Coronary and peripheral thrombolysis: Current status and recommendations

Gian Franco Gensini, Marco Comeglio, Andrea Colella

Research output: Contribution to journalArticle

Abstract

Thrombolytics are mainly indicated in acute myocardial infarction (AMI), with limited evidence of usefulness in stroke and acute peripheral arterial occlusion (PAO). Thrombolytics can successfully dissolve thrombi in any vessel, but clinical benefit varies according to the involved vascular bed. The anticipated clinical benefit of thrombolytics in treating AMI, stroke, and PAO must be carefully balanced against the risk of bleeding (especially intracranial hemorrhage). In AMI, fibrinolytic agents reduce mortality rates by as much as 30% when started within 6 h of symptom onset and by as much as 50% if given within 1 to 2 h. Therefore, the timing of fibrinolytic therapy largely determines the magnitude of reduction in mortality after AMI. Streptokinase is a well-documented treatment for AMI, with r-TPA plus IV heparin enabling better results, specially in anterior MI and in the elderly. Reteplase was not superior to alteplase in GUSTO-III and TNK-TPA is in the early phase of investigation. However their ease of administration and potential for more potent and specific clot lysis may prove advantageous. In acute stroke, the most recently reported phase III trials of streptokinase and recombinant tissue plasminogen activator (r-TPA) have stressed the importance of the clinical benefit/hemorrhage risk balance. These studies sup- ported the viewpoint that the use of fibrinolytic agents for stroke must be limited to r-TPA in well-characterized patients and with a narrow time window. Finally, local administration of thrombolytic agents in acute arterial thrombosis, mainly in the limbs, is commonly used by interventional radiologists. Goods results have been reported in terms of safety and effectiveness in the treatment of acute lower extremity ischemia. The preliminary results of the Thrombolysis or Peripheral Arterial Surgery (TOPAS) trial suggest that recombinant urokinase therapy (4,000 IU/min) is associated with limb salvage and patient survival rates similar to those achieved with surgery, concurrent with a reduced need for complex surgery after thrombolytic intervention. In summary, AMI represents the most important indication for thrombolysis, with large amounts of data supporting its use. In acute stroke, there is less evidence of efficacy and it is limited to a few well-characterized patients, whereas local administration in patients with acute PAO may favorably affect patient outcome despite of the absence of evidence of improved limb salvage.

Original languageEnglish
Pages (from-to)82-86
Number of pages5
JournalClinical and Applied Thrombosis/Hemostasis
Volume4
Issue number2
Publication statusPublished - Apr 1998

Keywords

  • Acute peripheral arterial occlusion
  • Myocardial infarction
  • Stroke
  • Thrombolysis

ASJC Scopus subject areas

  • Hematology

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