Volume 185 - Issue 5
Guidelines for the management of acute coronary syndromes 2006
Author: Andrew J Bezzina
Med J Aust 2006; 185 (5): 294-295. || doi: 10.5694/j.1326-5377.2006.tb00569.x
Published online: 4 September 2006
Published online: 4 September 2006
To the Editor: The discussion of fibrinolysis in the recently published guidelines for the management of acute coronary syndromes 20061 is interesting. The recommendations clearly indicate that second-generation agents should be preferred to streptokinase in all circumstances. The guidelines reference the GUSTO-I trial data2 as the primary support for those recommendations. These data are, at best, debatable in terms of showing any benefit of front-loaded tissue plasminogen activator over streptokinase, and then only in limited circumstances (ie, patients aged less than 75 years with anterior infarcts and within 4 hours of the onset of symptoms).3,4
To my knowledge, there have been no head-to-head trials of this size of the other fibrinolytic agents discussed against streptokinase. Thus there is no justification for the blanket superiority that is accredited to these agents, both by implication and explicitly, in the guidelines.
It is a matter of some concern that guidelines from such respected groups should make statements that will be used broadly by clinicians, but that go beyond the evidence base to which they refer.
On the balance of information available there is no compelling case to relegate streptokinase from the front line.
References
- Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184 (8 Suppl): S1-S32.
- The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 673-682. 0_CBBGDBJG
- Ridker PM, O’Donnell C, Marder VJ, Hennekens CH. Large-scale trials of thrombolytic therapy for acute myocardial infarction: GISSI-2, ISIS-3, and GUSTO-1. Ann Intern Med 1993; 119: 530-532. 0_CBBHADAH
- Brophy JM, Joseph L. Placing trials in context using Bayesian analysis: GUSTO revisited by Reverend Bayes. JAMA 1995; 273: 871-875. 0_i1091789