current practice and future developments in managing mi
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Current practice and future developments in managing MI
In their review of the current and future management of myocardial infarction (MI), Dr AH Gershlick from the University of Leicester and Dr RS More from St Mary's Hospital, Portsmouth, UK, comment that 'further major breakthroughs in the management of acute myocardial infarction are unlikely within the next year or two'.
Rapid thrombolysis With regard to current practice, Drs Gershlick
and More comment that thrombolysis should be commenced within 30 minutes of hospital admission for acute MI. In addition, early therapy with an ACE inhibitor or ~-blocker is indicated in those with impaired ventricular function, and subsequent life-long therapy with aspirin 'seems to be generally accepted'.
While streptokinase is generally used as first-line therapy because it is cheaper than alteplase [tPA, tissue plasminogen activator], the results of the GUSTO-I trial* indicated that a regimen of accelerated aJteplase improves patency rates.
However, Drs Gershlick and More note that current thrombolytic regimens 'are not wholly successful' in clearing obstructed vessels immediately, and 'are not particularly good at maintaining patency'.
New agents A range of new thrombolytic agents are currently
under development, including staphylokinase, monoclonal antibodies against fibrin and new plasminogen activator drugs such as prourokinase. In addition, antithrombin drugs, such as the direct-acting anti-thrombin agent hirudin, are under development to tackle the problem of reocclusion following thrombolysis.
Finally, coronary artery patency may be further improved by use of the glycoprotein IIblIIIa receptor antagonists such as abciximab [monoclonal antibody 7E3] and tirofiban, add Drs Gershlick and More.
While angioplasty appears to result in higher patency rates than thrombolysis in MI, Drs Gershlick and More note that 'primary angioplasty is unlikely to become widely available because most patients with myocardial infarction are admitted to hospitals without interventional facilities'. * Global Utilisation of Streptokinase and tm/or Occluded Coronary Arteries [see /nphanna 886: 3-5, 8 May 1993; 800197201 J Gershlick AH. More RS. Recent-advances: treatment of myocardial infarction.
British Medical Journal 316: 280-284, 24 Jan 1998 """''''.
Inpha""a- 31 Jan 1998 No. 1122 1173-832419811122-00041$01.00" Adls International Limited 1998. All rights rHMV8d