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Executive Summary

STREPTOKINASE NAMED "BEST BUY AWARD" WINNER by University of Michigan internal medicine professor Eric Topol, MD, in a presentation at the American Heart Association's annual scientific meeting held Nov. 11-15 in Dallas. In an AHA workshop on "New Therapies and Technologies for Cardiac Care," Topol attempted to guage value of various thrombolytics with an approach patterned on the "best buy" ratings of Consumer Reports magazine. With this method, he declared streptokinase his overall thrombolytic of choice. "What you can see," he asserted, "is that streptokinase gets the best buy award because it only costs $76, and it has the same profile with respect to survival as as compared to TPA [tissue plasminogen activator], which costs $2200, and APSAC [anistreplase], which costs $1700." Beginning with the question "Are all thrombolytics created equal?" Topol said he reviewed all of the major clinical trials to date which have compared the three therapies, and concluded there is no significant difference demonstrated in clinical effects between the three. While some clinical studies have attempted to suggest that TPA is superior because of its rapid effectiveness, Topol said, "patency, although shown to be superior in the early minutes of TPA, has not been translated into an advantage with respect to survival." Topol also added that "there is no clear cut evidence that one [of these thrombolytics] has more important side-effects with respect to bleeding complications." Topol remarked that "other factors such as lower rates of of administration that have been noted with steptokinase and bolus administration of APSAC, [and] the lack of immunogenic problems with TPA are relatively minor." The meeting included a number of sessions where scientists reported results of studies that begin to analyze new applications and second-generation drugs, rather than comparisons of the more established thrombolytics. Saruplase, a second-generation urokinase which is being developed at the University of Mainz in Germany, was the subject of a presentation at a Nov. 14 workshop. Lead investigator Frits Barr, MD, reported that patients receiving saruplase appeared "to achieve patency earlier, to sustain patency at a higher rate, and to have a lower reocclusion rate than patients receiving streptokinase." The results were from a prospective randomized double-blind trial comparing 201 patients receiving 1.5 mil. units of streptokinase versus 198 patients receiving 80 mg of saruplase. However, the findings were based on patency at 90 minutes after the start of thrombolysis. A partial analysis of patients who had been the subjects of long-term follow up, showed that after 24 hours, patency rates among the two patient populations reach equivalent levels of approximately 85%. Barr and his fellow investigators conceded that further research of the drug would be necessary to measure the role of saruplase in treating myocardial infarction. Re-administeration of thrombolytics to prevent threatened re-infarction was the focus of a separate AHA paper presented by Harvey White, MD, Green Lane Hospital, Auckland, New Zealand. White [et al]. examined readministration of thrombolytics in 31 patients with threatened reinfarctions. Following a readministration of either TPA or streptokinase, patients in the study underwent angiography or enzyme patency tests. Approximately 75% of all patients who were reexamined achieved patency a second time, leading the authors to conclude that "readministration of thrombolytic therapy appears to be an effective strategy for threatened reinfarction." However, they pointed out that there was a 50% incidence of allergic reactions in patients receiving readministrations of streptokinase and recommended that only TPA be used for readministration procedures.

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