Authors' objectives:

This review aims to examine the clinical and cost-effectiveness of available drugs for early thrombolysis in the treatment of acute myocardial infarction (AMI) in hospital and pre-hospital settings.

Authors' results and conclusions: Hospital: A total of 162 references were identified to which the inclusion criteria were applied. Of these, 20 studies reported in 50 articles fulfilled the inclusion criteria. These included 14 comparative studies involving a total study population of 142,907 paients. Data from two studies were combined in the study reports and this combination of data is maintained in the review. Definitive conclusions on efficacy (3035-day mortality) are that streptokinase is as effective as non-accelerated alteplase, that tenecteplase is as effective as accelerated alteplase, and that reteplase is at least as effective as streptokinase. Some conclusions require interpretation of data, i.e. whether streptokinase is as effective as, or inferior to accelerated alteplase; and whether reteplase is as effective as accelerated alteplase or not. Depending on these, two further conclusions on indirect comparisons arise, whether tenecteplase is superior to streptokinase or not, and whether reteplase is as effective as tenecteplase or not. That these questions remain to be resolved illustrates that any differences in mortality between drugs is small. There seem to be significant differences between drugs in incidence of stroke, with streptokinase having the lowest rate. Streptokinase causes more allergic reactions than other drugs. Pre-hospital: The search failed to identify any studies conducted in the pre-hospital setting that compared the effectiveness of different drugs. There is no reason to believe that the effectiveness of a drug will be altered by administration in the pre-hospital setting. Nine RCTs that examined the efficacy and safety of pre-hospital thrombolysis were identified and are discussed. The required use of heparin with either of the bolus products does not seem to provide any practical barrier to their widespread use.

Authors' recommendations: The decision regarding which agent to use is therefore a balance of the risks and benefits related to mortality and stroke. No clear conclusion, based on statistical comparison, can be drawn.

Authors' methods: Systematic review, Economic evaluation

Project Status: Completed

URL for project: http://www.hta.ac.uk/1273

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: NIHR Health Technology Assessment programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk

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