[Thrombolysis in acute myocardial infarct: prerequisites, current experiences and remaining problems]

Abstract

Left ventricular pump failure is today's main cause of in-hospital mortality from acute myocardial infarction and is directly dependent on infarct size. The first clinical attempts to preserve myocardium after acute infarction and to improve morbidity and prognosis by thrombolysis date from about twenty years ago. Through large multicenter studies and promising new agents, coronary thrombolysis has again attracted increased attention in the past two years. After a brief overview on the preconditions for successful thrombolysis, the efficacy, advantages, complications and problems of different thrombolytic agents and forms of administration are reviewed on the basis of the controlled studies published up to June 1986. They concern streptokinase by intracoronary and intravenous route, urokinase and the "clot specific" agents of the second generation, recombinant tissue-type plasminogen activator (rtPA) and anisoylated plasminogen streptokinase activator complex (APSAC) BRL 26921. Finally, questions that remain open even after successful thrombolysis with myocardial salvage are raised, and in particular the problem of reocclusion and postlytic treatment. In spite of justified hopes and the demonstrable feasibility of reopening a coronary artery, thrombolysis in acute myocardial infarction should not be used routinely as long as the beneficial long term effect is not definitely proven for patients, or at least for a known subgroup of patients, in terms of left ventricular function, mortality and morbidity following myocardial infarction.