Journal Mobile Options
Table of Contents
Vol. 91, No. 4, 1999
Issue release date: October 1999
Cardiology 1999;91:243–249

Thrombolytic Therapy with Streptokinase and Tissue Plasminogen Activator in a Patient with Suspected Acute Myocardial Infarction: A Decision Analysis

Hiatt M.D.
Wake Forest University School of Medicine, Winston-Salem, N.C., USA

Individual Users: Register with Karger Login Information

Please create your User ID & Password

Contact Information

I have read the Karger Terms and Conditions and agree.

To view the fulltext, please log in

To view the pdf, please log in


Two commonly used thrombolytic agents are streptokinase (SK) and tissue plasminogen activator (t-PA), which have different impacts on the incidence of mortality and thrombolysis-related acute intracranial hemorrhage. A decision-analytic model was developed to compare the use of SK and t-PA in the treatment of a patient with suspected acute myocardial infarction (AMI). The outcome was health-related quality of life as quantified in a measure of utility from the patient’s point of view. The model included three outcome states: death, nonfatal yet disabling stroke, and survival with no disabling stroke. The utility for disabling stroke was determined relative to the reference states of no disabling stroke (1.00) and death (0.00) by means of the time trade-off estimation technique. Probabilities were derived from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery trial, which revealed that although administering t-PA results in a lower percentage of deaths compared to SK, it may lead to a higher percentage of strokes. A decision tree was constructed to model the options and outcomes. The tree was analyzed by standard decision analytic techniques using SMLTREE software, and the stability of the results was examined as values of parameters were varied systematically in a sensitivity analysis. In the baseline analysis, SK yielded 0.9235, whereas t-PA yielded 0.9329. The sensitivity analysis revealed that if the probability of a disabling stroke attributable to t-PA were greater than 2.08%, SK would yield the higher expected utility. This threshold value, however, was much greater than the probability established in major trials. The administration of t-PA leads to a slightly better outcome than does the administration of SK in a patient with suspected AMI.

Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.


  1. Sobel BE: Thrombolysis in the treatment of acute myocardial infarction; in Fuster V, Verstraete M (eds): Thrombosis in Cardiovascular Disorders. Philadelphia, Saunders, 1992.
  2. Holmes DR, Califf RM, Topol EJ: Lessons we have learned from the GUSTO trial. J Am Coll Cardiol 1995;25:10S–17S.
  3. Taylor GJ: Thrombolytic therapy for acute myocardial infarction. Boston, Blackwell Scientific Publications, 1992.
  4. ACC/AHA Task Force Report: Guidelines for the early management of patients with acute myocardial infarction. J Am Coll Cardiol 1990;16:249–292.
  5. Morgan CD, Roberts RS, Haq A, et al: Coronary patency, infarct site, and left ventricular function after thrombolytic therapy for acute myocardial infarction: Results from the tissue plasminogen activator: Toronto (TPAT) Placebo Control Trial. J Am Coll Cardiol 1991;17:1451–1457.
  6. Blumfield DE: Thrombolysis in acute myocardial infarction; in Kapoor AS (ed): Interventional Cardiology. New York, Springer, 1989.
  7. Mark DB: Economic analysis methods and endpoints; in Califf RM, Mark DB, Wagner GS (eds): Acute Coronary Care. St Louis, Mosby, 1995.
  8. Sherry S: Appraisal of various thrombolytic agents in the treatment of acute myocardial infarction. Am J Med 1987;83:31–46.
  9. TIMI IIIB Investigators: Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB trial. Circulation 1994;89:1545–1556.
  10. Krumholz HM, Pasternak RC, Weinstein MC, Gottlieb CF, Ridker PM, Tosteson ANA, Goldman L: Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction. N Engl J Med 1992;327:7–13.
  11. Habib GB: Current status of thrombolysis in acute myocardial infarction. Part II. Chest 1995;107:528–534.
  12. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI): Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1994;i:397–402.
  13. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group: Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988;ii:349–360.
  14. AIMS Trial Study Group: Effect of intravenous APSAC on mortality after acute myocardial infarction: Preliminary report of a placebo-controlled clinical trial. Lancet 1988;i:545–549.
  15. Wilcox RG, von der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR: Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET). Lancet 1988;ii:525–530.
  16. GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Artery): An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329:673–682.
  17. Cannistra AJ, Ruocco NA: The role of thrombolytic therapy for acute coronary ischemia; in Lazar HL (ed): Current Therapy for Acute Coronary Ischemia. Mount Kisco, Futura, 1993.
  18. Topol EJ, Califf RM: Tissue plasminogen activator: Why the backlash? J Am Coll Cardiol 1989;13:1477–1480.

    External Resources

  19. Naylor CD: Health policy implications of thrombolytic therapy for acute myocardial infarction; in Califf RM, Mark DB, Wagner GS (eds): Acute Coronary Care. St Louis, Mosby, 1995.
  20. Gulba DC, Dechend R: Thrombolysis in thromboembolic diseases. Ann Hematol 1994;69:S41–S57.

    External Resources

  21. Jaegere PP, Arnd AA, Bulta AH, Simons ML: Intracranial hemorrhage in association with thrombolytic therapy: Incidence and clinical predictive factors. J Am Coll Cardiol 1992;19:289–294.
  22. Sane DC, Califf RM: Complications of thrombolytic therapy; in Bates ER (ed): Thrombolysis and Adjunctive Therapy for Acute Myocardial Infarction. New York, Dekker, 1993.
  23. Ganz W, Geft I, Shah PK, et al: Intravenous streptokinase in evolving acute myocardial infarction. Am J Cardiol 1984;53:1209.

    External Resources

  24. Wilson IB, Cleary PD: Linking clinical variables with health-related quality of life: A conceptual model of patient outcomes. JAMA 1995;273:59–65.
  25. Pauker SG, Kassirer JP: Medical progress: Decision analysis. N Engl J Med 1987;316:250–258.

    External Resources

  26. Richardson WS, Detsky AS: How to use a clinical decision analysis: Are the results of the study valid? JAMA 1995;273:1292–1295.
  27. Torrance GW: Utility approach to measuring health-related quality of life. J Chron Dis 1987;40:593–600.
  28. Torrance GW, Feeny D: Utilities and quality-adjusted life years. Int J Technol Assess Health Care 1989;5:559–575.

Pay-per-View Options
Direct payment This item at the regular price: USD 38.00
Payment from account With a Karger Pay-per-View account (down payment USD 150) you profit from a special rate for this and other single items.
This item at the discounted price: USD 26.50