Pharmacological treatment during AMI and in secondary prevention: the scientific evidence

Table 1. Thrombolytic therapy. Effect on mortality.
STUDY DRUG No. PATIENTS FOLLOW-UP VAR. P
GISSI (1986) [33] STREPTOKINASE 11,712 21 DAYS -18% 0.0002
ISIS-2 (1988) [45] STREPTOKINASE 17,187 5 WEEKS -25% <0.00001
GISSI-2 (1990) [34] tPA vs SK 12,490 5 DAYS mean +0.4% NS
ISIS-3 (1992) [46] APSAC vs SK
tPA vs SK		 27,553
27,526		 35 DAYS
35 DAYS		 -0.9%
-2.8%		 NS
NS
GUSTO (1993) [36] SK + IV HEP vs
SK + SC HEP
acc. tPA + SK vs SK
acc. TPA vsSK		 10,377
9,796
10,328
10,344


30 DAYS		 -2.7%

-4.0%
-14.0%		 NS

NS
0.0001
 
META-ANALYSES No. STUDIES No. PATIENTS FOLLOW-UP VAR. P
FTT (1994) [26] 9 58,600 35 DAYS -18.0% <0.00001

 

ACC/AHA GUIDELINES

  • Class I:
    • ST elevation (greater than 0.1 mV, 2 or more contiguous leads), time to therapy 12 hrs or less, age less than 75 yrs.
    • BBB (obscuring ST-segment analysis) and history suggesting acute MI.
  • Class IIa:
    • ST elevation, age 75 yrs or older.
  • Class IIb:
    • ST elevation, time to therapy > 12-24 hrs
    • BP on presentation > 180 mmHg systolic and/or > 110 mmHg diastolic associated with high.risk MI
  • Class III:
    • ST elevation, time to therapy > 24 hrs, ischemic pain resolved
    • ST-segment depression only

ANMCO-SIC CLINICAL GUIDELINES

Thrombolytic treatment should be given as soon as possible to all the patients presenting with (Type A evidence):

  • Angina > 20 min and not relieved by nitrates
  • ECG changes ST elevation or ST depression in V1-V4 (posterior infarct), or LBBB
  • no contraindications to thrombolysis

Thrombolytic treatment, evaluated in over 100.000 patients in controlled studies, will reduce mortality, but this is strictly dependent on how quickly it is given after the event and on the clinical severity and size of the infarct, at least for the first 12 hours after the symptoms started. After this interval, thrombolytic treatment may still have significant benefits in patients with persistent signs of coronary occlusion (angina, elevated ST) (Type C evidence) whereas in the other cases the potential benefits of revascularisation could be nulled by the potential adverse side effect of thrombolysis (intracranial bleeds)
Related articles:  [107], [108], [109]