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(Circulation. 1998;98:2649-2651.)
© 1998 American Heart Association, Inc.

Editorial

Ten Years of Benefit From a One-Hour Intervention

Robert M. Califf, MD

From the Duke Clinical Research Institute, Durham, NC.

Correspondence to Robert M. Califf, MD, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715.

Key Words: Editorials • trials • myocardial infarction • streptokinase

The publication of the 10-year follow-up from the GISSI-1 study in this issue of Circulation heralds an important event in the evolution of cardiovascular medicine worthy of a pause for reflection.¹ The follow-up to the trial demonstrates that a 1-hour infusion of streptokinase in patients with ST-segment–elevation myocardial infarction reduced the risk of death over the ensuing 10 years from 469 per 1000 patients treated to 450 per 1000. These figures result in a net benefit of 19 lives saved per 1000 patients treated over that time. In patients who presented for medical attention within 1 hour of the onset of symptoms, this benefit is dramatically magnified (80 lives saved per 1000 patients treated). In contrast, in the elderly and in patients with ST-segment depression at admission, the treatment effect went in the wrong direction, confirming previous results in the ST-segment depression group and raising an interesting issue for the elderly. In patients with nonanterior myocardial infarction, the benefit was relatively small.

Combined with the 10-year follow-up from ISIS-2, these data present a clear and impressive picture of what a simple and well-timed intervention can do to improve clinical outcome.² Furthermore, the GISSI project raises a number of interesting technical points about fibrinolytic therapy as well as critical issues in the development of therapeutic strategies for patients with acute coronary syndromes.

What is the mechanism of the sustained benefit? Only by mechanistic understanding can we improve on future therapy. The GISSI study itself provides no direct pathophysiological insight, but the . . . [Full Text of this Article]

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