A Randomized Trial of Intracoronary Streptokinase in the Treatment of Acute Myocardial Infarction

Anderson, Jeffrey L.; Marshall, Hiram W.; Bray, Bruce E.; Lutz, Joan R.; Frederick, Philip R.; Yanowitz, Frank G.; Datz, Frederick L.; Klausner, Steven C.; Hagan, Arthur D.

doi:10.1056/nejm198306023082202

Cited by 504 publications

(68 citation statements)

References 30 publications

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“…Electrocardiographic evolutionary changes were favorable after intravenous streptokinase and this is consistent with previous observations.4 13 recently developed based on R wave loss and Q wave development and have been correlated with left ventricular function after myocardial infarction.35' 36 The observed electrocardiographic results in our study may thus be interpreted as supporting a modest reduction in infarct size. The reason for initially rapid electrocardiographic evolution on reperfusion is unclear.…”

Section: Discussionsupporting

confidence: 91%

“…13 In an effort to allow earlier, easier application of thrombolytic therapy, we next undertook a prospective, randomized study to compare the intravenous with the intracoronary drug in treatment of patients with acute myocardial infarction. Results were also compared with those in our comparable historical control group of patients that did not receive thrombolytic therapy.…”

mentioning

confidence: 99%

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A randomized trial of intravenous and intracoronary streptokinase in patients with acute myocardial infarction.

Anderson¹,

Marshall²,

Askins³

et al. 1984

Circulation

132

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The clinical effects of intravenous streptokinase in patients with acute myocardial infarction were compared with those of intracoronary streptokinase in a randomized, prospective study. Comparisons were also made with a historical control group. Fifty patients were entered into the study at 2.4 + 1.2 hr after onset of pain, and 27 were assigned to intravenous and 23 to intracoronary therapy. The doses of streptokinase averaged 212,000 U ic and 845,000 U iv (0.75 x 106 U/5 hr, n = 14 or 106 U/1 hr, n = 13). Results of studies of the two intravenous dosage schedules were similar and so were combined. Streptokinase was administered at 2.8 + 1.0 hr after onset of pain in the intravenous and at 4.3 + 1.4 hr in the intracoronary drug group (p < .001). Convalescent (day 10) radionuclide ejection fractions were 54 + 14% for the intravenous and 50 + 16% for the intracoronary drug group. Change in ejection fraction from day 1 to 10 tended to be greater after intravenous drug: 5.1% (p < .08) vs 1.2% (NS). Semiquantitative regional wall motion indexes in the infarct zone showed significant and similar modest improvement from admission to day 10 in both groups (p < .02). Accelerated enzyme-release kinetics were noted after both therapies. Times of peak enzyme levels for patients on intravenous and intracoronary drug were, respectively, 12.5 ± 5.0 and 11.5 + 4.3 hr for creatine kinase MB isoenzyme and 31.7 + 11.8 and 28.1 + 12.7 hr for lactic dehydrogenase (LDH). Peak LDH-1 level was lower in patients receiving intravenous drug than in the historical control group (p < .05). Electrocardiographically summed ST segments diminished rapidly after therapy in both groups; Q wave development was similar and overall R wave loss was equivalent and less extensive compared with in historical control subjects. Infarct pain requiring morphine was diminished similarly in both treatment groups. Incidence of early arrhythmias and heart failure also did not differ. Posttherapy ischemic events and early surgery tended to be more common in the intracoronary group and bleeding was more common in the intravenous group. Intravenous drug did not decrease early hospital mortality (intravenous drug -5, historical control = 4, intracoronary drug -1); the differences in this parameter among groups were not significant. At convalescent angiographic evaluation, anterograde perfusion was present in 73% of those receiving intravenous and 76% of those receiving intracoronary drug. Thus, favorable relative effects were noted on cardiac function, clinical evaluations, and hospital course after intravenous streptokinase in early survivors of myocardial infarction and use of intravenous drug has the advantage of earlier and easier application. Additional studies will be required to address effects on mortality.

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Section: Discussionsupporting

confidence: 91%

mentioning

confidence: 99%

A randomized trial of intravenous and intracoronary streptokinase in patients with acute myocardial infarction.

Anderson¹,

Marshall²,

Askins³

et al. 1984

Circulation

132

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“…However, several randomized trials of ICSK were unable to show any beneficial effect on left ventricular function but the sample sizes were small (Kennedy et al, 1983;Khaja et al , 1983;Leiboff et al , 1984). One randomized study (Anderson et al, 1983) reported improvement in left ventricular function after thrombolytic therapy and not surprisingly, the interval between the onset of symptoms and thrombolytic therapy in this study was shorter than in the aforementioned three studies. Yet another study was able to demonstrate a beneficial effect on both global and regional left ventricular function in successfully reperfused patients.…”

Section: Salvage Of the Myocardiumcontrasting

confidence: 53%

“…There was no statistically significant difference in mortality rates after one year . Several other ICSK studies (Anderson et al, 1983;Khaja et al, 1983;Simoons et al, 1983) with small sample sizes were available but no positive conclusions can be derived from these. Furberg (1984) in an editorial, pooled data from 8 randomized trials of ICSK and concluded that there was an 11 % reduction of mortality in the patients treated with SK when compared to controls.…”

Section: Mortalitymentioning

confidence: 99%

Intravenous versus intracoronary streptokinase in acute myocardial infarction

1985

Clinical Cardiology

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Summary: Nine studies specifically dealing with the comparison of intravenous streptokinase (IVSK) and intracoronary streptokinase (ICSK) in the treatment of acute myocardial infarction (MI) were analyzed to determine if IVSK is as efficacious as ICSK in achieving thrombolysis. Pooled data from the studies yielded success rates of 73% for IVSK and 72% for ICSK. Considering that the studies which did not perform preintervention angiogram may have overestimated the thrombolytic success rate in IVSK patients, there is a possibility that ICSK may be slightly more effective in achieving acute reperfusion. Bleeding complications were similar, and a systemic lytic state was observed in both treatment groups. No definitive conclusions can be drawn regarding the differences between groups in improvements of left ventricular function and mortality rates. ICSK has the advantage of direct documentation of reperfusion and spares the patient the risk of anticoagulation should the attempt fail. On the other hand, IVSK is cheaper, easier to administer, and can logistically be given earlier (even in the emergency room or ambulance) than ICSK; it is therefore more widely available, and may be the preferred mode of treatment in community hospitals where cardiac catheterization facilities are not readily available, if streptokinase is to be given at all.

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“…Several experimental9' 10 and clinical studies' [1][2][3][4][5][6][7][8][9][10][11][12][13][14] have shown that the early reflow of blood to ischemic myocardium increases the creatine kinase (CK) recovery rate. Accordingly, the total amount of CK that is released into the plasma may be greater than the amount of CK released from an area of myocardial necrosis of the same size without reperfusion.…”

mentioning

confidence: 99%

Quantitative relationship between left ventricular function and serum cardiac myosin light chain I levels after coronary reperfusion in patients with acute myocardial infarction.

et al. 1987

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To estimate the extent of myocardial infarction after coronary artery reperfusion, serum levels of cardiac myosin light chain (LC) I and creatine kinase (CK) were determined serially in 49 patients with acute myocardial infarction. Intracoronary thrombolysis was successful in 25 patients (reperfusion group), and 24 patients were treated in a conventional manner (control group). The peak level of CK appeared significantly earlier in the reperfusion group (1 1.3 + 3. 1 hr, mean + SD) than in the control group (21.6 ± 7.2 hr). Cumulative release of CK was significantly related to angiographically determined left ventricular ejection fraction 1 month after the attack in both groups (r = -.50; -.45, respectively). However, the amount of cumulative release of CK in the reperfusion group was greater compared with that in those with the same left ventricular ejection fraction in the control group. Peak appearance time of LCI was almost equal in the two groups (3.8 ± 1.4 vs 3.9 ± 1.2 days). Peak levels of LCI were related to the left ventricular ejection fraction in the reperfusion group (r = -.63) and in the control group (r = -.74), and the slopes of their regression lines were similar. The cardiac index obtained on the day of onset in the two groups was related to peak levels of LCI but not to total release of CK. These results suggest that serum levels of LCI reflect the changes in left ventricular function after acute myocardial infarction, regardless of the presence of coronary reperfusion. Thus, serial determinations of LCI in serum facilitate noninvasive assessment of the effects of intracoronary thrombolysis on infarct size. Circulation 76, No. 6, 1251-1261, 1987 IT HAS BEEN SHOWN that the intracoronary infusion of thrombolytic drugs can bring about coronary artery recanalization and this has been proposed as a way of reducing the extent of acute myocardial infarction. 1, 2 Although recent clinical investigations suggest beneficial effects of intracoronary thrombolysis,-5 many laboratory studies have pointed out the deleterious effects of coronary reperfusion, including massive myocardial hemorrhage, refractory arrhythmias, or noreflow phenomenon.68 Therefore, for evaluation of salvage and damage to the myocardium after throm-

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A Randomized Trial of Intracoronary Streptokinase in the Treatment of Acute Myocardial Infarction

Cited by 504 publications

References 30 publications

A randomized trial of intravenous and intracoronary streptokinase in patients with acute myocardial infarction.

A randomized trial of intravenous and intracoronary streptokinase in patients with acute myocardial infarction.

Intravenous versus intracoronary streptokinase in acute myocardial infarction

Quantitative relationship between left ventricular function and serum cardiac myosin light chain I levels after coronary reperfusion in patients with acute myocardial infarction.

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