In reply: As Bezzina states, the GUSTO-I trial is the main source of evidence for the superiority of front-loaded alteplase (rt-PA) over streptokinase, showing a 1% absolute and 15% relative benefit.1 Subgroup analysis suggested that only certain groups benefited, but this is an inappropriate use of subgroups, and the result should be applied overall. A clear mechanistic reason for the advantage of rt-PA — greater 90-minute full coronary patency — has also been demonstrated.2
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- Philip Aylward1
- Constantine N Aroney2
- Ken Hossack3
- Andrew M Tonkin4
- 1 Flinders Medical Centre, Adelaide, SA.
- 2 Holy Spirit Northside Hospital, Brisbane, QLD.
- 3 Cardiac Society of Australia and New Zealand, Sydney, NSW.
- 4 National Heart Foundation of Australia, Melbourne, VIC.