Streptokinase Is Still the Agent of Choice for Most Patients with Myocardial Infarction.

I believe streptokinase is still the trombolytic of choice for the majority of patients with acute myocardial infarction for the following reasons: 1. The superiority of alteplase over streptokinase rests on insecure grounds, statistically (when net clinical benefit is computed for the SK/subcutaneous heparin arm versus the accelerated t-PA arm, the P value is only 0.04). 2. The excess of cerebral haemorrhage with t-PA is statistically highly significant and consistent over all trials. 3. Patients at greater risk of cerebral hemorrhage are those with raised systolic arterial pressure above about 130 to 140 on admission and those aged over about 55 years. These comprise the majority of patients admitted to ordinary Coronary Care Units. If t-PA is given to patients at low risk of cerebral hemorrhage, the extra cost per life saved will be very high, since such patients are at relatively low risk in any case. 4. The open design of the GUSTO-2 trial (the only trial showing a small mortality benefit for accelerated t-PA versus SK) introduces the possibility of bias. For example, unfamiliarity with SK in North American centers may have given risk to premature stopping of treatment because of hypotension; this might have resulted in a more favorable experience for accelerated t-PA in North American centers compared with the rest of the world. (The mortality benefit for accelerated t-PA in the GUSTO trial was seen only in North American centers.)