Volume 185 - Issue 5
Guidelines for the management of acute coronary syndromes 2006
Authors: Philip Aylward, Constantine N Aroney, Ken Hossack and Andrew M Tonkin
Med J Aust 2006; 185 (5): 294-295. || doi: 10.5694/j.1326-5377.2006.tb00570.x
Published online: 4 September 2006
Published online: 4 September 2006
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
Meta-analyses of the percutaneous coronary intervention (PCI) trials in acute myocardial infarction have all shown benefit over fibrinolysis. However, the benefit of PCI is greater compared with streptokinase than with plasminogen activators.3 Although not providing a head-to-head comparison, these data also support the superiority of plasminogen activators over streptokinase.
The second generation plasminogen activator studies have all compared these with the “gold standard” front-loaded rt-PA. These agents have been shown to not be inferior in relation to mortality,4,5 and tenecteplase showed a decrease in systemic bleeding.5 Administration as a bolus without the adverse reactions commonly seen with streptokinase (such as hypotension) make them much more convenient and safe, particularly in smaller institutions.
In addition, streptokinase is an inappropriate choice in Indigenous patients because many have high levels of anti-streptokinase IgG and streptokinase resistance.6
References
- The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 673-682.<eMJA full text>
- Simes RJ, Topol EJ, Holmes DR et al; for the GUSTO-I Investigators. Link between the angiographic substudy and mortality outcomes in a large randomized trial of myocardial reperfusion. Importance of early and complete infarct artery reperfusion. Circulation 1995; 91: 1923-1928. 0_CBBGJFHA
- Grines C, Patel A, Zijlstra F, et al. Primary coronary angioplasty compared with intravenous thrombolytic therapy for acute myocardial infarction: six-month follow up and analysis of individual patient data from randomized trials. Am Heart J 2003; 145: 47-57. 0_CBBBCIEF
- The Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. A comparison of reteplase with alteplase for acute myocardial infarction. N Engl J Med 1997; 337: 1118-1123. 0_i1091803
- Assessment of the Safety and Efficacy of a New Thrombolytic Investigators. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet 1999; 354: 716-722. 0_i1091807
- Urdahl KB, Mathews JD, Currie B. Anti-streptokinase antibodies and streptokinase resistance in an Aboriginal population in northern Australia. Aust N Z J Med 1996; 26: 49-53. 0_i1091808