Coronary Thrombolysis.
Randomized trials have demonstrated the overall benefits and risks of thrombolytic therapy for acute myocardial infarction, and have evaluated adjunctive drug therapies, adjunctive and primary angioplasty, various approaches to the timing of thrombolysis, and post-thrombolysis management. Three questions, which remain unanswered, are addressed in this Point-Counterpoint Series. The GUSTO trial provides convincing evidence of the greater efficacy of rt-PA by comparison to SK, but the size of the benefit is uncertain, as are the risk benefit ratios and cost-effectiveness in various patient subgroups. The issues of whether or not routine angiography is appropriate for patients who have received coronary thrombolysis remains unresolved. For the present, clinical guidelines are likely to advise against routine angiography, while many cardiologists, concerned about the shortcomings of available studies, may wish to undertake coronary angiography in many of their patients, even though definitive proof of its benefit is lacking. Although randomized clinical trials suggest a benefit of primary angioplasty over thrombolytic therapy, further studies are required to clarify the comparative benefits in terms of clinically important outcomes and cost-effectiveness.