The effects of recombinant tissue plasminogen activator (rt-PA) and urokinase on patency and early reocclusion of infarct-related coronary arteries were investigated in a single blind, randomized multicenter trial in 246 patients with acute myocardial infarction of less than 6 h duration. Both 70 mg of single chain rt-PA with an initial bolus of 10 mg and 3 million units of urokinase with an initial bolus of 1.5 million units were given intravenously over 90 min. The first angiographic study at the end of the infusion revealed a patent infarct-related artery (Thrombolysis in Myocardial Infarction trial [TIMI] grade 2 or 3) in 69.4% of 121 patients given rt-PA versus 65.8% of 117 patients given urokinase (p = NS). Among patients treated within 3 h from symptom onset a patent infarct-related artery was found in 63.9% of 72 patients given rt-PA versus 70% of 70 patients given urokinase (p = NS). There were five cardiac deaths in each group and one fatal intracranial hemorrhage in the rt-PA group. The in-hospital reinfarction rate was 8.9% versus 13.2% for patients treated with rt-PA and urokinase, respectively. There was no difference in left ventricular function at baseline and follow-up catheterization studies. Both drugs were well tolerated and there was no significant difference in cardiovascular or bleeding complications between the two groups. It is concluded that rt-PA and urokinase in the dosages used provide similar efficacy and safety in the treatment of acute myocardial infarction. Reocclusion during the first 24 h may be less frequent after urokinase treatment.

Definition of the problem: Diminishing resources seem to be forcing rationing of medical services. Rationing the public health care system means that there needs to be ethical discussion on justice. Several years before resource allocation could impact on the levels of morbidity and mortality, economic problems created numerous methods of regulating medical and nursing services. In clinical practice, regularisation means a reduction of the possibility to decide autonomously and therefore requires specific ethical discussion. Arguments: The different methods of regularisation from standards and quality control to managed care are discussed with respect to their influence on medical thinking and decision making. Formalised decisions in severe disease can also be a field for regularisation, for example guidelines on the termination of life sustaining treatment (vs. Do-Not-Attempt-Resuscitation Orders). The debate on futility is discussed as a part of the economic discussion, with special regard to the impact of the macroeconomic situation on "peripheral" medical decisions, which very often are made unconsciously, as shown by a new German study [26]. Conclusion: It is impossible to discuss the influence of macroeconomy, different attempts at regularisation and the individual decision of the doctor without reflecting on their principle interdependency. Ethical reflection in this field cannot be sectioned into an economic, medical decision-making and futility sections.Zusammenfassung. Die Ressourcenknappheit hat zu einer progredienten Regularisierung ärztlichen Handelns geführt, überwiegend durch staatliche und institutionelle Richt-und Leitlinien. Aber nicht nur der Spardruck, sondern ebenso "offiziell" instrumentierte Wissenschaft kann ärztliches Denken und damit ethische Reflexion behindern -selbst wenn sie in der optimalen Form evidenzba-

Main-HoechstPoliwoda u. a.: Zur thrombolytischen Therapie des frischen Herzinfarktes Dtsch. med. Wschr., 91.Jg.

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