Circulation. 1998;97:211-218
(Circulation. 1998;97:211-218.)
© 1998 American Heart Association, Inc.
Toward a New Frontier in Myocardial Reperfusion Therapy
Emerging Platelet Preeminence
Eric J. Topol, MD
From the Department of Cardiology, Cleveland Clinic Foundation,
Cleveland, Ohio.
Correspondence to Eric Topol, MD, Department of Cardiology, 9500 Euclid Ave, Desk F25, Cleveland Clinic Foundation, Cleveland, OH 44195. E-mail topole@cesmtp.ccf.org
Key Words: thrombolytic therapy • platelets • fibrinolytic therapy • myocardial reperfusion • coronary thrombus
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Introduction
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For
more than a decade, intravenous
thrombolytic therapy has been validated for the
reduction of mortality in evolving MI.1 2 3
Reperfusion therapy is the standard of care for patients with acute MI
who present early (within 12 hours of symptom onset) and have
significant ECG ST-segment elevation.4 However,
the limitations of the therapy are especially impressive.
First, even the most potent established thrombolytic
therapy does not achieve restoration of early and complete
coronary blood flow in 
50% of
patients.5 This 50% failure rate is
particularly important because the relationship of successful
reperfusion and survival is quite strong,5 6 such
that the death rate among patients who fail to achieve early
reperfusion is at least twofold to threefold
higher.5 6 7
Second, thrombolytic therapy induces a relatively high
rate of intracerebral hemorrhage. Although the
incidence is 1 in 150 to 200 treated
patients,8 the event is usually catastrophic,
resulting in fatality or a disabling stroke. Of note, the ability to
predict intracerebral bleeding is quite limited; save
for the commonly present demographic factors of the aged and
hypertension, little is known about who is predisposed or why this
dreaded complication occurs. In the recently completed third Global
Utilization of Strategies to Open Occluded Arteries (GUSTO-III) trial,
which assessed reteplase and alteplase, the incidence of hemorrhagic
stroke was increased compared with previous trials. The overall rate of
0.9%, or 1 in 100 patients, reflects, in part, the enrollment of
more elderly and hypertensive patients9 and
emphasizes the significance of the problem in contemporary trials and
likely . . . [Full Text of this Article]
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