Intracoronary streptokinase in acute evolving myocardial infarction: you can, but should you?

Intracoronary streptokinase infusion is an exciting new technique, it is feasible and relatively safe, and it can restore antegrade coronary flow in 80% of the patients with an evolving myocardial infarction. Current data indicate that successful reperfusion apparently is associated with improved left ventricular function. The ultimate benefit, a significant decrease in mortality, has not yet been established. Furthermore many questions have not been answered: what is the optimal dosage of streptokinase? How should it be administered: systemic, intracoronary or super selective? Which thrombolytic agent should we use? How can we prevent reocclusion? What is the role of PTCA or acute surgery? A major shortcoming of this technique is the impact on equipment and personnel together with the rather low percentage (25%) of patients with evolving myocardial infarction, in whom this technique is applicable. Of course, although not within the scope of this article, this i.c. streptokinase treatment will have to be compared with other interventions which may reduce morbidity and mortality in patients with acute myocardial infarction. Thus, antegrade flow with i.c. streptokinase can be restored in patients with an evolving myocardial infarction. The main question is: should you do so? Until now, management of patients with an acute myocardial infarction has been conservative and is directed to treatment of pain, arrhythmias and heart failure. At the moment this approach can be considered respectable. For those who propose active management and believe in i.c. streptokinase treatment, until now, insufficient scientific data are available to back this up. For those who have doubts, but like to be active, the best is to put their patients in a well-conducted randomized trial. This will eventually resolve the question: you can, but should you? However, even if i.c. streptokinase is proven to be beneficial to the patient, this technique will not receive widespread application because of its great impact on limited health resources.