complicated by left ventricular aneurysm formation . J Am Coll Cardiol. 1988;;12:19-24.
7 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet . 1986;;1:397-401.
8 +
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.  Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;;2:349-360.
9 +
Wilcox RG, Von Der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR for the ASSET Study Group.  Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET) . Lancet . 1988;;2:525-530.
10 +
AIMS Trial Study Group.  Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial . Lancet . 1988;;1:545-549.
11 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Long-term effects of intravenous thrombolysis in acute myocardial infarction: final report of the GISSI study . Lancet . 1987;;2:871-874.
12 +
Sheehan FH, Doerr R, Schmidt WG, et al.  Early recovery of left ventricular function after thrombolytic therapy for acute myocardial infarction: an important determinant of survival . J Am Coll Cardiol. 1988;;12:289-300.
13 +
Barnett HJM.  Spontaneous intracranial hemorrhage . In: Wyngaarden JB, Smith LH, eds. Cecil Textbook of Medicine . Philadelphia, Pa: WB Saunders Co; 1988;:2173-2180.
14 +
Thompson PL, Robinson JS.  Stroke after acute myocardial infarction: relation to infarct size . Br Med J. 1978;;2:457-459.
15 +
Komrad MS, Coffey CE, Coffey KS, McKinnis R, Massey EW, Califf RM.  Myocardial infarction and stroke . Neurology . 1984;; 34:1403-1409.
16 +
TIMI Operations Committee, Braunwald E, Knatterud GL, Passamani E, et al.  Update from the thrombolysis in myocardial infarction trial . J Am Coll Cardiol. 1987;;10:970.
17 +
Califf RM, Topol EJ, George BS, et al.  Hemorrhagic complications associated with the use of intravenous tissue plasminogen activator in treatment of acute myocardial infarction . Am J Med. 1988;;85:353-359.
18 +
Simoons ML, Arnold AER, Betriu A, et al for the European Cooperative Study Group for Recombinant Tissue—Type Plasminogen Activator (rt-PA).  Thrombolysis with tissue plasminogen activator in acute myocardial infarction: no additional benefit from immediate percutaneous coronary angioplasty . Lancet . 1988;;1:197-202.
19 +
Van De Werf F, Arnold AER for the European Cooperative Study Group for Recombinant Tissue— Type Plasminogen Activator (rt-PA).  Effect of intravenous tissue plasminogen activator on infarct size, left ventricular function and survival in patients with acute myocardial infarction . Br Med J. 1988;;297:1374-1379.
20 +
Rovelli F, De Vita C, Feruglio GA, et al.  GISSI trial: early results and late follow-up . J Am Coll Cardiol. 1987;;10:33B-39B.

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1 +
Fletcher AP, Alkjaersig N, Smyrniotis FE, Sherry S.  The treatment of patients suffering from early myocardial infarction with massive and prolonged streptokinase therapy . Trans Assoc Am Phys. 1958;;71:287-296.
2 +
Ritchie JL, Cerqueria M, Maynard C, Davis K, Kennedy JW.  Ventricular function and infarction size: the western Washington intravenous streptokinase in myocardial infarction trial . J Am Coll Cardiol. 1988;;11:689-697.
3 +
O'Rourke M, Baron D, Keogh A, et al.  Limitation of myocardial infarction by early infusion of recombinant tissue-type plasminogen activator . Circulation . 1988;;77:1311-1315.
4 +
National Heart Foundation of Australia Coronary Thrombolysis Group.  Coronary thrombolysis and myocardial salvage by tissue plasminogen activator given up to 4 hours after onset of myocardial infarction . Lancet . 1988;;1:203-207.
5 +
Guerci AD, Gerstenblith G, Brinker JA, et al.  A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty . N Engl J Med. 1987;;317:1613-1618.
6 +
Sager PT, Perlmutter RA, Rosenfeld LE, McPherson CA, Wackers FJ, Batsford WP.  Electrophysiologic effects of thrombolytic therapy in patients with a transmural anterior myocardial infarction complicated by left ventricular aneurysm formation . J Am Coll Cardiol. 1988;;12:19-24.
7 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet . 1986;;1:397-401.
8 +
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.  Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;;2:349-360.
9 +
Wilcox RG, Von Der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR for the ASSET Study Group.  Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET) . Lancet . 1988;;2:525-530.
10 +
AIMS Trial Study Group.  Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial . Lancet . 1988;;1:545-549.
11 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Long-term effects of intravenous thrombolysis in acute myocardial infarction: final report of the GISSI study . Lancet . 1987;;2:871-874.
12 +
Sheehan FH, Doerr R, Schmidt WG, et al.  Early recovery of left ventricular function after thrombolytic therapy for acute myocardial infarction: an important determinant of survival . J Am Coll Cardiol. 1988;;12:289-300.
13 +
Barnett HJM.  Spontaneous intracranial hemorrhage . In: Wyngaarden JB, Smith LH, eds. Cecil Textbook of Medicine . Philadelphia, Pa: WB Saunders Co; 1988;:2173-2180.
14 +
Thompson PL, Robinson JS.  Stroke after acute myocardial infarction: relation to infarct size . Br Med J. 1978;;2:457-459.
15 +
Komrad MS, Coffey CE, Coffey KS, McKinnis R, Massey EW, Califf RM.  Myocardial infarction and stroke . Neurology . 1984;; 34:1403-1409.
16 +
TIMI Operations Committee, Braunwald E, Knatterud GL, Passamani E, et al.  Update from the thrombolysis in myocardial infarction trial . J Am Coll Cardiol. 1987;;10:970.
17 +
Califf RM, Topol EJ, George BS, et al.  Hemorrhagic complications associated with the use of intravenous tissue plasminogen activator in treatment of acute myocardial infarction . Am J Med. 1988;;85:353-359.
18 +
Simoons ML, Arnold AER, Betriu A, et al for the European Cooperative Study Group for Recombinant Tissue—Type Plasminogen Activator (rt-PA).  Thrombolysis with tissue plasminogen activator in acute myocardial infarction: no additional benefit from immediate percutaneous coronary angioplasty . Lancet . 1988;;1:197-202.
19 +
Van De Werf F, Arnold AER for the European Cooperative Study Group for Recombinant Tissue— Type Plasminogen Activator (rt-PA).  Effect of intravenous tissue plasminogen activator on infarct size, left ventricular function and survival in patients with acute myocardial infarction . Br Med J. 1988;;297:1374-1379.
20 +
Rovelli F, De Vita C, Feruglio GA, et al.  GISSI trial: early results and late follow-up . J Am Coll Cardiol. 1987;;10:33B-39B.

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