State-of-the-Art Review

Thrombolytic Drugs in Acute Myocardial Infarction

*Omer Iqbal, M.D., *†Harry Messmore, M.D., *Debra Hoppensteadt, Ph.D., *‡Jawed Fareed, Ph.D.,
and †William Wehrmacher, M.D.

Departments of *Pathology, †Medicine, and ‡Pharmacology, Loyola University Medical Center, Maywood, Illinois, USA

Thrombolytic drugs play a crucial role in the manage- botic drug with the lytic agent because of an increase in
ment of patients with thrombotic and thromboembolic thrombin generation (2,3). In a recent study (Hirulog
complications during pre-, peri-, and postinterventional Early Reperfusion/Occlusion [HERO] trial) of a random-
cardiologic procedures and acute ischemic stroke. With ized double-blind comparison of hirulog versus heparin
advances in antithrombotic and anticoagulant drugs have in patients receiving streptokinase and aspirin for acute
come significant developments in the field of thrombo- myocardial infarction (AMI), White et al. (4) and
lytic therapy. It is now possible to produce recombinant Cheesebro (5) have shown that hirulog is more effective
forms of tissue-type plasminogen activator (tPA), uroki- at achieving early thrombolysis in myocardial infarction
nase, prourokinase, and staphylokinase etc. by the use of (TIMI) 3 flow than heparin does as an adjunct to strep-
recombinant DNA technology. Recombinant urokinase tokinase and aspirin in AMI, and that the effect of hiru-
and prourokinase are expressed from mouse hybridoma log may be dose dependent. The early patency achieved
cell line, and the latter, a precursor of urokinase, has such with streptokinase can be improved by adjunctive admin-
advantages as increased potency and increased effective- istration of the direct-acting thrombin inhibitor, hirulog.
ness of thrombolytic therapy.The development of longer The improved antithrombotic effect and the gain in pa-
acting tPAs, fibrin specific agents, and newer urokinase- tency were achieved at lower activated partial thrombo-
type plasminogen activators may be beneficial in new plastin time (aPTT) levels and were not associated with
indications of thrombolytic therapy such as thrombotic an increased risk of bleeding (4,5).
stroke. The thrombolytic agents can be divided into three gen-
Hemostasis represents a physiologic homeostasis re- erations as listed in Table 2.
sulting from a dynamic equilibrium between coagulation TIMING AND SURVIVAL BENEFIT
and fibrinolysis. An intact endothelium (a single layer of
cells lining the vascular lumen, estimated to be 1,000- Because no one thrombolytic agent has proven supe-
5,000 square meters) is the largest endocrine, paracrine, rior to the others, the important issue in thrombolytic
and autocrine organ in the body and serves as a unique therapy that should be emphasized is not which agent to
hemostatic tool in the regulation of coagulation by syn- use, but how quickly to use it. According to the Ameri-
can Heart Association, the time from presentation to ini-
thesizing procoagulant and anticoagulant substances (1)
(Table 1). tiation of thrombolytic therapy should not exceed 1 hour
Development of antithrombin drugs, glycoprotein (6,7). Longer delays result in unnecessary deaths. The
(GP) IIb/IIIa inhibitors, and low molecular weight hepa- earlier the thrombolytic drug is initiated, the greater the
rins (LMWHs) provide favorable options for use in com- survival benefit. According to the data from the Fibrino-
bination strategies for better long-term clinical outcome. lytic Therapy Trialists Collaborative Group (8), which
The more potent the antithrombotic drug, the more rapid included pooled results of nine clinical trials (60,000
and thorough the thrombolysis (2). As a result of en- patients), comparing thrombolytic therapy with different
hanced thrombolysis, there is a reduction in the residual thrombolytic agents to placebo in patients with AMI
mass of mural thrombus, residual stenosis, local shear showed that for every 1,000 patients who received
force, and increased platelet deposition and reocclusion. thrombolytic therapy, 18 patients survived because of the
To maximize the extent of thrombolysis, there is a ne- therapy. The survival benefit (in lives saved per 1,000
cessity of the simultaneous administration of antithrom- patients treated) of thrombolytic therapy in relation to the
time after the onset of chest pain that therapy is initiated
shows that after 12 hours following the onset of chest
Manuscript received May 14, 1999; accepted August 23, 1999. pain, the survival benefit of thrombolytic therapy is lost.
Address correspondence and reprint requests to Dr. Omer Iqbal,
Over the 12-hour effective treatment period, the decline
Dept. of Pathology, Loyola University Medical Center, 2160 S. First
Avenue, Maywood, Illinois 60153, U.S.A. in survival benefit averages 1.6 lives lost per 1,000 pa-

1
2

TABLE 1. Substances secreted by the endothelium TABLE 3. Selection criteria for thrombolytic therapy

Relative contraindication are not included because the

survival benefit for thrombolytic therapy should justify
tients per hour delay. In the first 6 hours, the hourly the risks associated with relative contraindication (11). It
decline in survival (2.6 per 1,000) is greater than in the should be noted that neither advanced age nor the pres-
final 6 hours (0.6 per 1,000). ence of indwelling venous catheter (including central ve-

nous pressure and pulmonary arterial catheters) are rea-

SELECTION CRITERIA FOR LYTIC THERAPY sons to exclude a patient from thrombolytic therapy. Al-

Patients who candidates for

though bleeding complications are more common in the
are thrombolytic therapy elderly, the survival benefit of thrombolytic therapy is
must be identified possible after presentation,
as soon as
also greater in the elderly (11).
using the National Heart Attack Alert Program Coordi- More than 90% of patients who present with ST seg-
nating Committee eligibility criteria (9). About 20% of ment elevation have coronary thrombotic occlusion and
the patients with AMI receive thrombolytic therapy. An
additional 15% are eligible but never receive the therapy
early thrombolytic intervention reduced the mortality by
Table 3 for the selection criteria for thrombo-
approximately 30% as per the placebo-controlled ran-
(10). See domized trials of the 1980s (12-17).
lytic therapy.
FIRST-GENERATION THROMBOLYTIC
TABLE 2. Three generations of throbolytic agents AGENTS (TABLE 4)

Streptokinase
Streptokinase is the first most extensively studied
agent to date. It is not an enzyme and activates the fi-

TABLE 4. Characteristics of first-generation

thrombolytic drugs
 3

brinolytic system by forming a 1:1 stoichiometric com- a direct plasminogen activator.The angiographic studies
plex with plasminogen that in turn converts plasminogen of urokinase have demonstrated that the 90-minute an-
to plasmin. Streptokinase causes systemic conversion of giographic patency rate of 60% (confidence interval [CI]
plasminogen to plasmin and depletion of circulating fi- 55%-64%) is slightly improved relative to streptokinase
brinogen, plasminogen, and factors V and VIII. With the (32-36). Furthermore, the data suggest that the infarct
usual dose of 1.5 million units streptokinase, the fibrino- vessel patency rates are not superior to those with an-
gen level drops to20% of the pretreatment level with isoylated plasminogen streptokinase activator complex
corresponding higher levels of fibrinogen degradation (APSAC) or accelerated tPA.
products that may result in a modest increase in bleeding
complications. SECOND-GENERATION THROMBOLYTIC
Although most patients have preformed antistrepto- AGENTS (TABLE 5)
coccal antibodies (18), only 4% of patients in the Second
International Study of Infarct Survival trial (ISIS-2) re-
Tissue-type plasminogen activator
ceiving streptokinase were reported to have allergic re- This is a naturally occurring serine protease and is
actions and the occurrence of anaphylactoid shock in
considered to be an endogenous physiologic plasmino-
0.5% (13). Hypotension is a frequent side effect. There
are persistent neutralizing IgG titers for at least 4 or more
gen activator in humans. Following exercise, the vascu-
lar endothelium produces increasing levels of tPA, which
years following streptokinase or anistreplase administra- are counter regulated by plasminogen activator inhibitors
tion (18-21).
(PAI-1). A single-chain version, alteplase, and a two-
Hypotension should be treated by slowing or interrupt- chain version, duteplase, are commercially available.
ing the infusion, placing the patient in Trendelenburg
position, and administering fluids. There is no clear evi- Tissue-type plasminogen activator has marked affinity
for plasminogen-fibrin-binary complex, making it a fi-
dence that adjunctive heparin is beneficial in patients
brin-selective agent. It causes activation of circulating
given streptokinase, unlike seen in patients given tPA.
Several studies have shown that streptokinase is plasminogen (37). With routine doses the low decline in
highly effective in achieving patency of the infarcted
fibrinogen is approximately 50%, and there is less gen-
eration of fibrin split products. Tissue-type plasminogen
vessel at 3-24 hours after treatment is initiated (22-25). activator lyses clot more rapidly than streptokinase (38)
Urokinase and is accompanied by a higher rate of reocclusion as-
Urokinase has not been specifically approved for sociated with the lack of fibrinogen depletion. The higher
AMI, but small studies have demonstrated that it induces fibrinolytic potential of tPA induces hemorrhagic stroke,
coronary thrombolysis (26). This naturally occurring higher than streptokinase. However, tPA has the ability
plasminogen activator was first used to treat AMI in the to achieve lysis with relatively aged, cross-linked fibrin
1960s (17,27-31). Two forms of urokinase, a low mo- due to its fibrin-specificity. Tissue-type plasminogen ac-
lecular weight form (33,000 d) and a high molecular tivator produces faster reperfusion especially when given
weight form, (55,000 d) are available. in the first 4 hours.A front-loaded or accelerated tPA
Compared to streptokinase, urokinase has much less regimen initiated by Nehaus et al. in 1989 (39), consist-
antigenicity and it can be given as a bolus. Like strep- ing of an initial bolus of 15 mg, 50 mg over the next 30
tokinase, urokinase has a relatively low rate of reocclu- minutes, and 35 mg over the following 60 minutes
sion.Urokinase, unlike streptokinase, is an enzyme and is achieves higher early patency rates than previous dosing

TABLE 5. Characteristics of second generation thrombolytic drugs

4

schedules. Reocclusion rates are higher with tPA because regimen consisting of 20-mg bolus followed by a 60-mg
of its shorter half-life. infusion over 60 minutes. The saruplase regimen in-
.
..... , I
:.-..’.-
cluded concomitant infusion of heparin.
Anistreplase (APSAC) In the Study in Europe with Saruplase and Alteplase in
Anisoylated plasminogen streptokinase activator com- Myocardial Infarction (SESAM) study (48), saruplase
plex is a conjugate of streptokinase that is inactive until and a 3-hour infusion of recombinant tPA (rtPA) pro-
the anisoyl group is hydrolyzed, which gradually occurs
duced similar 90-minute TIMI grade 2/3 flow rates
after injection thus prolonging the half-life of the drug to
(79.9% and 81.4%, respectively), reocclusion was simi-
approximately 100 minutes and allowing for a bolus lar with both the drugs, and complication rates were not
rather than infusion mode of administration. It is given in
a dose of 30 mg bolus over 2-5 minutes. The drug is
significantly different between the two treatment groups.
The infarct vessel patency rates with SCU-PA was 70%
concentrated at the site of the thrombus and is activated
at 90 minutes after initiation, similar to conventional tPA
locally. It can be injected as a bolus, and it will provide and anistreplase in the Prourokinase in Myocardial In-
continuing thrombolytic activity. This makes APSAC a farction (PRIMI) trial (49).
convenient agent to administer out of the hospital or in a
busy Saruplase could be modified and coupled with tPA in
emergency room. chimeric variants of plasminogen activator. Two kringle
Since streptokinase is the primary constituent of the
domains of tPA and the serine protease domain of saru-
agent, the antigenicity and side-effect profile of APSAC
is similar to streptokinase. However, there is a higher plase could be coupled to form a chimera. This chimera,
when tested in animal models, has been found to have a
rate of intracerebral hemorrhage from the ISIS-3 trial,
similar between duteplase tPA and anistreplase and greater thrombolytic potential than alteplase or saruplase
about twice the incidence found with streptokinase. Al-
alone, mainly because of a prolonged half-life. This chi-
mera has also been given as a double bolus to a small
though commercially available, it is rarely used. The
rates of recanalization at each time point are intermediate
group of patients (109). Saruplase could also be chemi-
between tPA dosing and streptokinase (40). cally cross-linked with antifibrin and antiplatelet anti-
bodies or their Fab fragments to increase the concentra-
Saruplase, single-chain urokinase plasminogen tion of thrombolytic at the site of thrombus. This has
activator (SCU-PA) resulted in increased thrombolytic potency in vivo in a
Prourokinase or SCU-PA (Saruplase) is the polypep- rabbit jugular vein thrombus model compared with sa-
tide precursor of urokinase. It is also known as recom- ruplase alone (51). , _ . _ ,

binant single-chain urokinase-type plasminogen activa-

tor (r-SCU-PA) or prourokinase. It is a prodrug produced
THIRD-GENERATION THROMBOLYTIC
from naturally occurring physiologic protease. The en-
AGENTS (TABLE 6)
zyme has fibrin selectivity like tPA, which is linked to a
circulating plasma inhibitor that is inactivated in the Rapidityof reperfusion is as important as achieving
presence of fibrin. The amino acid sequence of saruplase of the infarct-related artery. Commonly used
resembles that of tPA. Its half-life is 7-8 minutes (41) patency
and is cleared by the liver. Saruplase is a single-chain plasminogen activators leave a third of the arteries still
occluded (52). Opening vessels early in the infarct course
polypeptide consisting of 411 amino acids, which is in is more important than achieving patency later (53). This
vivo partially converted by plasmin into an active two-
led to development of new thrombolytic strategies to
chain, low molecular weight form of urokinase with 276 achieve higher initial patency rates than those accompa-
amino acids (41,42). Saruplase causes a systemic de-
nied with the 90-minute rtPA infusion and faster clot
crease in plasmin levels as reflected by a decrease in
lysis. The following are newer approaches to achieve the
fibrinogen and a-2 antiplasmin and increase in fibrino- above goals (54-57).
gen degradation products (43). When compared with
streptokinase, it causes less systemic fibrinolytic activity 1. Bolus delivery of agents and prehospital administra-
but greater than that of alteplase (44,45). The COMPASS tion of drugs to improve time to treatment.
(comparison of saruplase and streptokinase) trial resulted 2. Use of potent adjunctive agents such as direct throm-
in a lower incidence of all cause mortality at 30 days with bin inhibitors and GP IIb/IIIa inhibitors rather than
saruplase compared with streptokinase (5.7% vs. 6.7%, currently followed heparin and aspirin regimen.
respectively) (46). Although the rates of stroke and re- 3. When TIMI flow is less than grade 3, combination
infarction were similar with both the drugs, the rates of strategies such as lytic agent followed by rescue an-
intracranial hemorrhage (ICH) were considerably higher gioplasty.
with saruplase (0.9%) than with streptokinase (0.3%). 4. Development of newer plasminogen activators that
The Practical Applicability of Saruplase Study (PASS) will produce higher ratesof TIMI grade 3 flow and
(47) confirmed the safety and efficacy of a saruplase faster action.
 5

TABLE 6. Characteristics of third-generation thrombolytic drugs

Several plasminogen activators have been produced tPA. There is a large ongoing trial IN- TIME-II trial (63)
from the human tPA or developed from animal and bac- with more than 15,000 patients enrolled.
terial proteins. Phase III trials with these agents are ex- Lanoteplase is a mutant of wild-type tPA. It has a
pected to conclude in the early part of 1999. half-life of approximately 37 minutes. Although it has

Reteplase (rPA) improved lytic activity relative to native tPA in animal

models, it has reduced fibrin affinity. Taking into con-
Reteplase is a deletion mutant of wild-type human tPA
in which the finger, epidermal growth factor (EGF), and sideration its clearance rate and half-life, this agent is
suitable for a single-bolus administration (64).
kringle-I regions have been deleted. These mutations
In a Phase II trial known as intravenous nPA for Treat-
produce a molecule with a prolonged half-life (18 min-
ment of Infarcting Myocardium Early (In Time), several
utes), 3-4 times longer than native tPA. The longer half-
life of rPA permits administration as a double bolus single bolus doses of 15, 20, 60, and 120 U/kg nPA
given 30 minutes apart (58). The superior patency at 90 against rtPA were selected (65). At 90 minutes the high-
minutes in the early Recombinant Plasminogen Activator est dose of nPA was more effective than rtPA. The TIMI
International Dose-Finding Study-I (RAPID-1) and grade 3 flow was 57% with nPA and 46% with rtPA.
RAPID-II trials, which enrolled small number of subjects However, there were no differences in the 30-day com-
in the rtPA arms of these trials, suggests that the differ- posite end point of major bleeding, heart failure, nonfatal
ence observed was not actually the result of a higher reinfarction, or death. The event rates were higher in the
patency with rPA but rather reflects the unusually low rtPA group. It is observed that about 60% of the infarct-
success rate with rtPA that was probably due to chance. related arteries reach TIMI grade 3 flow after adminis-
In the Global Utilization of Streptokinase and yt-PA for tration of accelerated rtPA. However, in the RAPID I
Occluded Coronary Arteries III (GUSTO III) trial, which (rtPA) (66), RAPID II (rtPA) (67), and In Time (nPA)
enrolled more than 15,000 patients, the 30-day mortality (65) trials, the TIMI-grade 3 flow rates were 40%,
rate was 7.47% in the reteplase group and 7.24% for 45.2%, and 46%, respectively. A phase III trial In Time
alteplase; a very small difference. Thus, reteplase pro- II has been designed to test the equivalence of nPA
vided no additional survival benefit over alteplase (59). against rtPA with the mortality as the primary end point.
There is some evidence suggesting that rPA is associated
with a greater incidence of reocclusion than rtPA. rPA is
Tenecteplase
less fibrin specific than rtPA (60,61). There is also evi-
Tenecteplase is a recombinant version of tPA. It is
dence that rPA activates platelets markedly when com-
highly fibrin specific and resistant to PAI-1. In a double-
pared to rtPA (62). To prevent or decrease reocclusion blind, randomized trial of 16,505 patients with AMI, te-
rates rPA is combined with a potent GP IIb/IIIa inhibitor
as used in the ongoing GUSTO IV trial.
necteplase was compared with tPA and was given as a
weight-adjusted single bolus and tPA was given as a 90
Lanoteplase (n-PA) minute infusion. At 30 days, the mortality rates were
Lanoteplase is a deletion mutant of wild-type tPA. It 6.2% with each treatment group, the rates of ICH were
has a half-life of 37 minutes, improved lytic activity in 0.93% with tenecteplase and 0.94% with the tPA group.
animal models, and reduced fibrin affinity. It is given as However, the need of transfusions as a result of serious
a single bolus. It has been assessed in an angiographic bleeds was 4.3% with tenecteplase, significantly less
trial of intravenous n-PA for Treating Infarcting Myo- when compared with 5.5% with tPA. It is thought that
cardium Early (IN-TIME-I). The infarct vessel patency the ease of administration may make tenecteplase ideal
was found to be comparable with that with accelerated for emergency room treatment (66).
6

TNK-tPA platelet aggregation, eventually increasing the PAI-1I

TNK-tPA is a mutant of
wild-type tPA. It is a bioen- at the thrombolytic site (72).
gineered form of tPA that has been systematically modi- 9. Compared with other plasminogen activators TNK-
fied at three sites. This variant of tPA has reduced clear- tPA is less thrombogenic. No increase in TAT com-
ance, enhanced fibrin specificity, and PAI-1 resistance; plex levels were noticed after its administration.
the mutations in three regions were combined in T 103N, However, streptokinase and rtPA cause a fourfold
N117Q, KHRR(296-299)AAAA (67). The resulting tPA and twofold increase of TAT, respectively, after
variant, TNK-tPA is more potent than the wild-type tPA. their administration (73).
It has reduced clearance and hence could be administered 10. It has been shown that single-bolus TNK-tPA is as
as a single bolus. It has a 14-fold greater fibrin specificity effective as the parent tPA in causing lysis of the
than wild-type tPA, and an 80-fold greater resistance to infarct-related artery.
inactivation by PAI-1. It is less thrombogenic than other 11. TNK-tPA produces a TIMI grade 3 flow in 60 min-
utes compared with 90 minutes by other agents.
plasminogen activators. There was no increase in throm-
bin-antithrombin complex after TNK-tPA administration
in contrast to the 4-fold increase following streptokinase In the TIMI 10A trial (74), a single bolus, dose rang-

and a doubling after rtPA (68). Single-bolus TNK-tPA is ing, angiographic trial, the effects of eight different
found to be as effective as the parent tPA in producing doses, 5, 5, 10, 15, 20, 30, 40, and 50 mg were followed
in 113 patients with AMI. The TIMI grade 3 flow at 90
lysis of the infarct artery. minutes ranged from 57%-64% in patients receiving 30-
In the TIMI 10A (69) trial, TIMI grade 3 flow at 90
50 mg and the rates were better than rtPA (75) and re-
minutes ranged from 57% to 64% in patients receiving
30-50 mg doses (similar or slightly better than with ac- teplase (76,77). The TIMI 10B trial was an angiographi-
celerated rtPA and reteplase). There was a low incidence cally controlled study where patients were randomized to
30 or 50 mg boluses of TNK-tPA or the accelerated
of major bleeding (6.2%). It causes average decreases in
fibrinogen (3%), in plasminogen (13%), and a-2 anti- regimen of rtPA (79). Since the 50-mg bolus dose was
realized to be a risk of ICH, the dose was later reduced
plasmin (25%-30%). In the TIMI-lOB trial, because of to 40 mg. The 40-mg dose of TNK-tPA produced TIMI
increased incidence of ICH with 50 mg dosage, the dose
had to be decreased to 40 mg of TNK-tPA producing grade 3 flow in 57% of patients when compared to rtPA
TIMI grade 3 flow in 57% of patients. This was well regimen which was well within the range. In TIMI 10A,
62%-68% of patients receiving TNK-tPA had TIMII
within the range achieved with the accelerated rtPA regi-
frame counts of <40,and 45% of these patients had a
men (70). TNK-tPA is being assessed in the large scale
frame count of <27 (74). In TIMI IOB, the average frame
Assessment of the Safety and Efficacy of a New Throm-
count in patent vessels was 28.7 in the 40-mg TNK-tPA-
bolytic Agent (ASSENT-II) trial in which it is being dose group and 32.6 in patients receiving accelerated
compared with accelerated tPA in more than 17,000 pa- rtPA (79,80).
tients.
To assess the safety of TNK-tPA, the assessment of
The various advantages of TNK-tPA over other
the Safety of a New Thrombolytic (ASSENT I) trial was
thrombolytics are as follows: conducted in parallel with TIMI lOB. Patients with AMI
1. Specifically bioengineered to preserve the full fibri- received a single-bolus of TNK-tPA in a dosage of 30,
nolytic activity of wild-type tPA. 40, or 50 mg. The 50- mg dose was later discontinued.
2. TNK-tPA has four times the reduced clearance than The 40-mg dose had an ICH rate of 0.76% compared to
native tPA. rtPA (81). The phase III ASSENT II trial is in progress
3. It can be administered as a single bolus. to assess the equivalence of TNK-tPA with a 30-day
4. It has a longer duration of action and is convenient to mortality end point.
administer.
5. It has 14 times greater fibrin specificity than the Staphylokinase
wild-type tPA. Recombinant staphylokinase is a plasminogen activa-
6. Greater fibrin specificity permits targeting of the in- tor of bacterial origin (strains of staphylococcus aureus).
farct-related clot while minimizing the &dquo;plasmino- It forms a 1:1 stoichiometric complex with plasminogen.
gen steal&dquo; effect (71). The plasminogen activators then convert this staphylo-
7. It has an 80-fold greater resistance to inactivation by kinase-plasminogen complex to an active staphyloki-
PAI-1. nase-plasmin complex. Staphylokinase-plasmin com-
8. Enhanced PAI resistance is desirable because the plex is highly fibrin specific. In the absence of fibrin it is
thrombolytic action of plasminogen activators af- quickly neutralized by a-2 antiplasmin. However, in the
fects the fibrin-rich coronary clot, exposing clot- presence of fibrin, this complex is highly resistant to the
bound thrombin causing further thrombin-induced action of a-2 antiplasmin neutralization at the clot sur-
 7

face. The result is a localized fibrin degradation and lim- Vampire bat salivary plasminogen activator
ited systemic plasminogen activation (82,83). Saliva of the vampire bat, desmodus rotundus, con-
In the Recombinant Staphylokinase (STAR) study tains four plasminogen activators namely desmodus sali-
(84), 100 patients with AMI were randomized to treat- vary plasminogen activators (DSPAs). Of these, DSPA
ment with a 10-mg infusion of staphylokinase or accel- cx-1 and batPA are structurally more homologous to hu-
erated rtPA. Poor TIMI 3 flow rates of 50% at 90 min- man tPA. BatPA is produced by recombinant technology

utes prompted an increase in dosage to 20 mg that re- in mammalian cells. It is highly fibrin specific and has
sulted in an increase in TIMI grade 3 flow to 74%, but demonstrated faster and more sustained reperfusion than
not significantly different from the 58% seen with rtPA. human tPA in animal models (95,96). In the only clinical
Staphylokinase did not alter the levels of fibrinogen, trial of batPA reported to date, the drug’s half-life is 2.8
plasminogen, and a-2 antiplasmin. No allergic reactions hours, a factor that would allow for a single bolus ad-
or ICH were observed. Staphylokinase triggers an im- ministration in clinical use. Currently, several trials are
mune response in patients. Antibodies develop in the in progress.
Four DSPAs are identified, namely, DSPA a-1, DSPA
majority of patients within 2 weeks after initial admin-
a -2, DSPA -~3, and DSPAy. Since DSPA a-1 exhibited
istration, and they persist for at least 7 months. It has a
half-life of 6 minutes and it is to be resolved whether a most favorable thrombolytic profile, it was chosen for

bolus dosing will prove successful. further study. The single most important feature that dis-

Staphylokinase (Sak) is a 136 amino acid protein. tinguishes DSPA from several other plasminogen activa-
tors is its extraordinary fibrin specificity. The activity of
Three natural variants have been characterized such as
DSPA a-1 is several thousandfold higher in the presense
Sak42D, Sak~c, and SakSTAR (85-87). By introducing
of fibrin than in its absence. BatPA is produced by re-
recombinant plasmins in E. Coli that produces intracellu-
combinant DNA technology. Fibrinogen, a fairly potent
lar Sak up to 10%-15% of total cell protein, large quan-
cofactor for plasminogen activation by tPA, has no effect
tities of two variants SakSTAR and Sak42D have been
on DSPA a-1. Similarly it is not activated by fibrinogen
produced that were later studied in preclinical and clini-
cal evaluation (88). degradation products or denatured protein. Therefore,
DSPA a-1 does not lower the level of plasminogen
In a pilot recanalization study, 10 patients with infarct-
related artery occlusion TIMI grade 0 flow that was con- (&dquo;plasminogen steal&dquo;), or coagulation factors during
firmed angiographically were treated with 10 mg intra-
thrombolytic treatment. Thus plasminogen activation is
restricted to the clot surface, without the systemic acti-
venously (IV) Sak (Variant SakSTAR), given as a 1-mg vation leading to fibrinogen consumption and degrada-
bolus followed by an infusion of 9 mg over 30 minutes
tion of factors VIII and V. Like staphylokinase and other
(88-90). Angiography was performed every 10 minutes nonhuman proteins, DSPA a-1 is immunogenic. Anti-
for 40 minutes. All but one of the occluded coronary
body formation could be induced by a single-bolus ad-
arteries achieved TIMI grade 3 flow in eight patients and ministration of 10 mg. Repeat administration of DSPA
TIMI grade 2 flow in one patient with a mean delay to a-1 could lead to detection of antibodies for 32-49
reperfusion in recanalized arteries to 20 ± 4.0 minutes weeks. However, no allergic reactions were observed
compared to >45-minute delay reported with SK and (92). Desmodus salivary plasminogen activator a-1 is
rtPA (91). However, plasma levels of fibrinogen, plas- shown to be more potent and more clot specific than tPA
minogen, and a-2 antiplasmin were not decreased. Sak, in a lung embolism model in rats. In an arterial throm-
therefore, proved to induce rapid and sustained restora- bosis model in rats, significant properties of DSPA a-1
tion of normal coronary flow at a dose that did not result such as higher potency, clot specificity, and prolonged
in a systemic lytic effect. Intravenous Sak combined with half-life over tPA were demonstrated. Desmodus sali-
heparin and aspirin is a regimen that is potent, rapid vary plasminogen activator a-1 also showed faster re-
acting, and very fibrin specific in AMI patients. If fibrin canalization and a lower incidence of reocclusion com-
specificity, safety, and efficacy for coronary thromboly- pared with tPA in a coronary thrombosis model of AMI
sis is comparable with rtPA, large comparative clinical in dogs. A lower hemorrhagic potential was demon-
trials are needed to compare the relative benefit of Sak strated in a rat mesenteric vein model. Desmodus sali-
versus plasminogen activators.
vary plasminogen activator a-1 has a lower total clear-
Regarding the immunogenecity of staphylokinase, like ance and longer half-life when compared with tPA,

streptokinase, it is a protein of nonhuman origin and which favors an IV bolus administration. Desmodus sali-
therefore triggers an immune response in those adminis- vary plasminogen activator a-1 could be administered at
tered and may persist for up to 7 months (92,93). No a dose of 0.5 mg/kg body weight based on pharmacoki-

allergic reactions were reported in the first 300 patients netic data available in animals. No toxic effects were
treated (94), perhaps due to its low molecular weight reported in animal studies. A bolus of 10 mg/kg resulted
compared to streptokinase (41). in myonecrosis and myocarditis in rats. Desmodus sali-
8

vary plasminogen activator a-1 may have a lower hem- tion. ST resolution was measured as percent resolution of
orrhagic risk such as intracranial bleeding in the elderly the sum of ST segment elevation at 90 minutes compared
population, based on the fact that it is not activated by to the baseline ECG. The squared standardized log odds
(3-amyloid peptides seen frequently in the vasculature ratio statistic was used to assess the optimal cutoff point
(97). that best predicts infarct vessel patency. It was concluded
_

that ST resolution of 20% for anterior infarcts and 30%

for inferior infarcts 90 minutes after the start of throm-
POSTTHROMBOLYTIC MANAGEMENT
bolysis can predict patent infarct vessels in patients with
AMI with a specificity and sensitivity of 70%. It is sug-
Aspirin should be continued after the completion of
the thrombolytic infusion. After tPA, anticoagulation gested that these cutoff points may be used as indications
for the success of thrombolysis (99).
with heparin is continued for 24 hours, and it is optional
for streptokinase. The reason for this is the presence of GUSTO I and III trials
thrombin, factor Xa, and activated platelets in the re- Earlier thrombolytic trials reported a 2%-6% reinfarc-
sidual thrombus. Prophylactic treatment with antacids tion after thrombolytic therapy. The results of the
and H2 blockers is indicated. Reperfusion rates of 50%- GUSTO I and III were combined to better define the
80% can be expected, determined primarily by the extent incidence, management, and outcomes of reinfarction. It
of thrombosis, time of onset, and beginning of thrombo- is concluded that reinfarction occurred infrequently after
lytic therapy. thrombolysis, but was associated with an elevated risk of
death (100).
RESULTS OF SOME RECENT In Time study
CLINICAL TRIALS In Time was a double-blind, dose-ranging angio-

PAMI Stent Randomized Trial graphic trial of lanoteplase in AMI patients presenting
with 6 hours. Lanoteplase (15, 30, 60, 120 KU/Kg bolus
It was mentioned earlier that the survival benefit after
over 1-2 minutes or tPA (100 mg, accelerated regimen)
thrombolytic therapy for AMI is strongly dependent on was given. The extent of systemic plasmin generation
the time to treatment. The results of this trial have shown
that the outcome of patients after primary percutaneous expressed as lowered fibrinogen, plasminogen, and a-2
transluminal coronary angioplasty (PTCA) may be antiplasmin values for the 120-KU/Kg dose was similar
to that of tPA regimen. It was also concluded that lano-
equally favorable with early or late treatment. Primary
PTCA achieves TIMI 3 flow rates that remain high and teplase administration resulted in lower PAI-1 values at
12 and 24 hours (101).
mortality and reinfarction rates that are relatively con- _

stant with increasing time to perfusion. It is concluded

that some factors that are independent of the time to ADJUNCTIVE ANTITHROMBITIC STRATEGIES
reperfusion may be responsible for the survival benefit
with primary PTCA (98). Thrombolytic agents, besides inducing a prothrom-
botic state, also cause activation of platelets (102). The
TIMI 10B and ASSENT I trials fibrin-selective tPA that have a short half- life (103-105)
The bleeding potential of TNK-tPA and rtPA was cause a prothrombotic state when compared with the

compared. In TIMI lOB, patients treated with 30, 40, and nonfibrin-selective streptokinase. In the GUSTO study
50 mg TNK-tPA were less likely to have a serious bleed- where patients were treated with streptokinase, the con-
ing event that required transfusion during the 30-day comitant administration of heparin did not result in ad-
follow-up than patients treated with rtPA. In ASSENT I, ditional benefit.
1.3% of patients experienced serious bleeding events that
required transfusion during the 30-day follow-up period. ADJUNCTIVE ANTIPLATELET STRATEGIES
It was concluded that TNK-tPA may be associated with
fewer serious bleeding events that require transfusion Several strategies were discussed and reported in a
than rtPA. special report (106) on reperfusion in AMI of the Inter-
national Society and Federation of Cardiology and
ASSENT III trial
World Health Organization Task Force on Myocardial
This is an ongoing phase III trial where the safety and
Reperfusion. It was earlier demonstrated in the ISIS-2
efficacy of TNK-tPA is being compared with rtPA.
study that early treatment with aspirin at a dose of 160
The HIT-4 angiographic substudy mg/daily reduced the mortality by 23% (107). Since it
This evaluated 90-minute angiographic patency and has been realized that clinical benefit is largely deter-
ST resolution at 90 minutes after start of streptokinase mined by rapid restoration of TIMI grade 3 flow (108),
infusion in patients with AMI of less than a 6-hour dura- aspirin has been invariably used in all subsequent trials
 9

and noexcessive bleeding was observed when aspirin ginine derivative, have been tried in animal models. A
was combined with tPA and intravenous heparin. The combination of G-4120, an RGD-containing synthetic
optimal dose of aspirin in AMI is uncertain. Strategies peptide, and argatroban have shown synergistic response
other than the inhibition of the cyclooxygenase pathway in a hamster femoral vein platelet-rich thrombosis model
have been tried in animal models. Some of these strate- ( 111 ). To inhibit further fibrin deposition at sites of
gies include the use off GP IIb/IIIa inhibitors, throm- thrombosis while avoiding systemic anticoagulation,
boxane A2 synthase inhibitors, serotonin, or endoperoxi- Bode et al. (120) synthesized a bifunctional molecule and
dase receptor antagonists (109-113). The GP IIb/IIIa re- incorporated the antifibrin antibody 59D8 and thrombin
ceptor antagonists include monoclonal antibodies that inhibitor, hirudin. When the 59D8-hirudin conjugate was
bind to the fibrinogen receptor and the snake venom tested in the baboon model, the activity of 59D8-hirudin
extracts or small peptides that contain the Arg-Gly-Asp was six times higher than that of the unconjugated hiru-

(RGD) sequence. After considerable evaluations in ani- din (Runge et al., unpublished data, 1996). An active
mal models (112), F(ab’)2 fragments of the monoclonal 59D8-hirudin fusion protein was obtained by insertion of
antibody 7E3 were administered to humans with unstable a peptide sequence susceptible to cleavage by factor Xa

angina and Fab fragments have been administered to between the antibody segment and the hirudin segment
patients with AMI who were treated with rtPA (114) and of the fusion protein. Several other alternatives to anti-
the patients had fewest thrombotic complications. Exces- thrombin drugs are also being evaluated.
sive bleeding was not observed in these groups of pa-
tients. CONCLUSIONS AND
Various snake venom extracts containing the RGD FUTURE CONSIDERATIONS
sequence, which were evaluated in various animal
models of thrombolysis with rtPA, include Bitistatin, In the treatment of AMI, thrombolytic therapy reduced
Echistatin, and Kistrin. Various synthetic analogs of the the 30-day mortality from 20%-25% at 30 days to 7%-
RGD sequence have been investigated (109-111). 8%. Early administration of an appropriate thrombolytic
agent can achieve early reperfusion, limiting infarct size,
ANTICOAGULANT STRATEGIES reducing left ventricular dysfunction and congestive
heart failure, thereby diminishing the early and late mor-
In the GUSTO study the combination of streptokinase tality. Thrombolytic drugs have come a long way in the
and subcutaneous heparin (12,500 U, 4 hours after the effective management of thrombotic and thromboem-
streptokinase treatment) was associated with a 30-day bolic disorders; however, there are still some major limi-
mortality of 7.2% and 0.5% of stroke (115). Currently, tations. They are the (a) failure of plasminogen activators
no data shows that patients treated with streptokinase and to lyse all thrombi (15%-40% of patients do not expe-
aspirin benefit from the addition of subcutaneous or in- rience early reperfusion, (b) delay in restoration of per-
travenous heparin. However, whenever thrombolytic fusion by >45 minutes from the initiation of therapy, (c)
therapy is carried out with tPA, intravenous heparin high rates (5%-25%) of early reocclusion after throm-
should be administered concomitantly at a dose of 5,000 bolysis, and (d) intracerebral hemorrhage in 0.3%-0.7%
U bolus followed by 1,000 U/h infusion. of patients treated. Several strategies are being followed
To achieve prevention of platelet-rich arterial throm- to overcome these limitations. Modifications of thera-
bosis, acceleration of thrombolysis, and reduction of peutic regimens by combination thrombolytic agents and
early or late reocclusion after reflow, several selective adjunctive use of direct antithrombin drugs, which in-
thrombin inhibitors may be tried (109,110). Some trials hibit clot-bound thrombin and other GP IIb/IIIa inhibi-
with hirudin, a thrombin inhibitor versus heparin therapy tors and LMWHs, may provide faster and more complete
in combination with thrombolytic agents, and aspirin and sustained reperfusion in large number of patients and
were prematurely terminated because of increased inci- fewer or no resulting complications. The new clinical
dence of ICH ( 116-118). Recently, in concluded com- trials will provide some innovations in treatment regi-
parative trials of reduced doses of recombinant hirudin mens.
versus heparin for the treatment of acute coronary syn- Plasminogen activators lyse fibrin, leaving thrombin
dromes, it was reported that r-hirudin provided a very exposed to stimulate the formation of more thrombin and
small advantage related to a reduction in nonfatal myo- platelet aggregation resulting in a hypercoagulable state
cardial infarction compared with heparin. Hirugen a hi- induced by fibrinolysis. Platelets are not only fully re-
rudin-based compound, a peptide derived from residues sistant to fibrinolysis but secrete PAI-1. There is con-
53-64 demonstrated enhanced rtPA-induced thromboly- vincing evidence and sound rationale to use direct throm-
sis and delayed reocclusion in a canine left anterior de- bin inhibitors like hirudin or hirulog to inhibit the clot-
scending coronary artery model (119). Similarly, bound thrombin, and the adjunctive use of GP IIb/IIIa
PPACK (D-Phe-Pro-Arg-Ch2Cl) and argatroban, an ar- inhibitors like ReoPro, Eptifiban, Tirofiban, Lamifiban,
10

&dquo;

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 11

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