COMPARISON OF INTRAVENOUS ANISOYLATED PLASMINOGEN STREPTOKINASE ACTIVATOR COMPLEX (APSAC) AND INTRACORONARY STREPTOKINASE IN ACUTE MYOCARDIAL INFARCTION

To compare the reperfusion potential of intravenous anisoy-lated plasminogen streptokinase activator complex (APSAC) a new thrombolytic, and standard therapy with intracoronary streptokinase in acute myocardial infarction (AMI), a randomized multicenter reperfusion trial was performed. Consenting patients with clinical signs of AMI and documented coronary occlusion (flow grade 0 or 1) were randomized to treatment within 6 hours of symptoms (mean, 3.4h) with intravenous APSAC (30 U in 2-4 min) or intracoronary streptokinase (bolus, then 2,000 U/min x 60 min). Reperfusion success was defined as grade 2 or 3 flow at 60 min for intracoronary and 90 min for intravenous therapy. A total of 189 patients (pt) were randomized and 179 pt were evaluable for efficacy. Reperfusion was similar for the two treatments: 52% (49/94) for APSAC and 61% (52/85) for streptokinase (p≤0.2). Success was dependent on initial occlusion grade (p≤0.001): 49% (65/133) for grade 0 (APSAC= 45%, streptokinase=54%), but 78% for grade 1 (APSAC=80%, strepto-kinase=77%). The success of intravenous (APSAC) therapy was also dependent on time to treatment: 59% for ≤4h, versus 36% after 4h (p<0.04). APSAC was well tolerated, the change in mean blood pressure after bolus injection being modest (−11 mmHg). Systemic fibrinolysis was somewhat greater after APSAC than low dose streptokinase: fibrinogen levels averaged 39 ± 4% (SE) of control at 90 minutes after APSAC, versus 64 ± 5% after streptokinase (p<0.01) in the subgroup tested. The rate of bleeding complications was acceptable for both regimens, and other adverse reactions were comparable. Rates of early occlusion were low in both treatment groups, and evolution of ECG and enzymatic indicators were similar. Thus, APSAC provides approximately similar reperfusion results as intracoronary streptokinase, especially when given within 4h, but is easier to administer and is well tolerated.