Therapy

• older patients ^a
• patients with an anterior MI ^a
• patients who have received streptokinase or anistreplase in the previous 5 days to 6 months ^d  

Why?

• Alteplase reduces death ^a and reinfarction better than streptokinase, but causes more strokes. ^a  
• Fewer patients on alteplase suffer allergic reactions or profound hypotension. ^a
• However alteplase costs more than streptokinase - it is most cost-effective in elderly patients and patients with anterior myocardial infarction. ^a It is not clearly cost-effective for patients aged < 40 with an anterior MI, or patients aged < 60 with an inferior MI. ^a

Alteplase reduces death, and reinfarction compared with streptokinase, but causes more stroke

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
myocardial infarction a	tPA	streptokinase	death at 12 months	10%	12% (5% to 20%)	80 (49 to 230)
			stroke at 4 weeks	1.2%	-28% (-63% to -1%)	-290 (-5000 to -150)
myocardial infarction a	tPA	streptokinase	reinfarction at 4 weeks	3.5%	16% (4% to 26%)	180 (100 to 800)
			allergic reaction at 4 weeks	3.6%	78% (73% to 82%)	35 (32 to 40)
			profound hypotension at 4 weeks	12%	40% (35% to 44%)	21 (19 to 25)

Note:

• Combining alteplase and streptokinase is less effective than using alteplase alone. ^a