Selecting a thrombolytic agent.

Streptokinase remains the most widely used agent worldwide, largely because it is the cheapest. Because of cost considerations when the incremental cost of the use of accelerated TPA exceeds $35,000 (US) per life year added, and because an iatrogenically induced stroke in a patient who is otherwise likely to have a good outcome is unacceptable, streptokinase may be used in patients with small to moderate-sized infarctions and those aged less than 60 years. Streptokinase is the agent of choice in patients who have an increased risk of stroke and may be used in patients presenting after 6 hours. Streptokinase also may have a role in patients with cardiogenic shock. Administration of accelerated TPA is the treatment of choice in patients at high risk such as those with large anterior infarctions, the elderly, and patients with bypass grafts, and it is an alternative to urokinase when streptokinase has been administered previously. The most important approach is to treat as many patients as early as possible with thrombolytic therapy regardless of which agent is used. Thrombolytic therapy still is widely underused. More lives will be saved, regardless of which thrombolytic drug is used, by encouraging patients to present early, improving on the "door-to-needle" time, and treating more patients with a therapy that can save thousands of lives worldwide.