On the future of thrombolytic therapy for acute myocardial infarction.

The beneficial effects of thrombolytic therapy in acute ischemic coronary syndromes, and particularly in acute myocardial infarction, are now well established. The limited efficacy and potentially life-threatening side effects of currently available thrombolytic agents, however, remain a problem. Available evidence suggests that the efficacy of coronary thrombolysis could be augmented either by shortening the time to treatment, by improvement of the potency and specificity of fibrin-dissolving agents, by optimized conjunctive treatment with anticoagulant and antiplatelet agents, or by a combination of all 3. These objectives can be pursued by intensified education of the public, paramedical personnel, and physicians; development of novel thrombolytic agents; and further elucidation of pathophysiologic determinants of recanalization and its maintenance. Although it is clear that compounds with antithrombin or antiplatelet properties may enhance and sustain the action of thrombolytic agents, their optimal use and potential hemorrhagic side effects remain to be further explored. Optimized thrombolytic therapy eventually will most likely consist of administration of potent specific plasminogen activators in combination with conjunctive targeted anticoagulant and/or antiplatelet agents.