THROMBOLYSIS DEBATE RESTARTS WITH GUSTO

Despite the unquestioned benefits seen with the use of thrombolysis on mortality in acute myocardial infarction patients, the controversy over which is the best thrombolytic agent to use has restarted following the publication of the final results of the GUSTO study in the New England Journal of Medicine (September 2).

Two previous studies, GISSI-2 and ISIS-3, failed to show a significant difference in mortality between patients treated with either streptokinase, t-PA or anistreplase, neither did the addition of subcutaneous heparin provide a benefit in mortality compared with no heparin. Streptokinase is marketed by Astra AB, Kabi Pharmacia and Hoechst, Genentech markets t-PA under the trade name Activase, while Smithline Beecham markets anistreplase as Eminase.

Following the publication of these results, particularly those of the 60,000-patient ISIS-3 study, it was widely held that streptokinase, at a fraction of the cost ($320 per dose) of the $2,300-a-dose recombinant t-PA product, was the most cost-effective option, particularly as there was some indication that t-PA was associated with a slight but statistically higher risk of stroke (1.5% overall incidence versus 1.1% with streptokinase).