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Study of Adverse Events of Streptokinase Therapy in Patients with Acute ST Elevation Myocardial Infarction

Although primary percutaneous coronary intervention (PCI) is the preferred treatment option for STEMI, the value of fibrinolytic therapy should not be overlooked in situations where primary PCI is not available or cannot be delivered in the appropriate timeframe. Among different types of fibrinolytic agents, streptokinase (SK) is the most widely used agent especially in economically burdened countries due to the higher cost of the more effective recent generations of fibrinolytic such as tissue plasminogen activator (t-PA).

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 A History of Streptokinase Use in Acute Myocardial Infarction

The streptokinase era dates back to 1933, when Dr. William Smith Tillett19 (Fig. 1) discovered the agent through sheer serendipity. Tillett was Associate Professor of Medicine and Director of the Biological Division at Johns Hopkins University, at that time. The work of Tillett was strikingly distinct from that of his contemporaries, probably because he was such a keen observer. Louis Pasteur's famous saying (now elevated to the status of cliché) applies aptly to Tillett: “Chance favors the prepared mind.”

 Could Pharmacoinvasive Strategy Using Streptokinase Be an Alternative to Primary Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction in Resource Poor Settings?

Primary Percutaneous Coronary Intervention (PCI) is the gold standard in the management of ST Elevation Myocardial Infarction (STEMI). Timely PCI remains a challenge especially in developing countries where the number of centers performing PCI are few and timely transfer to such centers are constrained by the dearth of emergency ambulance services and poor road infrastructure. Pharmacoinvasive strategy refers to routine angiography with a view to revascularize the infarct related vessel 3-24 hours after fibrinolysis. Due to cost constraints, streptokinase is the widely used fibrinolytic agent in our setting as against western countries where tenecteplase is the preferred agent.

Articles of Interest

A Systematic Review of the Efficacy and Safety of Tenecteplase Versus Streptokinase in the Management of Myocardial Infarction in Developing Countries

According to this narrative synthesis, TNK is more efficacious than SK regarding symptom relief and complete ST-segment resolution. Both agents are similar in terms of successful fibrinolysis. There is conflicting evidence regarding no ST-segment resolution and reinfarction. Concerning safety parameters, SK has a higher risk of bleeding, one-year mortality, hypotension, allergy, and anaphylaxis.

Efficacy of thrombolytic therapy with IV streptokinase in acute ST elevation myocardial infarction patients

Now there are a number of drugs for Thrombolysis but still Streptokinase is used in many of the centers because of the ease of availability and less cost.

Streptokinase almost 30 years after its demonstrated efficacy in acute myocardial infarction

Conclusions: percutaneous coronary intervention is the ideal form of reperfusion in patients with acute myocardial infarction but, at the same time, it is not yet a common practice in developed countries. Reperfusion with thrombolytic remains the first alternative in second-level hospitals and streptokinase is a safe treatment option.

Streptokinase as an antithrombotic agent

Dr. Tillett, an original and profound student of both the clinical and laboratory aspects of infectious disease, discovered in 1933 that hemolytic streptococci produce an enzyme, fibrinolysin, now known as streptokinase, a substance which dissolves human fibrin clots. Twelve years later, Dr. Christensen, a microbiologist with a strong biochemical bent, demonstrated, after a characteristically penetrating and persistent investigation, that streptokinase functions by activation of another protein-digesting enzyme present in blood plasma, but usually in an inactive state

The Origin of Thrombolytic Therapy

The history of thrombolytic therapy actually began in 1933 with the report by Tillett and Garner (2), which stated that Lancefield Group A beta-hemolytic streptococci isolated from patients produced a fibrinolytic substance. Tillett named this material streptococcal fibrinolysin. Although he envisioned that this substance ultimately could be used to dissolve fibrinous exudates, he did not have the training to attempt to isolate or purify this substance.

The Streptokinase Therapy Complications and its Associated Risk Factors in Patients with Acute ST Elevation Myocardial Infarction

Acute myocardial infarction (AMI) is one of the main leading causes of mortality and morbidity. Despite the progress in the treatment of AMI, streptokinase is still being used in many countries.

Resources

Streptokinase.com

Streptokinase has proven efficacy in thousands of myocardial infarctions around the world. The therapy is cost effective, most widely tested in clinical trials

StatPearls

Streptokinase is a polypeptide derived from beta-hemolytic streptococci of Lancefield group C bacteria. It forms a complex with plasminogen, which then converts to the proteolytic enzyme plasmin. This process results in a cascade that ultimately leads to the lysis of fibrin clots. Streptokinase causes a systemic thrombolytic state that usually resolves within 48 hours of administration.