Have we reached the limit with thrombolytic therapy?

In the 13 years since the publication of the GISSI-1 study in 1986, and the incorporation of thrombolysis into the standard management of myocardial infarction, this treatment has, apparently, fulfilled its promise. Short-term mortality gains are accompanied by improvements in ventricular function and a reduction in major cardiovascular complications. Follow-up studies have demonstrated that these short-term gains, following a single thrombolytic administration, are sustained for at least 8 years with persistent separation of the survival curves. In terms of cost effectiveness, this is a remarkable success. Streptokinase and accelerated tPA administration are the most widely used thrombolytic agents, and yet only about 50% of patients achieve unrestricted flow (TIMI 3) within 90 minutes of administration. Newer agents, including genetically modified tPA and a much older agent, staphylokinase, appear to offer superior patency rates and simpler administration. However, bleeding risks remain a concern and cannot be predicted from smaller scale studies. This lesson has been learned from the attempts to augment heparin or other antithrombotic treatment in conjunction with thrombolysis, resulting in increased rates of major and cerebral bleeding. We have not reached the limit in applying thrombolysis to all potentially eligible patients. By doing so, with a minimum of delay, more lives would be saved than by substitution of thrombolytic agents or by using adjunctive treatments with marginal survival advantages.