New strategies for enhancing the speed and rate of coronary reperfusion

Abstract

Large, controlled clinical trials have conclusively demonstrated that intravenous thrombolytic therapy reduces mortality in patients with acute myocardial infarction. The recently published Global Utillzation of Streptokinase and t-PA for Occluded Arteries (GUSTO) study demonstrated that patency within 90 minutes is predictive of survival. As a consequence, the interest in new strategies for enhancing the speed and rate of coronary reperfusion has been renewed. Further improvements in coronary patency can be anticipated by adopting a variety of approaches. Some of these approaches are simple and require only the application of proven principles, whereas others are more complex and require further research. The first approaches include earlier treatment after the onset of clinical symptoms, because of the strong relation between early treatment and improved clinical efficacy. Other approaches include development of more effective dosage regimens for the available thrombolytic agents, development of more fibrin-specific agents in an attempt to speed up lysis, and development of safer, more effective adjunctive antithrombotic agents to accelerate thrombolysis and prevent rethrombosis. The potential benefits from these latter approaches must not be offset by unacceptable increases in major bleeding or in the costs of treatment. The application of proven principles to improve coronary reperfusion should not be obscured by the research of more effective pharmacologic approaches. Actually, earlier and wider use of the currently available thrombolytic agents could potentially save more lives than the development of technically more exciting new approaches.