Thrombolytic therapy: Controversies in the management of acute myocardial infarction

Current controversies in the management of acute myocardial infarction concern thrombolytic agent selection, patient eligibility criteria, and use of adjuvant therapy. Although t-PA is more effective than streptokinase or APSAC in acutely lysing thrombus, late vessel patency, improvement in ventricular function, survival benefits, and incidence of complications are comparable among all agents. Thrombolytic therapy improves the survival of patients with large or anterior infarctions. The improvement is less pronounced among patients with small or inferior infarctions. Thrombolytic therapy can reduce the risk of death from acute myocardial infarction in elderly patients, without excessively increasing the rate of bleeding complications. Patients ST-segment depression and no ST-segment elevation on the initial ECG do not appear to benefit from thrombolytic drugs. Aspirin and β-blockers each enhance the benefit achieved with thrombolytic therapy; the optimal use of heparin is currently under investigation.