Prospective randomized trial ofintravenous and intracoronary streptokinase in acutemyocardial infarction

Toevaluate therelative thrombolytic efficacy andcomplications ofintracoronary vs high-dose, short-term intravenous streptokinase infusion inpatients withacutemyocardial infarction, we performed baseline coronaryarteriography andthenrandomly allocated 51patients withacute myocardial infarction toreceive either intracoronary (n= 25)orintravenous (n= 26)streptokinase. Patients getting thedrugbytheintracoronary routereceived 240,000 IUofstreptokinase intothe infarct-related artery over 1hr,whereas those getting thedrugbytheintravenous routereceived either 500,000 IUofstreptokinase over15min(n= 10) or I million IUofstreptokinase over45min(n= 16). Angiographically observed thrombolysis occurred in76%(19/25) ofthepatients receiving intra- coronarystreptokinase, in10%(1/10) ofthepatients receiving 500,000 IUofstreptokinase intrave- nously, andin44%(7/16) ofthepatients receiving 1million IUofstreptokinase intravenously. Among patients inwhomthrombolysis was observed, mean elapsed timefromonsetofstreptokinase infusion until lysis was 31± 18mininpatients receiving intracoronary streptokinase and38+ 20mininthose receivingintravenous streptokinase (p= NS).Amongpatients inwhomintravenous streptokinase "failed," intracoronary streptokinase incombination withintracoronary guidewire manipulation re- canalized only7%(1/15). Fibrinogen levels within 6hrafter streptokinase weresignificantly lower in thepatients receiving intravenous streptokinase (39± 17mg/dl) thanthelevels inthose receiving intracoronary streptokinase (88+ 70mg/dl) (p< .05) butweresimilar 24hrafter streptokinase inthe twogroups.Bleeding requiring transfusion occurred inone patient ineachgroup.Thus,inthis prospective randomized trial ofintracoronary vsintravenous streptokinase, hemorrhagic complications werefew,although bothregimens produced asystemic lytic state. Although thethrombolytic efficacy ofintracoronary streptokinase wassuperior tothat ofhigh-dose, short-term intravenous streptokinase, thehigher-dose intravenous regimen (1million IUover45min)achieved thrombolysis inasignificant minority (44%)ofpatients andmight beuseful therapy forpatients nothaving accesstoemergency catheterization.