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Open AccessJournal ArticleDOI

An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction.

Maarten L. Simoons, +14 more
- 01 Jan 1993 - 
- Vol. 329, Iss: 10, pp 673-682
TLDR
The findings of this large-scale trial indicate that accelerated t-PA given with intravenous heparin provides a survival benefit over previous standard thrombolytic regimens.
Abstract: 
BACKGROUND: The relative efficacy of streptokinase and tissue plasminogen activator and the roles of intravenous as compared with subcutaneous heparin as adjunctive therapy in acute myocardial infarction are unresolved questions. The current trial was designed to compare new, aggressive thrombolytic strategies with standard thrombolytic regimens in the treatment of acute myocardial infarction. Our hypothesis was that newer thrombolytic strategies that produce earlier and sustained reperfusion would improve survival. METHODS: In 15 countries and 1081 hospitals, 41,021 patients with evolving myocardial infarction were randomly assigned to four different thrombolytic strategies, consisting of the use of streptokinase and subcutaneous heparin, streptokinase and intravenous heparin, accelerated tissue plasminogen activator (t-PA) and intravenous heparin, or a combination of streptokinase plus t-PA with intravenous heparin. ("Accelerated" refers to the administration of t-PA over a period of 1 1/2 hours--with two thirds of the dose given in the first 30 minutes--rather than the conventional period of 3 hours.) The primary end point was 30-day mortality. RESULTS: The mortality rates in the four treatment groups were as follows: streptokinase and subcutaneous heparin, 7.2 percent; streptokinase and intravenous heparin, 7.4 percent; accelerated t-PA and intravenous heparin, 6.3 percent, and the combination of both thrombolytic agents with intravenous heparin, 7.0 percent. This represented a 14 percent reduction (95 percent confidence interval, 5.9 to 21.3 percent) in mortality for accelerated t-PA as compared with the two streptokinase-only strategies (P = 0.001). The rates of hemorrhagic stroke were 0.49 percent, 0.54 percent, 0.72 percent, and 0.94 percent in the four groups, respectively, which represented a significant excess of hemorrhagic strokes for accelerated t-PA (P = 0.03) and for the combination strategy (P < 0.001), as compared with streptokinase only. A combined end point of death or disabling stroke was significantly lower in the accelerated-tPA group than in the streptokinase-only groups (6.9 percent vs. 7.8 percent, P = 0.006). CONCLUSIONS: The findings of this large-scale trial indicate that accelerated t-PA given with intravenous heparin provides a survival benefit over previous standard thrombolytic regimens

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The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org at ERASMUS UNIVERSITY on July 30, 2010. For personal use only. No other uses without permission.
Copyright © 1993 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org at ERASMUS UNIVERSITY on July 30, 2010. For personal use only. No other uses without permission.
Copyright © 1993 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org at ERASMUS UNIVERSITY on July 30, 2010. For personal use only. No other uses without permission.
Copyright © 1993 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org at ERASMUS UNIVERSITY on July 30, 2010. For personal use only. No other uses without permission.
Copyright © 1993 Massachusetts Medical Society. All rights reserved.
The New England Journal of Medicine as published by New England Journal of Medicine.
Downloaded from www.nejm.org at ERASMUS UNIVERSITY on July 30, 2010. For personal use only. No other uses without permission.
Copyright © 1993 Massachusetts Medical Society. All rights reserved.
Citations
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ESC Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation

Stefan James, +10 more
- 01 Oct 2012 - 
TL;DR: The once-in-a-lifetime treatment with Abciximab Intracoronary for acute coronary syndrome and a second dose intravenously for atrial fibrillation is recommended for adults with high blood pressure.
Journal ArticleDOI

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).

Borja Ibanez, +18 more
- 07 Jan 2018 - 
TL;DR: 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation are published.
Journal ArticleDOI

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Patrick T. O'Gara, +22 more
- 29 Jan 2013 - 
TL;DR: The 2017-18 FAHA/FACC/FAHA Education and Research Grants will be focused on advancing the profession’s understanding of central nervous system disorders and the management of post-traumatic stress disorder.
Journal ArticleDOI

Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction : A quantitative review of 23 randomised trials

Ellen C. Keeley, +2 more
- 04 Jan 2003 - 
TL;DR: The results seen with primary PTCA remained better than those seen with thrombolytic therapy during long-term follow-up, and were independent of both the type of throm bolytic agent used and whether or not the patient was transferred for primary P TCA.
Journal ArticleDOI

Standardized Bleeding Definitions for Cardiovascular Clinical Trials A Consensus Report From the Bleeding Academic Research Consortium

Roxana Mehran, +19 more
- 14 Jun 2011 - 
TL;DR: Bleeding complications have been associated with an increased risk of subsequent adverse outcomes, including MI, stroke, stent thrombosis, and death, in patients with ACS and in those undergoing percutaneous coronary intervention (PCI) as well as in the long-term antithrombotic setting.
References
More filters
Journal ArticleDOI

A multiple testing procedure for clinical trials.

Peter C. O'Brien, +1 more
- 01 Sep 1979 - 
TL;DR: The overall size of the procedure is shown to be controlled with virtually the same accuracy as the single sample chi-square test based on N(m1 + m2) observations and the power is found to bevirtually the same.
Journal ArticleDOI

Discrete sequential boundaries for clinical trials

K. K. Gordon Lan, +1 more
- 01 Dec 1983 - 
TL;DR: In this article, the authors proposed a more flexible method to construct discrete sequential boundaries based on the choice of a function, a*(t), which characterizes the rate at which the error level ac is spent.
Journal ArticleDOI

In-hospital mortality and clinical course of 20,891 patients with suspected acute myocardial infarction randomised between alteplase and streptokinase with or without heparin

F. Van de Werf, +18 more
- 01 Jan 1990 - 
Journal ArticleDOI

A Comparison between Heparin and Low-Dose Aspirin as Adjunctive Therapy with Tissue Plasminogen Activator for Acute Myocardial Infarction

Judith Hsia, +5 more
- 22 Nov 1990 - 
TL;DR: Coronary patency rates associated with rt-PA are higher with early concomitant systemic heparin treatment than with concomant low-dose oral aspirin, and should be considered in the design and interpretation of clinical trials involving coronary thrombolytic therapy.
Journal ArticleDOI

Illusion of reperfusion. Does anyone achieve optimal reperfusion during acute myocardial infarction

A.M. Lincoff, +1 more
- 01 Sep 1993 - 
TL;DR: Emerging strategies to achieve optimal reperfusion are directed at enhancement of the velocity and quality of thrombolysis, amelioration of the adverse effects of reperfusions, and use of alternative pathways to myocardial salvage.
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Indications for fibrinolytic therapy in suspected acute myocardial infarction : collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients

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Gruppo Italiano Per Lo Studio Della Streptochinasi Nell' Infarto Miocardico
- 22 Feb 1986 - 

Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.

R B Sleight, +5 more
- 12 Aug 1988 - 

急性心筋梗塞の疑いのある17187症例におけるストレプトキナーゼ静脈内投与,アスピリン経口投与,上記2つの併用または無処置の無作偽試験 isis-2

Dienstl F, +8 more
- 01 Jan 1988 - 

A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group.

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