Thrombolytic agents: balancing cost, efficacy, and side effects.

Balancing the benefits, risks, and cost of thrombolytic treatment is a complex issue which depends considerably upon the variable threat of the thrombus to organ physiology and patient survival. For example, after deep vein thrombosis (DVT), the major risk is long-term disability due to the postphlebitic syndrome, while in pulmonary embolism (PE) patients, the risks concern short-term mortality and impaired pulmonary physiology. Thus, for treating DVT or PE, the question is whether thrombolytic therapy would be valuable in addition to other antithrombotic approaches. Clearly, the best indication for thrombolytic therapy is in acute myocardial infarction (MI) patients, because this therapy has the potential for reducing coronary artery thrombus mortality. In acute MI the major issues concern the choice of thrombolytic agent and the relative merits of nonpharmacologic interventions such as angioplasty and bypass surgery. An optimal window of treatment opportunity exists for all of the indications. The window is shortest for MI, intermediate for PE, and longest for DVT patients.