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Volume 329:673-682 September 2, 1993 Number 10 Next

	Full Text Letters Letters Letters Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited Related Article by Topol, E. J. PubMed Citation

ABSTRACT

Background The relative efficacy of streptokinase and tissue plasminogen activator and the roles of intravenous as compared with subcutaneous heparin as adjunctive therapy in acute myocardial infarction are unresolved questions. The current trial was designed to compare new, aggressive thrombolytic strategies with standard thrombolytic regimens in the treatment of acute myocardial infarction. Our hypothesis was that newer thrombolytic strategies that produce earlier and sustained reperfusion would improve survival.

Methods In 15 countries and 1081 hospitals, 41,021 patients with evolving myocardial infarction were randomly assigned to four different thrombolytic strategies, consisting of the use of streptokinase and subcutaneous heparin, streptokinase and intravenous heparin, accelerated tissue plasminogen activator (t-PA) and intravenous heparin, or a combination of streptokinase plus t-PA with intravenous heparin. ("Accelerated" refers to the administration of t-PA over a period of 1 1/2 hours -- with two thirds of the dose given in the first 30 minutes -- rather than the conventional period of 3 hours.) The primary end point was 30-day mortality.

Results The mortality rates in the four treatment groups were as follows: streptokinase and subcutaneous heparin, 7.2 percent; streptokinase and intravenous heparin, 7.4 percent; accelerated t-PA and intravenous heparin, 6.3 percent; and the combination of both thrombolytic agents with intravenous heparin, 7.0 percent. This represented a 14 percent reduction (95 percent confidence interval, 5.9 to 21.3 percent) in mortality for accelerated t-PA as compared with the two streptokinase-only strategies (P = 0.001). The rates of hemorrhagic stroke were 0.49 percent, 0.54 percent, 0.72 percent, and 0.94 percent in the four groups, respectively, which represented a significant excess of hemorrhagic strokes for accelerated t-PA (P = 0.03) and for the combination strategy (P<0.001), as compared with streptokinase only. A combined end point of death or disabling stroke was significantly lower in the accelerated-t-PA group than in the streptokinase-only groups (6.9 percent vs. 7.8 percent, P = 0.006).

Conclusions The findings of this large-scale trial indicate that accelerated t-PA given with intravenous heparin provides a survival benefit over previous standard thrombolytic regimens.

Source Information

Dr. Topol, as chairman of the study, assumes full responsibility for the overall content and integrity of the manuscript.A list of the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) investigators appears in the Appendix.

Address reprint requests to Dr. Eric Topol at the Department of Cardiology, One Clinic Center, Cleveland Clinic Foundation, Cleveland, OH 44195.

Full Text of this Article

Related Letters:

Thrombolytic Therapy for Myocardial Infarction
Montgomery H., Speechly-Dick M.E., Pechlaner C., Lechleitner P., Ross A. M.
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Thrombolytic Therapy for Acute Myocardial Infarction: GUSTO Criticized
Friedman H. S., Chelluri L., Sirio C. A., Angus D. C., Ogunyankin K., Topol E. J., Califf R. M., Van de Werf F., Fuster V.
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N Engl J Med 1994; 330:504-506, Feb 17, 1994. Correspondence

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N Engl J Med 1994; 331:277-278, Jul 28, 1994. Correspondence

Thrombolytic Therapy for Myocardial Infarction
Frei S., Brophy J., Andreotti F., Thron C. D., Topol E. J., Califf R. M., Wilcox R., The GUSTO III Steering Committee , Van de Werf F., The COBALT Investigators , Ware J. H., Antman E. M.
Extract | Full Text  
N Engl J Med 1998; 338:545-548, Feb 19, 1998. Correspondence

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