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Streptokinase stability pattern during storage in various solvents and at different tempertures.

The activity drop of 5 u streptiokinasewas measured in 1 ml each of various solutions (9.9% NaCl solution, 5% glucose solution, 5% levulose solution, 10% dextran solution, gelatin solution, 3% albumin solution, michaelis buffer, glucose (5%)-heparin (750 u/ml) solution) at different incubation temperatures (-20 degrees C, 4 DEGREES C, 20 DEGREES C, 37 DEGREES C), and over different observations periods (15 min, 30 min, 45 min, 60 min, 6 h, 12 h, 24 h, and 48 h). Solution media tested for streptodinase-protecting quality were broken down into three groups. Group I: Solvents displaying excellent stabilizing properties gelatin and albumin solutions). Group II: Solvents displaying medium stabilizing properties (dextran and levulose solutions). Group III: Solvents displaying poor stabilizing properties (NaCl and glucose solutions, Michaelis buffer). In testing streptokinase concentrations as used for therapeutic purposes (1500 u/ml, 50,000 u/ml), no decay was found to take place over observation periods of up to 48 h, and no invluence by different solvents (Group I. II or III) was traceable. Heparin stored with streptokinase at room temperature over a period of 48 h did not alteranisms concerning the stability pattern of striptokinase are discussed. It appears that low streptokinase concentrations need negatively chargedcolloids to keep the protein structure intact. The streptokinase-protecting macro-molecules tested so far were albumin, gelatin, and streptokinase. Obviously, streptokinase by itself was able to preserve its own stability provided its concentration was of a certain order magnitude (1500 u/ml, 50,000 u/ml) .

Buffers↗

Studies on the labeling of streptokinase with 99mTc for use as a radiopharmaceutical in the detection of deep-vein thrombosis: concise communication.

Streptokinase was labeled with 99mTc using both stannous chloride and stannous pyrophosphate as reducing agents. Sixty to seventy-five percent of the 99m Tc was incorporated into streptokinase using stannous chloride as a reducing agent at pH 1-2, wheras 50-60% was incorporated using stannous pyrophosphate at neutral pH. Increasing the pH from 2 to 7 in the presence of stannous chloride caused the release of 15-20% of the protein-bound 99mTc. Incorporation of 99mTc into protein was relatively slow: labeling required 2-3 hr at room temperature. The concentration of stannous pyrophosphate required for optimum labeling varied between 10(-5) and 10(-2) M. Polyacrylamide-gel electrophoresis showed that the filler substance in commercial streptokinase was also labeled with 99mTc. However pure streptokinase gave a homogenous protein band after polyacrylamide-gel electrophoresis. This protein band coincided with the peak of streptokinase-bound 99mTc. The results obtained may partially explain why 99mTc-labeled streptokinase lacks the necessary specificity for the satisfactory location of blood clots in vivo.

Chromatography, Thin Layer↗

[Structural-dynamic and functional properties of native and modified streptokinase].

The process of streptokinase modification by a polymer and the dynamics of protein molecules and the polymer in a protein-polymer (dialdehyde dextran, DAD) conjugate were studied with the aid of luminescent methods. Conclusions were drawn on the structure of the protein-DAD conjugate and the selection of optimum conditions for the preparation of modified streptokinase. It is shown that modified streptokinase is more stable to the action of denaturating agents. The interaction between streptokinase and plasminogen activated by it and changes in the streptokinase-plasminogen complex for modified streptokinase were detected.

Dextrans↗

[Study of the role of histidine residues in streptokinase molecule using modification with diethylpyrocarbonate].

The interaction of streptokinase with diethylpyrocarbonate resulting in partial inactivation of the protein was studied. Eight histidine residues are blocked per streptokinase molecule by this reagent. Ethoxyformylation of streptokinase histidyls is characterized by a rate constant corresponding to modification of free L-histidine. No reactivation of streptokinase was achieved by treatment of the modified protein with hydroxylamine. The CD spectroscopy data suggest that the residues modified by diethylpyrocarbonate are of no consequence for the stabilization of the protein secondary structure. The specificity of modification of streptokinase histidine residues by diethylpyrocarbonate is discussed. Based on the gel chromatography data, it was assumed that partial inactivation of streptokinase depends on the formation of protein oligomers with a decreased activatory function.

Chemical Phenomena↗

[On the possibility of accelerating thrombolytic therapy in the acute phase of myocardial infarction: efficacy of and tolerance to the infusion of 1.5 million units of streptokinase in 30 minutes].

To evaluate efficacy and tolerability of the systemic infusion of 1,500,000 streptokinase units in 30', we treated 26 consecutive patients with acute myocardial infarction within 3 hours of the onset of chest pain. They were 23 men and 3 women, mean age was 59 +/- 8 years. None of them had a history of previous myocardial infarction. From clinical and electrocardiographic data, as well as from creatine kinase curves, we assumed myocardial reperfusion in 19 patients (73%). Within 30' after infusion, thrombin time increased to more than 300" in 25/26 patients (96%). Streptokinase induced hypotension (which we defined as a decrease in systolic blood pressure of more than 30 mmHg) in 13 patients (50%), and in 5 of them (19%) systolic blood pressure fell below 90 mmHg. Hypotension was counteracted by adopting the Trendelenburg position in 7 patients, and by an intravenous infusion of atropine in 5. In the remaining patient, streptokinase infusion was slowed down. Due to these interventions, a non-significant decrease in systolic blood pressure was observed from 129 +/- 26 to 112 +/- 20 mmHg at the end of the infusion. Streptokinase-induced hypotension was not predicted either by clinical, or electrocardiographic, or chest X-ray film data, or laboratory findings. No other side-effects occurred. Hence, the infusion of 1,500,000 streptokinase units in 30' in the acute phase of myocardial infarction is active, and well tolerated. It must be emphasized, however, that during the infusion, hypotension occurs frequently and unpredictably, sometimes reaching alarm levels. This makes the monitoring of systolic blood pressure imperative during streptokinase infusion.

Adult↗

Alterations in lactate dehydrogenase isoenzyme patterns after therapy with streptokinase or streptococcal infection.

Serum samples from patients receiving intravenous streptokinase were examined for evidence of interaction in vivo between streptokinase and lactate dehydrogenase (EC 1.1.1.27; LD). We found that this treatment produced a band of LD activity that remained at the electrophoretic origin of LD isoenzyme analysis. Treatment with tissue plasminogen activator produced no such band. The streptokinase-LD complex could be removed from serum by ultracentrifugation. It remained in the circulation for as long as 48 h after streptokinase infusion. A similar phenomenon was observed in a case of pneumococcal sepsis. Examination of supernates from both cultures of several species of Gram-positive cocci revealed interactions between human LD and Streptococcus groups A and C and also Streptococcus pneumoniae. Evidently streptokinase can form complexes with LD in vivo after either streptokinase therapy or infection, with consequent alteration of the LD isoenzyme pattern.

Aged↗

[Comparative randomized study of the effectiveness of intravenous recombinant tissue-type plasminogen activator and intravenous streptokinase in patients with acute myocardial infarct. Report of the European Cooperative Study Group for Recombinant Tissue-Type Plasminogen Activator].

In a single-blind randomised trial in patients with acute myocardial infarction of less than 6 h duration, the frequency of coronary patency was found to be higher after intravenous administration of recombinant human tissue-type plasminogen activator (rt-PA) than after intravenous streptokinase. 64 patients were allocated to 0.75 mg rt-PA/kg over 90 min, and the infarct-related coronary artery was patent in 70% of 61 assessable coronary angiograms taken 75-90 min after the start of infusion; 65 patients were allocated to 1,500,000 IU streptokinase over 60 min, and the infarct-related vessel was patent in 55% of 62 assessable angiograms. The 95% confidence interval of the difference ranges from +30 to -2% (p = 0.054). Bleeding episodes and other complications were less common in the rt-PA patients than in the streptokinase group. Hospital mortality was identical in the 2 treatment groups. At the end of the rt-PA infusion the circulating fibrinogen level was 61 +/- 35% of the starting value, as measured by a coagulation-rate assay, and 69 +/- 25% as measured by sodium sulphite precipitation. After streptokinase infusion, corresponding fibrinogen levels were 12 +/- 18% and 20 +/- 11%. In the rt-PA group only 4.5% of the fibrinogen was measured as incoagulable fibrinogen degradation products, compared with 30% in the streptokinase group. Activation of the systemic fibrinolytic system was far less pronounced with rt-PA than with streptokinase.

Adult↗

Intra-arterial streptokinase in the treatment of acute arterial thrombosis.

Streptokinase and catheter thrombectomy were retrospectively compared in 25 patients who presented with acute ischemia to investigate whether the use of intra-arterial streptokinase offers an advantage in the treatment of acute arterial or graft thrombosis. Streptokinase was used in all patients presenting with acute thrombosis unless the ischemic limb would not tolerate the time required for clot lysis. Complete thrombolysis was achieved in 47 per cent of the occlusions treated with streptokinase and initial limb salvage rate in 37 per cent of the patients. Subsequent surgical procedures were required in seven of eight patients with successful thrombolysis. Catheter thrombectomy reestablished vessel or graft patency in 86 per cent of the procedures and achieved initial limb salvage in 67 per cent of the patients. Long term (greater than six months) patency was achieved in 25 per cent of the patients treated with streptokinase and 44 per cent of the patients with catheter thrombectomy. Streptokinase did not prevent the need for further surgical intervention, improve early patency of these vessels or promote limb salvage when compared with that of catheter thrombectomy.

Acute Disease↗

The international standard for streptokinase-streptodornase.

The National Institute for Medical Research, London, was asked by the WHO Expert Committee on Biological Standardization to take steps to set up an international standard of streptokinase-streptodornase. This paper describes the nature and handling of the material and its establishment as the International Standard for Streptokinase-Streptodornase, with a defined potency of 3100 International Units of Streptokinase and 2400 International Units of Streptodornase per ampoule. The International Unit of Streptokinase is defined as the activity contained in 0.002090 mg of the International Standard for Streptokinase-Streptodornase. The International Unit of Streptodornase is defined as the activity contained in 0.002700 mg of the International Standard for Streptokinase-Streptodornase.

Biological Assay↗

[Studies of the heterogeneity of streptokinases; IV. Evidence for isostreptokinases in Streptococcus pyogenes type 1 (author's transl)].

Two strains of Streptococcus pyogenes, originating from the same Griffith strain SF 130/13 but different in M protein synthesis, produce two isostreptokinases. The molecular weights of both isostreptokinases are the same (about 50 000 daltons) as well as the specific activities (38 000 and 43 000 U/mg, resp.). The activity values are influenced by an incomplete removal of ampholytes. The isoelectric points were determined as pI 6.3, and 6.5, resp. The presence of isostreptokinases was concluded by (1) the absence of proteolytic activities in the culture filtrate, (2) the same molecular weights, (3) the same specific activities, (4) the constant quantitative relation of about 1:2.5 between both isostreptokinases after refocusing, (5) a lack of cystein- or cystin residues in the molecule, (6) the appearance of both isostreptokinases in untreated culture filtrates, (7) the separability by disc electrophoresis, and (8) the lack of such double bands in streptokinases of other streptococci. Isoelectric focusing of streptokinase produced by a type 3 strain of S. pyogenes was followed by the appearance of four bands with streptokinase activity. It is unlikely that these four bands represent isostreptokinases. Both streptokinases (type 1 and type 3 streptococci) differ from streptokinases of other types by their relatively high content of tryptophane (table 1) and the high isoelectric points (6.5 to 6.0; streptokinases of other types and groups show pI's between 5.05 to 5.65 (6).

Isoelectric Point↗

[Systemic thrombolysis with short-term streptokinase infusion in acute myocardial infarct].

Within 6 hours after the onset of acute myocardial infarction, 93 patients received a brief high-dose intravenous infusion of streptokinase, 49 patients received 500,000 IU within 30 min and 44 patients received 1,500,000 IU within 60 min. 26 patients had angiography in the acute phase, after 24 hours, and in the 4th week; 52 patients had angiography in the 4th week only; and 15 had no angiography. 7 patients died in hospital and 6 suffered a nonfatal reinfarction. There were no complications with bleeding. In 52% of cases, reopening of an occluded infarct vessel was achieved within 1 hour of the beginning of treatment. During the 4th week after infarction a patent infarct vessel was found in 84%, and 58% had a residual stenosis less than 70%. In contrast, in a control group that received no streptokinase treatment, 25% had a patent infarct vessel and 4% had a residual stenosis less than 70%. Indicative for salvage of ischemic myocardium are a significant improvement in local contraction disorders between the acute phase and the 4th week and a significant correlation between infarct size in the 4th week and beginning of treatment after onset of symptoms. 1. It may be concluded that: brief intravenous infusion of streptokinase results in restoration of blood flow in an infarcted coronary artery in a high percentage of cases; the shorter thrombus-lysis time with intracoronary streptokinase infusion could be made up for by the earlier initiation of intravenous streptokinase treatment; and a conclusive randomized trial is needed to ascertain the true impact of a brief high-dose intravenous infusion of streptokinase on mortality and morbidity following acute myocardial infarction.

Adult↗

Anaphylactoid purpura like vasculitis following fibrinolytic therapy: role of the immune response to streptokinase.

We report the case of a patient who presented with a clinical picture of serum sickness with some characteristics of anaphylactoid purpura (Henoch-Schönlein purpura) five days after receiving streptokinase as a treatment for myocardial infarction. The appearance of Henoch-Schönlein like vasculitis after streptokinase treatment was particularly intriguing in view of the common association of streptococcus infection with this type of vasculitis. The production of streptokinase specific IgG and IgA antibodies was studied in the patient and compared with six controls treated with identical doses of streptokinase without adverse effects. A more rapid increase of streptokinase specific IgA was detected in the patient, with a significant higher amount of streptokinase specific IgA and IgG after six days of treatment. These results suggest that different kinetics could induce a precipitation of the immune complexes responsible for vasculitis. However, we cannot exclude that the IgA found in the vessel walls was only an "innocent bystander" deposited as a secondary event.

Aged↗

Potentiating effect of clopidogrel and SR 46349, a novel 5-HT2 antagonist, on streptokinase-induced thrombolysis in the rabbit.

Current thrombolytic strategies have a number of important shortcomings including resistance to recanalization and development of acute reocclusion. The purpose of this study was to investigate whether the lysis of venous thrombi by streptokinase could be enhanced by SR 46349, a novel 5-HT2 receptor antagonist, or clopidogrel, an analogue of ticlopidine. The activity of these compounds was evaluated by following the lysis of radiolabelled fibrin under a continuous infusion of streptokinase (4,000 IU kg-1 h-1 over 4 h). Streptokinase alone induced 42% thrombolysis when compared to saline. The i.v. co-administration of SR 46349 or clopidogrel (10 mg/kg) enhanced significantly streptokinase-induced thrombolysis. Thrombolysis measured by [125I]-fibrinogen lysis increased to 65 and 59% respectively. This efficacy was achieved without additional prolongation of the template bleeding time observed with streptokinase alone. Thus, the concomitant use of a 5-HT2 receptor antagonist or an anti-ADP agent during streptokinase therapy may facilitate clot lysis.

Animals↗

Platelet Activity in the Early Stage of Acute Myocardial Infarction: Relation to Time of Presentation, Treatment with Either Tissue Plasminogen Activator or Streptokinase and Cyclooxygenase Inhibition.

Background. Platelet activation after myocardial infarction and thrombolytic treatment has been documented; but its relationship with the onset of symptoms and with thrombolysis, and the influence of aspirin in this setting is not well defined. In this study we measured platelet activity in the early phase of myocardial infarction treated with either streptokinase or rt-PA and evaluated influence of aspirin in this framework.Methods. 41 patients (age 57 +/- 6 years) were treated with thtombolytic therapy during myocardial infarction; 21 patients with 1,5 million units of streptokinase (Group 1) and 20 patients with 100 mg of rt-PA (Group 2); 10 randomly selected patients in each group were given 500 mg aspirin i.v. prior to infusion of thrombolytic drug and, subsequently, 325 mg aspirin a day orally. Consecutive samples of beta-thromboglobulin (BTG), a marker of platelet activity, were collected at admission and after thrombolysis for the following 48 hours. Results. At admission, BTG plasma levels averaged 125 +/- 31 IU/ml in Group I and 134 +/- 35 IU/ml in Group 2 (p = 0.81). Thrombolysis was followed by a similar increase of platelet activity with maximal values reached at the 3rd hour in both groups (196 +/- 43 IU/ml in Group 1 and 192 +/- 39 in Group 2: p < 001versus baseline and p NS between the groups). Higher levels of BTG were observed in streptakinase-treated group starting from the 24th hour (p < 0.05). Patients treated with aspirin showed lower levels of BTG only from the 48th hour after thrombolysis in both groups. An inverse correlation was found between time elapsed from onset of symptoms to admission and BTG value on admission (r = -0.86 p < 0,001); in patients admitted within two hours from the beginning of symptoms, with higher levels of BTG, thrombolysis not induced a significant increase of platelet activity; who was observed in patients admitted later.Conclusions. A marked platelet activation is more evident in the first hours of myocardial infarction and is differently influenced by thrombolytic treatment in relation with the delay of patient presentation. Both streptokinase and rt-PA induce a similar increase of platelet activity which is more persistent after streptokinase; cyclooxygenase inhibition seems to influence the platelet activity only from the second day.Condensed abstract. Influence of aspirin on platelet activity during myocardial infarction treated with thrombolytic therapy is not well defined. Twenty-one patients treated with streptokinase (Group 1) and 20 patients treated with rt-PA (Group 2) were randomly selected to give 500 mg of aspirin i.v. prior thrombolysis and subsequently 325 mg a day orally. Platelet activity was evaluated through determination of beta-thromboglobulin plasma levels. Thrombolysis was followed by a similar increase of platelet activity in both groups with maximal values reached at the 3rd hour; higher levels of beta-thromboglobulin were observed in streptokinase-treated group starting from 24th hour. Treatment with aspirin reduced beta-thromboglobulin plasma levels only at 48th hour in both groups.

Journal Article↗

Streptokinase in acute myocardial infarction.

In a controlled trial of streptokinase in acute myocardial infarction, 512 of 2338 patients at 11 European centers were stratified according to clinical severity. Three hundred fifteen patients allocated to medium-risk and high-risk groups were randomized to a 24-hour infusion of streptokinase or glucose. There were no essential differences in the severity of illness in the two groups before infusion. The overall mortality rates within six months were significantly lower (P less than 0.01) in the streptokinase group (15.6 per cent) than in the control group (30.6 per cent). Bleeding complications were more frequent in the streptokinase group; except for two nonfatal cerebral hemorrhages these complications were clinically unimportant. The treatment was generally well tolerated. We tolerated. We conclude that streptokinase given under the conditions of this trial -- to medium-risk patients admitted to a coronary-care unit within 12 hours of onset of symptoms -- reduces mortality at six months. (N Engl J Med 301:797-802, 1979)

Acute Disease↗

Variations in patient management and outcomes for acute myocardial infarction in the United States and other countries. Results from the GUSTO trial. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries.

OBJECTIVE: To examine differences in outcomes and patient management between patients in the United States and outside the United States undergoing thrombolysis for acute myocardial infarction. DESIGN, SETTING, AND PATIENTS: Patients in the United States (n = 23,105) and 14 other countries (n = 17,916) were randomized to receive streptokinase plus either subcutaneous or intravenous (IV) heparin, accelerated recombinant tissue-type plasminogen activator (rt-PA) plus IV heparin, or combined streptokinase and rt-PA plus IV heparin. OUTCOME MEASURES: Differences in 30-day mortality and patient management were compared among treatments and between US and non-US patients. Treatment-by-country interactions were assessed by logistic regression analyses. Expected mortality of US and non-US patients was estimated using a predictive model and was compared with observed mortality. RESULTS: Mortality reduction with accelerated rt-PA vs streptokinase was greater in the United States (1.2% absolute decrease vs 0.7% elsewhere), but the test for treatment-by-country interaction against streptokinase was not significant (P = .30). Benefits of accelerated rt-PA over combination therapy were observed in the United States, but not in other countries (P = .02). Despite differences in base-line characteristics and patient management, 30-day mortality was not significantly different: 6.8% in the United States vs 7.2% elsewhere (P = .09). After adjustment for baseline differences, observed vs predicted outcomes were slightly better in the United States (6.8% vs 7.0%) than elsewhere (7.2% vs 7.0%), indicating that enrollment in the United States was a marginally significant predictor of better survival (P = .047). CONCLUSIONS: No significant evidence for a differentially greater benefit of accelerated rt-PA over streptokinase was found in US vs non-US patients. However, increased procedure and treatment use in the United States was associated with only a small decrease in short-term mortality. Long-term follow-up is required to clarify the relationship between survival and the more intensive US management approach.

Aged↗

A comparative randomized trial of heparin versus streptokinase in the treatment of acute proximal venous thrombosis: an interim report of a prospective trial.

A controlled, prospective study comparing streptokinase and heparin treatment has been completed in 51 patients presenting with acute proximal venous thrombosis of less than 8 days' clinical duration. Patients were studied by means of pre-treatment, post-treatment, 3- and 12-monthly phlebography and pulmonary perfusion scanning and were followed up at 3-monthly intervals. Of the 26 patients randomized to receive streptokinase, therapy was stopped in 3 because of complications. Phlebography 5 days after starting treatment showed 80--100 per cent lysis in 17 of the 23 patients who completed the course of streptokinase. Two patients later developed partial rethrombosis. One patient developed an asymptomatic pulmonary embolus during treatment. During follow-up (mean 19 months) only 1 of the 17 patients with 80--100 per cent lysis developed postphlebitic symptoms, 3 patients died of unrelated causes and 1 patient was lost to follow-up. In patients randomized to heparin therapy no significant lysis was achieved in any of the 25 patients and only 2 of these patients were found to have asymptomatic legs on follow-up. Two patients in this group died and autopsy confirmed massive pulmonary embolus during treatment. These data suggest that streptokinase is superior to heparin in the treatment of acute proximal venous thrombosis of less than 1 week's clinical duration especially if the thrombus is largely non-occlusive. It must be stressed that in order to avoid the bleeding complications of thrombolytic therapy, streptokinase must not be used within 10 days of major surgery, or even longer after vascular, neurosurgical or eye operations.

Adult↗

Intra-arterial streptokinase infusion in acute lower limb ischaemia.

Between 1986 and 1988, 38 patients (29 men and nine women), median age 65 years (range 38-85 years), underwent local intra-arterial streptokinase therapy for acute lower limb ischaemia. Three patient groups were identified: 15 with acute on chronic ischaemia (group 1), 12 postangioplasty (group 2) and 11 postfemorodistal bypass (group 3). Distal arteriographic run-off was a significant discriminant between success and failure in group 1 (n = 15, chi 2 = 11.5, P = 0.001) and in the overall group (n = 38, chi 2 = 17.2, P less than 0.001). In group 2, four patients with good run-off had an unsuccessful outcome; this was due in all cases to technical problems (haemorrhage in two and intimal dissection in two). In group 3, two patients with good run-off had unsuccessful streptokinase infusions. In both cases the graft failed in the early postoperative period (less than 30 days). By contrast, the four patients whose grafts occluded after 30 days had successful streptokinase infusions and long-term graft patency was achieved by further surgery and balloon dilatation. In all groups, no patient with a poor run-off had a successful outcome following streptokinase administration. The role of local intra-arterial streptokinase therapy in the critically ischaemic limb remains controversial, but these results suggest that an adequate run-off is an important factor in the selection of patients for treatment.

Acute Disease↗