Fibrinolysis for acute myocardial infarction: the future is here and now.

“The reports of my death are greatly exaggerated.” — —Mark Twain, 1897, cable from London to the Associated Press Pharmacological reperfusion therapy for acute myocardial infarction was incorporated into the armamentarium of clinicians over 15 years ago and has had an extraordinarily beneficial impact on outcome of patients with ST-elevation myocardial infarction (STEMI). There are 3 fundamental components to pharmacological reperfusion; these consist of the core fibrinolytic agent as well as the accompanying antithrombotic and antiplatelet conjunctive therapies. No contemporary therapy in cardiovascular medicine has been as carefully and critically examined in multiple large randomized trials. These have comprehensively examined the efficacy, safety, and impact of novel therapeutic third-generation fibrinolytics and advances in conjunctive therapies aimed at enhancing restoration of myocardial flow in the epicardial infarct-related coronary artery.1–3 The tissue plasminogen activator (tPA) congeners tenecteplase (TNK-tPA) and reteplase (rPA) that possess initial plasma half-lives of 15 to 30 minutes constitute the newest, most conveniently administered bolus fibrinolytics. They not only reduce the potential for medication errors but also greatly simplify the prospects of prehospital fibrinolysis.2–4 Although these newer agents do not confer additional mortality reduction over that achieved by the 90-minute weight-adjusted accelerated t-PA regimen, the enhanced fibrin specificity of TNK-tPA results in a significant reduction in systemic bleeding.4 Whereas conjunctive therapy with intravenous glycoprotein IIb/IIIa (IV GP IIb/IIIa) inhibitors enhances epicardial flow and myocardial perfusion and reduces reinfarction, these advantages have not resulted in the expected improvement in survival.5,6 Indeed, the increase in systemic bleeding and apparent excess of intracranial hemorrhage among STEMI patients over 75 years has led to reassessment of the suitability of combination reperfusion with IV GP IIb/IIIa inhibitors and reduced dose fibrinolysis.7,8 Currently, the combination of full dose fibrinolysis and low molecular weight heparin or a direct antithrombin appears to …

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