A Comparison of Reteplase with Alteplase for Acute Myocardial Infarction
Topic: Thrombolytics in acute coronary syndrome
- New recombinant tPA agent, reteplase, is superior to physiological tPA, alteplase, in patients with acute myocardial infarction.
- Prospective, multi-centered, open-labeled, randomized, placebo controlled
- Reteplase (two bolus doses of 10 MU given 30 minutes apart), aspirin 160 mg, and 5000U heparin bolus followed by heparin infusion.
- Alteplase (15 mg bolus, followed by infusion of 0.75 mg/kg over a 30 minutes, and 0.5 mg/kg over the next 60 minutes), aspirin 160 mg, and 5000U heparin bolus followed by heparin infusion.
- 15,059 patients
- Presented within 6 hours after onset of ischemic chest pain.
- ST elevation of > 1 mm in two or more limb leads, ST elevation > 2mm in the precordial leads, new LBBB.
- Active bleeding
- History of stroke or CNS damage
- Recent major surgery
- SBP > 200 mm Hg or DBP > 110
- Recent arterial puncture
- Anticoagulant use or INR > 2.0
- 30 days
- Mortality at 30 days.
- Net clinical benefit (defined as freedom from death or disabling stroke), death or nonfatal stroke, re-infarction, CHF, and mortality at 24 hours.
- Mean age 63, 27% were women.
- Median interval between onset of symptoms and treatment was 2.7 hours.
- The mortality rate at 30 days was 7.47 percent in the reteplase group and 7.24 percent in the alteplase group (odds ratio, 1.03; 95 percent confidence interval, 0.91 to 1.18; unadjusted P = 0.61; covariate adjusted P = 0.54).
- At 24 hours, the mortality rate was 3.03 percent with reteplase and 2.72 percent with alteplase (odds ratio, 1.12; 95 percent confidence interval, 0.91 to 1.37).
- The patients who were at highest risk, such as elderly patients or those with anterior infarction, had a slightly higher mortality rate with reteplase than with alteplase.
TAKE AWAY: No additional survival benefit with reteplase compared with accelerated infusion of alteplase in treatment of acute MI.
Reference: Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. A comparison of reteplase with alteplase for acute myocardial infarction. N Engl J Med. 1997;337(16):1118-23.