Safety outcomes of ticagrelor among patients with STE-ACS post streptokinase therapy-a retrospective observational study.

From the restriction of access to primary percutaneous coronary intervention, about 46% of patients with ST-elevation acute coronary syndrome (STE-ACS) received fibrinolytic therapy as a reperfusion strategy; streptokinase is frequently used in Thailand. Despite the guidelines recommending potent P2Y12 inhibitors among these patients, the data are limited, especially among patients with STE-ACS post streptokinase therapy. The study was proposed to describe factors for P2Y12 inhibitors selection and evaluate outcomes of pharmacoinvasively treated STE-ACS receiving ticagrelor compared with clopidogrel in Thailand. We performed a retrospective observational study of patients with STE-ACS post streptokinase therapy followed by percutaneous coronary intervention (PCI) with coronary stent placement and receiving ticagrelor or clopidogrel as P2Y12 inhibitor treatment from January 2017 to June 2021. The primary outcomes described factors for P2Y12 inhibitor selection and evaluated safety outcomes with inverse probability weight (IPW) adjustment. The secondary outcome was a composite of all-cause death, myocardial infarction and stroke. The median time from streptokinase therapy to initiating ticagrelor in the switch group was 25.7 (IQR, 1.9-4.4) hours. The factors related to switching from clopidogrel to ticagrelor included young age, history of coronary artery disease (CAD), dose of streptokinase and use of intravascular imaging. Any bleeding events occurred among 83 patients (41.71%) in the switch group and 83 patients (41.09%) in the no switch group (adjusted HR 1.04, 95% CI 0.75-1.44; p = 0.826). The composite of efficacy outcomes occurred in 6 patients in the switch group (3.02%) and 12 patients (5.94%) in the no switch group (adjusted HR 0.57, 95% CI 0.21-1.57; p = 0.279). Conclusion: In real practice, ticagrelor switching among patients with STE-ACS post streptokinase therapy did not differ regarding safety outcomes and composite of efficacy outcomes compared with clopidogrel.

Assessing the Efficacy and Outcomes Following Irrigation with Streptokinase Versus Hydrogen Peroxide in Necrotizing Pancreatitis: A Randomized Pilot Study.

BACKGROUND: Percutaneous catheter drainage (PCD's) are prone to blockage because of necrosum. To improve the efficacy of PCD, necrolytic agents have been used. The present study compared the use of Streptokinase with H2O2 in saline irrigation. MATERIALS AND METHODS: This is a single-center randomized pilot study (from July 2018 to Dec 2019). Patients with infected pancreatic necrosis not showing response to PCD and saline irrigation were included in the study. Patients received either Streptokinase (Streptokinase group 50,000 IU in 100 ml normal saline) or 3% H2O2 (3% H2O2 in 100 ml normal saline in 1:10 dilution). Primary endpoints were the need for surgery and mortality while secondary endpoints were hospital stay and complications attributable to necrolytic agents. RESULTS: There were 30 patients in the study, 15 in each arm. Organ failure was seen in 23 (76.6%), single organ failure was present in 11 (47%), and multi-organ failure in 12 (53%). Bleeding complications (20% in H2O2 vs 6.6% in Streptokinase), need for surgery (73% in H2O2 vs 33.3% in Streptokinase) and mortality (60% in H2O2 vs 33% in Streptokinase) were higher in H2O2 group but the difference was not significant statistically. Post-irrigation hospital stay was lesser in the Streptokinase group compared to H2O2 group but the difference did not reach statistical significance (14.1 ± 7.7 vs 19.2 ± 11.7, p = 0.09) CONCLUSIONS: Streptokinase irrigation led to a trend for reduced need for necrosectomy and mortality. H2O2 group had more bleeding complications. Post-irrigation hospital stay was lesser in Streptokinase group.

Comparison of QT dispersion in patients with ST elevation acute myocardial infarction (STEMI) before and after treatment by streptokinase versus primary percutaneous coronary intervention (PCI).

BACKGROUND: QT dispersion (QTD) represents inhomogeneous ventricular repolarization such that an increased QTD may predispose the heart to malignant ventricular arrhythmias (VAs). This study was conducted to compare QTD in patients with ST-elevation myocardial infarction (STEMI) before and after treatment by streptokinase (SK) versus primary percutaneous coronary intervention (PCI). METHODS: The present case-control study was conducted on 185 STEMI patients who received SK (115 cases) or underwent primary PCI (70 cases). QTD and QT corrected dispersion before and 24 h after treatment. Likewise, they were also found to correct fatal arrhythmias (VT and VF) during the first 24 h after admission, and ejection fraction (EF) 24 h after treatment was evaluated. RESULTS: QTD decreased in the primary PCI group, though no significant difference was seen between the two studied groups (P > 0.05). A significant increase was detected in the EF mean values for the primary PCI-treated patients (P = 0.022). Moreover, there was a significant reduction in QTD of patients with fatal arrhythmias in the primary PCI group (P = 0.022). CONCLUSION: An overall QTD reduction in the primary PCI group and a significant decrease in QTD of patients with fatal arrhythmias in the primary PCI group show that this treatment strategy is more efficient than thrombolytic therapy. As an important indicator of proper myocardial function, EF can independently predict improved myocardial function in the primary PCI group.

Safety of thrombolytic therapy in patients with prosthetic heart valve thrombosis who have high international normalized ratio levels.

BACKGROUND AND AIM: Prosthetic valve thrombosis (PVT) is a rare but life-threatening complication of heart valve replacement. Based on the current guidelines, the treatment of a large number of these patients could be performed through the administration of thrombolytic agents. In the present study, we aim to assess the safety of thrombolytic therapy in patients with PVT who have high international normalized ratio (INR) levels. METHODS: In this study, we retrospectively analyzed outcomes of thrombolytic therapy in 65 PVT patients with different levels of INR at the time of fibrinolysis at a tertiary cardiac center. RESULTS: Mean age of patients was 51.6 ± 12.47 years. The tricuspid valve was the most common site of prosthetic valve thrombosis (64.6%). The Median (range) of INR was 2.1 (0.9-4.9). The majority of patients (50.8%) achieved a complete response following thrombolytic treatment. There were no cases of intracranial hemorrhage. Other major and minor bleedings occurred in 3 (4.6%) and 10 (15.4%) patients, respectively. No embolic stroke and systemic embolism were observed. We found no significant difference in the frequency of major (P-value = .809) and minor (P-value = .483) bleeding as well as response to thrombolytic therapy (P-value = .658) between patients with different levels of INR. Total administered dose of Streptokinase was also similar in PVT patients with or without major (P-value = .467) and minor (P-value = .221) bleeding complications. CONCLUSIONS: We concluded that there was no significant difference between PVT patients presenting with subtherapeutic and high INR levels who received thrombolytic treatments regarding both minor and major bleeding complications as well as response to thrombolysis.

The Efficacy of VATS and Intrapleural Fibrinolytic Therapy in Parapneumonic Empyema Treatment.

BACKGROUND: Development of multiloculation-septation is a challenging entity in empyema patients. In this study, it is aimed to investigate the success rates of videothoracoscopic deloculation (VATS-D) and intrapleural fibrinolytic (IPFib) application after tube thoracostomy. METHODS: The study retrospectively examined the patients diagnosed with empyema with multiloculation and septation between January 2005 and December 2014. Among these patients, the study included those who received VATS-D or IPFib therapy. RESULTS: VATS-D (Group 1) was applied to 54 patients and IPFib (Group 2) was applied to 24 patients. The success of both procedures was evaluated considering the need of decortication in the following periods. In the VATS-D group, 4 (7.4%) patients required decortication via thoracotomy where it was 1 (4.1%) patient (p = 0.577) in the IPFib group. The length of hospital stay was 6.81 ± 2.55 (4-15) days in Group 1 compared to 14.25 ± 6.44 (7-27) days in Group 2 (p <0.001). CONCLUSIONS: It was demonstrated that both of the methods applied in the study have high efficacy and are preferable methods based on the general conditions of patients. Additionally, the shorter length of hospital stays in patients received VATS-D was established as a significant parameter.

Balancing the risk of spontaneous ischemic and major bleeding events in acute coronary syndromes.

Evaluation of antithrombotic treatments for acute coronary syndromes (ACS) requires balancing ischemic and bleeding risks to assess net benefit. We sought to compare the relative effects of ischemic and bleeding events on mortality. METHODS: In the PLATelet inhibition and patient Outcomes (PLATO) trial, we compared spontaneous ischemic events (myocardial infarction or stroke) with spontaneous major bleeding events (PLATO major, Thrombolysis In Myocardial Infarction [TIMI] major, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries [GUSTO] severe) with respect to risk of mortality using time-dependent Cox proportional hazards models. The comparison was performed using ratio of hazard ratios for mortality increase after ischemic vs bleeding events. RESULTS: A total of 822 patients (4.4%) had ≥1 spontaneous ischemic event; 485 patients (2.6%), ≥1 spontaneous PLATO major bleed, 282 (1.5%), ≥1 spontaneous TIMI major bleed; and 207 (1.1%), ≥1 spontaneous severe GUSTO bleed. In patients who had both events, bleeding occurred first in most patients. Regardless of classification, major bleeding events were associated with increased short- and long-term mortality that were not significantly different from the increase associated with spontaneous ischemic events: ratio of hazard ratios (95% CIs) for short- and long-term mortality after spontaneous ischemic vs bleeding events: 1.46 (0.98-2.19) and 0.92 (0.52-1.62) (PLATO major); 1.26 (0.80-1.96) and 1.19 (0.58-2.24) (TIMI major), 0.72 (0.47-1.10) and 0.83 (0.38-1.79) (GUSTO severe) (all P>0.05) CONCLUSIONS: In patients with ACS on dual antiplatelet therapy, spontaneous major bleeding events seem "prognostically equivalent" to spontaneous ischemic complications. This result allows quantitative comparisons between both actual and predicted bleeding and ischemic risks. Our findings help to better define net clinical benefit of antithrombotic treatments and more accurately estimate mortality after ischemic and bleeding events in patients with ACS.

Thrombolysis for Left-Sided Prosthetic Valve Thrombosis: Short- and Long-Term Outcomes.

BACKGROUND AND AIM OF THE STUDY: Emergency valve replacement has long been the treatment of choice in left-sided prosthetic valve thrombosis (PVT) for critically ill patients in NYHA classes III-IV. Thrombolytic therapy is recommended for NYHA class I/II patients with a small thrombotic burden. METHODS: The results of thrombolytic therapy to treat left-sided PVT (eight mitral, three aortic) with streptokinase (STK) in critically ill NYHA class III/IV patients were analyzed, where surgery was either refused due to financial constraints or by the surgical team. Results were assessed clinically, using fluoroscopy and transthoracic and transesophageal echocardiography. RESULTS: Mechanical bileaflet prosthetic valves (eight mitral, four aortic) were implanted between two and 10 years previously in 11 patients (four females, seven males; age range: 32-54 years). One patient had diabetes and had undergone prior percutaneous coronary intervention with drug-eluting stent implantation to the ostial left main artery. All had cardiomegaly with ejection fraction 24-63% and an increased mean gradient across the immobile prosthetic valve. Patients presented in a hemodynamically unstable state with pulmonary edema and/or hypotensive shock. The International Normalized Ratio was <2.5 in nine patients. Eight patients with mitral valve thrombosis responded to thrombolytic therapy and survived, with complete resolution of thrombus and return of full mobility of leaflets and resolution of valve gradients. To date, all responders have survived (up to five years) without any recurrence of re-thrombosis (PVT). CONCLUSION: Intravenous STK may be life-saving in critically ill NYHA class III/IV patients with left-sided PVT. Thrombolytic therapy is much cheaper and easier to administer than surgical replacement of the thrombosed prosthetic valve.

Successful fibrinolytic treatment of prosthetic heart valve thrombosis using streptokinase.

OBJECTIVES: This study aims to evaluate the clinical outcome of fibrinolytic treatment of prosthetic valve thrombosis (PVT) with 'streptokinase' as a first line treatment for these cases. METHODS: The study group was 20 consecutive patients (10 females) diagnosed with PVT. The protocol for streptokinase administration was either accelerated (intravenous infusion of 0.5 million IU over 30 minutes followed by 0.15 million IU/h) or conventional (intravenous infusion of 0.25 million IU over 30 minutes followed by 0.15 million IU/h). Success of fibrinolytic therapy was defined as complete restoration of valve function in the presence or absence of complications. RESULTS: Eighteen patients (90%) had mitral PVT and two (10%) had aortic PVT. Thrombolytic therapy with streptokinase was successful in all but one case, with a total mortality of four cases (20%). In PVT episodes, before streptokinase therapy, the prosthetic valve areas (in all cases, mitral and aortic positions) were 0.82 ± 0.21, 0.83 ± 0.21, and 0.73 ± 0.18 cm²; and the peak and mean transvalvular gradients were 38.7 ± 16.7 and 25.4 ± 8.7, 34.1 ± 8.8 and 23.2 ± 5.4, and 80.0 ± 14.1 and 45.0 ± 7.1 mmHg, respectively. After streptokinase therapy, the prosthetic valve area and peak and mean transvalvular gradients improved significantly (for all cases, mitral and aortic positions: valve area 2.17 ± 0.58, 2.21 ± 0.61, and 1.85 ± 0.07 cm², peak gradient 18.7 ± 11.0, 16.4 ± 7.7, and 39.0 ± 18.4, and mean gradient 9.6 ± 7.1, 8.2 ± 5.3, and 22.0 ± 11.3 mmHg, respectively; paired t-test, P<0.001 for pre- versus post-streptokinase infusion for all variables). CONCLUSION: Fibrinolytic therapy using streptokinase was an effective therapeutic strategy for the management of PVT and is a reasonable alternative to surgery.

Fibrinolytic therapy of thrombosis in 27 newborns followed-up in neonatal intensive care unit.

BACKGROUND AND AIM: We aimed to report newborns with thrombosis and needed fibrinolytic treatment. PATIENTS AND METHODS: This was a retrospective study conducted on 27 newborns with thrombosis followed-up in a neonatal intensive care unit between December 2007 and December 2012. The patients were divided into two groups according to treatment protocol; Group 1 (n = 15): recombinant tissue-type plasminogen activator (r-tPA) and Group 2 (n = 12): streptokinase (STK). The groups were compared in terms of the efficacy and complications of the treatments. RESULTS: In Group 1, flow restoration was complete in nine (60%) patients, partial in two (13.3%), and absent in four (26.7%). In Group 2, flow restoration was complete in seven (58.3%) patients, partial in three (25%), and absent in two (16.0%). The incidence of complete/partial recovery was similar in the groups. There was no difference between the two groups with regard to the duration of thrombus resolution. Fibrinolytic treatment was terminated in seven patients (46.7%) in Group 1, while in three patients (25%) in Group 2 due to the complications. The most common complications were minor or major bleedings. There was no statistically significant difference with regard to all bleedings complications between the two groups (P = .08), although the incidence of skin hemorrhages was higher in Group 1 (P = .007). There was no significant difference between the mortality rates. CONCLUSION: Even though the use of STK is not further recommended because of its potential undesirable side effects in newborns, its efficacy and safety appears to be similar to those of r-tPA.

Efficacy of a new accelerated streptokinase regime in acute myocardial infarction: a double blind randomized clinical trial.

BACKGROUND: Studies of thrombolysis in acute ST-elevation myocardial infarction (STEMI) have focused on differences in outcome between groups receiving various regimes. Expedited treatment may influence the efficacy of nonfibrin specific thrombolytic agents in restoring early patency of the infarct-related artery (IRA), which is a major determinant of survival after ST-elevation myocardial infarction (STEMI). METHODS: We performed a randomized double blind clinical trial comparing an accelerated infusion (1.5 MU/20 min; group A, n = 200) with the conventional infusion (1.5 MU/60 min; group B, n = 100) of streptokinase (SK) in 300 patients with their first episode of acute STEMI. Demographics, clinical reperfusion rates, angiographic study findings, left ventricular ejection fraction (LVEF), in-hospital morbidity and mortality and one year mortality were compared between two groups. RESULTS: Mean age was 59 ± 12 years (79% male). There were no differences in baseline data between groups. Clinical, electrocardiographic and physiologic reperfusion indices revealed significant faster and higher reperfusion rates and better preserved LVEF at discharge in group A. Sixty-three percent of patients in either group underwent invasive coronary angiography at a mean of 5 days with comparable findings. Atrial fibrillation, malignant ventricular arrhythmias in the second day, in-hospital and late mortalities rates occurred more frequently in group B patients. In multivariate analysis, accelerated SK infusion was the only independent predictor of higher electrocardiographic reperfusion (OR = 3.2, CI: 1.93-5.3, P < 0.001). CONCLUSIONS: The accelerated SK infusion regimen of 1.5 MU in 20 min is safe and well tolerated with significantly faster and higher clinical reperfusion rates, more preserved LV systolic function, less atrial and ventricular sustained arrhythmias, and less in-hospital and 1 year mortality rates in acute STEMI.

Comparison of fibrinolytic versus surgical therapy in the treatment of obstructive prosthetic valve thrombosis: a single-center experience.

OBJECTIVE: Prosthetic heart valve thrombosis (PVT) is a rare but severe cardiac condition. There are only a few data regarding comparison of the fibrinolytic and surgical approaches for the treatment of PVT. In this study, we compared the results of fibrinolytic therapy versus surgery in patients who presented to our institution with a diagnosis of obstructive-type PVT. METHODS: From January 2001 to August 2008 in our institution, 33 patients who met clinical and echocardiographic criteria for obstructive-type PVT were included in the study. Fifteen of these patients underwent fibrinolytic treatment with streptokinase, which consisted of an initial bolus of 250,000 U followed by 100,000 U/h. Eighteen patients were treated with surgery. RESULTS: The 2 groups had similar baseline characteristics, including New York Heart Association functional status, types and positions of prosthetic valves, international normalized ratio values, and presentation symptoms. Full hemodynamic success was achieved in 12 patients who underwent fibrinolytic therapy and in 15 patients in the surgery group. The mean (±SD) streptokinase infusion time was 17.8 ± 11.1 hours. Two major hemorrhages and 2 cases of systemic embolism were observed in the fibrinolytic group. The 2 groups did not differ with respect to mortality rate (P = .79). The duration of hospitalization was longer in the fibrinolytic group than in the surgery group (10.7 ± 6.6 days versus 6.9 ± 6.7 days, P = .045). CONCLUSIONS: Although fibrinolytic therapy is generally recommended for the treatment of PVT for specific patient groups, our results suggest that it may be as efficacious and safe as surgery, depending on patient selection.

Dolor lumbar por estreptoquinasa recombinante: presentación de un caso / Lumbar pain caused by recombinant streptokinase: a case presentation

La Heberkinasa® (estreptoquinasa recombinante), es un trombolítico utilizado en el tratamiento del infarto agudo del miocardio, presentada en forma de liofilizado en bulbos estériles, de conocidos y probados efectos de reperfusión coronaria y reducción del tamaño del infarto, además de otras aplicaciones como en la trombosis venosa profunda, trombosis de acceso vascular permanente de pacientes con insuficiencia renal crónica terminal tratados por hemodiálisis periódicas, disfunción de prótesis valvulares cardíacas por trombos y en el tromboembolismo pulmonar; se asocian reacciones adversas durante el tratamiento, frecuentes y menos frecuentes, dentro de las que se encuentra el dolor lumbar. Se presenta a una paciente con el diagnóstico de un infarto agudo del miocardio, de cara diafragmática, a quien se le aplicó la trombolisis con Heberkinasa y durante esta presentó dolor lumbar agudo, intenso, que cedió con la reducción de goteo de la infusión y esta se pudo continuar sin más problemas.

The Heberkinase® (recombinant streptokinase) is a thrombolytic agent used in treatment of acute myocardial infarction, presented as sterile bulbs, of known and proved effects of coronary reperfusion and reduction of infarction dimension, besides of other applications e.g. the deep venous thrombosis, permanent vascular access thrombosis in patients presenting with terminal chronic renal insufficiency treated by periodical hemodialysis, dysfunction of cardiac vascular prostheses by thrombi, and in case of pulmonary thromboembolism; there are adverse reactions associated during treatment, frequent and less frequent including those of lumbar pain. Authors present a case of a woman diagnosed with acute myocardial infarction of diaphragmatic side undergoing thrombolysis with Heberkinase, and during it she had intense and acute lumbar pain improving with reduction of dripping infusion without subsequent problems.

Intrapleural streptokinase treatment in children with empyema.

Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.

[Liver rupture of a subcapsular haematoma after pharmacologic revascularization (Streptokinase) for acute myocardial infarction--case report]. / Ruptura de ficat post revascularizare farmacologica (streptokinaza) pentru infarct miocardic acut.

We report the case of a 56 years old male patient, smoker, obese, with untreated arterial hypertension, hospitalized on 16.02.07 with the diagnosis of inferior acute myocardial infarction, for which he received thrombolysis with streptokinase, followed by anticoagulation with non fractioned heparin. Two days later he started to complain of acute abdominal pain, and laboratory findings showed a low hemoglobin level. Imaging findings (ultrasonography and CT scan) showed evidence of subcapsular liver haematoma, caused by bleeding at hepatic and splenic level. He received red blood packed cells, fresh frozen plasma, cryoprecipitate, activated factor VII and was transferred by helicopter to Fundeni Clinical Institute--Intensive care unit (ICU). On admission, the patient was conscious, anxious, dyspneic, with mild hypoxia, with no signs of low cardiac output and with a painful abdomen. ECG, echocardiography and elevated myocardial necrosis enzymes confirmed myocardial infarction. Shortly after admission there was a worsening of his clinical condition, with a decrease in hemoglobin level despite red blood packed cells administration (Hb=7.8 g/dl) and thrombocytopenia (82000/mmc), with normal coagulation tests, thus suggesting active intraabdominal bleeding. Echography and CT scan confirmed bleeding. Emergency surgery was performed, showing massive haemoperitoneum (approx 4.5 L of blood), due to spontaneous rupture of a subcapsular hematoma in the liver. The surgical hemostasis was performed on the liver parenchyma laceration. Duration of surgery was 4 hours. There were no significant cardiac events during surgery (no signs of ischemia on ECG, no ST elevation), despite the need for inotropic agent. After surgery, the patient was referred to the ICU, intubated and ventilated, with inotropic support - dobutamine. Sequential ECG's, enzymatic trend and echocardiographies were performed to monitor myocardial ischemia. The outcome was favourable, no further bleeding and no postoperative myocardial infarction occurred. Secondary prevention was started early (thromboprophylaxis, selective beta-blocker, angiotensin inhibitors and statins). The patient had a favorable outcome and was discharged from the ICU the fourth day after surgery. He had a total length of stay in hospital of seven days, with a follow-up in the cardiology department.

Spontaneous subperiosteal orbital hemorrhage following thrombolytic therapy for myocardial infarction.

A 60-year-old man experienced right orbital pain, periorbital swelling, and double vision 2 hours after treatment with streptokinase and heparin for myocardial infarction. Orbital CT revealed a right superior subperiosteal orbital hemorrhage. Conservative management in the absence of visual compromise was sufficient, as his symptoms and signs resolved completely in approximately 6 weeks with no recurrence during 6 months of follow-up. This case demonstrates that nontraumatic subperiosteal orbital hemorrhage may occur after thrombolytic therapy for myocardial infarction. Conservative treatment with cold compresses in the absence of visual impairment may be sufficient, as was in our patient and others.

Utilidad de la terapia trombolítica con estreptokinasa a dosis baja en infarto agudo del miocardio / Usefulness of thrombolytic therapy with low doses of streptokinase in acute myocardial infarction

Background: The optimal dose of Streptokinase in the treatment of acute myocardial infarction is not well established. Apparently, the thrombolytic efficacy would not increase with doses over 750.000 units. Aim: To compare the effectiveness and safety of treatment with low doses of Streptokinase, ranging from 500.000 to 750.000 units, in patients with ST elevation acute myocardial infarction. Patients and methods: From September 1993 to September 1998, the GEMI register of patients with acute myocardial infarction, was carried out in 37 hospitals, incorporating 4,938 patients. Of these, 1,631 patients received streptokinase. According to the administered dose of Streptokinase, patients were divided in two groups: 1,465 patients who received 1.5 millions U in 60 minutes (classical therapy group), and 166 patients with ischemic chest discomfort and either ST-segment elevation or left bundle-branch block on the electrocardiogram, who received 500.000 to 750.000 U streptokinase administered in no more than 30 minutes, with heparin, within 0 to 6 hours of symptom onset. Successful reperfusion, mortality, complications, and hospital outcome was evaluated in both groups. Results: The low dose group of patients had a better reperfusion criteria profile. No differences between groups were observed in patient evolution, mortality, maximum Killip classification, post myocardial infarction heart failure, ischemic complications, arrhythmias or mechanical complications. Conclusions: These results suggest that streptokinase in low doses is at least as effective as classical therapy, in the treatment of ST elevation acute myocardial infarction.

Safety profile of the intravitreal streptokinase-plasmin complex as an adjunct to vitrectomy in the rabbit.

BACKGROUND: The generation of an atraumatic posterior vitreous detachment (PVD), a common goal in vitreoretinal surgery, is a challenge, particularly in children and young trauma patients. Plasmin has been proposed as an adjunct to vitrectomy to enzymatically generate a PVD. Low doses of streptokinase-activated plasmin were tested in human pilot studies. This dose-escalation study assesses the safety range of intravitreal human streptokinase-plasmin in rabbits. METHODS: Plasminogen was isolated from human plasma by affinity chromatography, followed by activation with streptokinase (1:1), to generate the streptokinase-plasmin complex. Enzyme doses from 0.1-7 activity units (AU, in 0.1 ml) were injected into the mid-vitreous of 35 eyes; six control eyes were injected with balanced salt solution (BSS, 0.1 ml). Thirty minutes after injection, a two-port vitrectomy was performed. Fundus and slit lamp examinations were performed on days 1 and 7. On days 2 and 7, bright flash electroretinography was performed and compared with preoperative recordings. Some animals receiving higher doses of streptokinase-plasmin (1-7 AU) were followed clinically and with electroretinography for up to 9 months. RESULTS: A mild-to-moderate inflammatory response was seen in both control and plasmin-treated eyes on day 1, but had disappeared completely by day 7 in most eyes. In the 7 AU group, inflammation was stronger and more protracted. Two of three eyes from this group developed wrinkling of the medullary rays; one of them showed discoloration and traction at the medullary rays in the late follow-up. Electroretinograms (ERGs) of vitrectomized control eyes showed the following changes from preoperative values: 48 h, a-wave -11.10% [no significant (n.s.)], b-wave -14.62% (P=0.046); 7 days, a-wave +9.18% (n.s.), b wave +11.69% (n.s.). For the enzyme-treated eyes: 48 h: a-wave -20.43% (P<0.001), b-wave -9.57% (p<0.001); 7 days: a wave -14.21% (P<0.001), b-wave +2.48% (P<0.001). There was no evidence of dose-dependent ERG changes in enzyme-treated eyes at doses up to 5 AU. Groups of up to 3 AU were investigated by light and transmission electron microscopy, without evidence of toxicity. CONCLUSION: Streptokinase-plasmin doses up to 3 AU were found to be safe when injected into rabbit eyes followed by vitrectomy.

Angioedema relacionado ao uso de estreptoquinase / Angioedema related to the use of streptokinase

O angioedema é uma reacão rara, aguda e potencialmente fatal, à estreptoquinase, devendo ser diagnosticada prontamente e tratada para garantir melhor prognóstico ao paciente. Descrevemos aqui o caso de um homem de 65 anos, que apresentou reacão anafilática após o início de trombólise com estreptoquinase, sendo rapidamente tratado, permaneceu uma semana internado em Unidade de Terapia Intensiva.

U.K. Controlled trial of intrapleural streptokinase for pleural infection.

BACKGROUND: Intrapleural fibrinolytic agents are used in the drainage of infected pleural-fluid collections. This use is based on small trials that did not have the statistical power to evaluate accurately important clinical outcomes, including safety. We conducted a trial to clarify the therapeutic role of intrapleural streptokinase. METHODS: In this double-blind trial, 454 patients with pleural infection (defined by the presence of purulent pleural fluid or pleural fluid with a pH below 7.2 with signs of infection or by proven bacterial invasion of the pleural space) were randomly assigned to receive either intrapleural streptokinase (250,000 IU twice daily for three days) or placebo. Patients received antibiotics and underwent chest-tube drainage, surgery, and other treatment as part of routine care. The number of patients in the two groups who had died or needed surgical drainage at three months was compared (the primary end point); secondary end points were the rates of death and of surgery (analyzed separately), the radiographic outcome, and the length of the hospital stay. RESULTS: The groups were well matched at baseline. Among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery (with streptokinase: 64 of 206 patients [31 percent]; with placebo: 60 of 221 [27 percent]; relative risk, 1.14 [95 percent confidence interval, 0.85 to 1.54; P=0.43), a result that excluded a clinically significant benefit of streptokinase. There was no benefit to streptokinase in terms of mortality, rate of surgery, radiographic outcomes, or length of the hospital stay. Serious adverse events (chest pain, fever, or allergy) were more common with streptokinase (7 percent, vs. 3 percent with placebo; relative risk, 2.49 [95 percent confidence interval, 0.98 to 6.36]; P=0.08). CONCLUSIONS: The intrapleural administration of streptokinase does not improve mortality, the rate of surgery, or the length of the hospital stay among patients with pleural infection.