1
|
Disharoon D, Marr DW, Neeves KB. Engineered microparticles and nanoparticles for fibrinolysis. J Thromb Haemost 2019; 17:2004-2015. [PMID: 31529593 PMCID: PMC6893081 DOI: 10.1111/jth.14637] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/28/2022]
Abstract
Fibrinolytic agents including plasmin and plasminogen activators improve outcomes in acute ischemic stroke and thrombosis by recanalizing occluded vessels. In the decades since their introduction into clinical practice, several limitations of have been identified in terms of both efficacy and bleeding risk associated with these agents. Engineered nanoparticles and microparticles address some of these limitations by improving circulation time, reducing inhibition and degradation in circulation, accelerating recanalization, improving targeting to thrombotic occlusions, and reducing off-target effects; however, many particle-based approaches have only been used in preclinical studies to date. This review covers four advances in coupling fibrinolytic agents with engineered particles: (a) modifications of plasminogen activators with macromolecules, (b) encapsulation of plasminogen activators and plasmin in polymer and liposomal particles, (c) triggered release of encapsulated fibrinolytic agents and mechanical disruption of clots with ultrasound, and (d) enhancing targeting with magnetic particles and magnetic fields. Technical challenges for the translation of these approaches to the clinic are discussed.
Collapse
Affiliation(s)
- Dante Disharoon
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO
| | - David W.M. Marr
- Department of Chemical and Biological Engineering, Colorado School of Mines, Golden, CO
| | - Keith B. Neeves
- Departments of Bioengineering and Pediatrics, Hemophilia and Thrombosis Center, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
2
|
|
3
|
Comparative study of the reactivity of natural and mutated streptokinase with total antistreptokinase antibodies in human sera. Blood Coagul Fibrinolysis 2012; 23:734-8. [DOI: 10.1097/mbc.0b013e328358e87b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
4
|
|
5
|
Courval M, Palisaitis DA, Diodati JG, Lesperance B, Pharand C. Inhibition of Streptokinase-Induced, Antibody-Mediated Platelet Aggregation with Tirofiban After Exposure to Streptokinase or Streptococcal Infection. Pharmacotherapy 2004; 24:558-63. [PMID: 15162889 DOI: 10.1592/phco.24.6.558.34734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of tirofiban (a glycoprotein IIb-IIIa inhibitor) in preventing streptokinase-induced, antibody-mediated platelet aggregation after administration of streptokinase or development of a streptococcal infection. DESIGN Prospective analysis. SETTING Research center of a Canadian hospital. PARTICIPANTS Forty-five healthy volunteers, 45 patients who had received streptokinase within the past 3 years, and 13 patients who had a severe streptococcal infection also within the past 3 years. INTERVENTION Blood samples were drawn to measure the extent of inhibition of streptokinase-induced, antibody-mediated platelet activation and aggregation by tirofiban. MEASUREMENTS AND MAIN RESULTS Platelet aggregation was measured by using a turbidimetric method. The extent of inhibition by tirofiban was measured by incubating tirofiban for 2 minutes before adding streptokinase 5000 U/ml. Also, tirofiban was added 2 minutes before adding adenosine 5'-diphosphate (ADP) 2 microM/L into the last tube as a comparison. Strepto-kinase-induced, antibody-mediated platelet aggregation was observed in 10 (22%) of the 45 patients treated with streptokinase, in 3 (23%) of the 13 patients with streptococcal infection, and in none of the 45 healthy volunteers. Tirofiban inhibited streptokinase-induced, antibody-mediated platelet aggregation by 89 +/- 14% (p<0.001). Similarly, ADP-induced platelet aggregation was inhibited by 92 +/- 6% (p<0.001) with tirofiban. CONCLUSION Streptokinase-induced, antibody-mediated platelet aggregation occurred in 13 (22%) of 58 patients who received streptokinase or were exposed to a streptococcal infection in the past 3 years. Such patients may not benefit from streptokinase therapy. In these patients, tirofiban significantly decreased the extent of antistreptokinase antibody-mediated platelet aggregation. Hence, patients undergoing streptokinase therapy may benefit from tirofiban as adjunctive therapy.
Collapse
Affiliation(s)
- Maryse Courval
- Research Center, Hôpital du Sacré-Coeur de Montréal, Quebec, Canada
| | | | | | | | | |
Collapse
|
6
|
Courval M, Palisaitis DA, Diodati JG, Lesperance B, Pharand C. Platelet activity and antibody titers after exposure to streptokinase or streptococcal infection. Thromb Res 2003; 111:243-9. [PMID: 14693171 DOI: 10.1016/j.thromres.2003.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Streptokinase use, in acute myocardial infarction, is hindered by failure to reperfuse (60%) and early reocclusion (16%). This phenomenon may, among other causes, be due to systemic inactivation of streptokinase, as well as streptokinase-induced platelet aggregation and clot propagation from antibodies to streptokinase produced after streptokinase administration or streptococcal infections. The purpose of this study was to determine the incidence of streptokinase-induced, antibody-mediated, platelet activation and aggregation after administration of SK or development of a streptococcal infection. MATERIALS AND METHODS We included 45 normal volunteers (Control group), as well as 45 patients who had received streptokinase (Streptokinase group) and 13 who had suffered a severe streptococcal infection (Streptococcal infection group) within the past 3 years. Extent of streptokinase-induced, antibody-mediated, platelet activation and aggregation, as well as anti-streptokinase antibody and streptokinase resistance titers (lowest streptokinase concentration to cause clot lysis within 10 min) were measured. RESULTS Whereas streptokinase-induced, antibody-mediated, platelet activation was observed in 49% of streptokinase patients and in only 17% and 15% of streptococcal infection patients and normal volunteers (p<0.05 Streptokinase vs. Control and Streptokinase vs. Streptococcal infection), streptokinase-induced platelet aggregation was observed in 23% of streptokinase patients and streptococcal infection patients, and in none of the control patients (p<0.05). CONCLUSIONS Streptokinase-induced, antibody-mediated, platelet activation and aggregation occur in patients with high titers of anti-streptokinase antibody and may play a role in failure of streptokinase therapy. Streptococcal infection patients behave like streptokinase patients in terms of the reactivity of their platelets to subsequent streptokinase dose in vitro.
Collapse
Affiliation(s)
- Maryse Courval
- Research Center, Hôpital du Sacré-Coeur de Montréal and Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | | | | | | | | |
Collapse
|
7
|
Torrèns I, Ojalvo AG, Seralena A, Hayes O, de la Fuente J. A mutant streptokinase lacking the C-terminal 42 amino acids is less immunogenic. Immunol Lett 1999; 70:213-8. [PMID: 10656677 DOI: 10.1016/s0165-2478(99)00151-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Streptokinase (SK) is the most widely used compound for the treatment of myocardial infarction and the least expensive thrombolytic agent, but a drawback to its use is the widespread presence of anti-SK antibodies (Abs). Clinical failure of the activation of the fibrinolytic system by SK has been reported due to the presence of a high titer of anti-SK neutralizing Abs. Patients receiving SK therapy develop high anti-SK antibody titers, which might provoke severe allergic reactions. These Abs are sufficient to neutralize a standard dose of SK up to four years after initial SK administration. This is a clinical problem because of the increasing number of patients who have been treated once with SK for acute myocardial infarction (AMI) and are likely to require plasminogen activator treatment in the future. In previous in vitro studies, we have shown that a deletion mutant (mut-C42), lacking the 42 C-terminal residues, was significantly less antigenic when compared with the native molecule (SKC-2). In this study, 14 monkeys were subjected to treatment with SKC-2 and mut-C42 in order to compare their humoral response by determining SK neutralizing activity in monkey's sera. All monkeys developed anti-SKC-2 Ab titers, but in the case where treatment induced Abs directed against the C-terminus of SKC-2, neutralizing activity against the native protein was significantly higher than that developed against mutant SK mut-C42.
Collapse
Affiliation(s)
- I Torrèns
- Division of Pharmaceutical, Centro de Ingenierià Genètica y Biotecnologìa, Havana, Cuba.
| | | | | | | | | |
Collapse
|
8
|
Ojalvo AG, Pozo L, Labarta V, Torréns I. Prevalence of circulating antibodies against a streptokinase C-terminal peptide in normal blood donors. Biochem Biophys Res Commun 1999; 263:454-9. [PMID: 10491315 DOI: 10.1006/bbrc.1999.1397] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Streptokinase (SK) is a streptococcal protein widely used as a thrombolytic agent. Anti-SK antibodies (Abs) are found in most individuals due to common streptococcal infections. The presence of these Abs increases the possibility of allergic reactions and may reduce the thrombolytic efficacy of SK upon a first therapy. Previous studies report on the immunodominance of the SK C-terminus and the role of this region in plasminogen (Plg) activation. The aim of this study was to assess the prevalence of circulating Abs to the SK C-terminus in normal blood donors. Sera from 1008 subjects aged 30 to 60 years were tested by Ultra-Micro-ELISA using a synthetic peptide resembling the SKC-2 C-terminus. An overall prevalence of 30. 4% was found. Prevalence was significantly higher among male than among female donors (RR = 1.70, 1.13 < CI < 2.55). No age effect was observed. This is the first extensive study about Abs directed against a particular region of SK in normal subjects.
Collapse
Affiliation(s)
- A G Ojalvo
- Division of Pharmaceutical, Centro de Ingeniería Genética y Biotecnología, Havana, Cuba
| | | | | | | |
Collapse
|
9
|
el Gaylani N, Davies S, Tovey J, Kinnarid T, Duly E, Buchalter MB. Systemic lytic state is not a predictor of coronary reperfusion in acute myocardial infarction. Int J Cardiol 1996; 57:45-50. [PMID: 8960942 DOI: 10.1016/s0167-5273(96)02780-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To investigate why approximately one third of patients thrombolysed with streptokinase fail to reperfuse, we assessed the lytic status, antistreptokinase antibody and non invasive parameters of reperfusion in 95 consecutive patients with acute myocardial infarction treated with streptokinase for the first time. The lytic status was assessed by Clauss fibrinogen assay and thrombin clotting time before and 2 h after streptokinase infusion. Antistreptokinase antibody was measured prior to the infusion. Reperfusion was assessed by measurement of the 24:96 h troponin-T ratio (a ratio > 1 indicating reperfusion) and ST segment resolution 2 h post streptokinase. Ninety-two (97%) patients achieved a systemic lytic state with a fibrinogen titre of less than 1.0 g/l and thrombin clotting time ratio of > 2.5. Despite this, 27% failed to reperfuse with a mean 24:96 h troponin-T of 0.9, SD 0.6 vs. 3.4 +/- 3.2 in the reperfused group, (P < 0.0001). 83% of the reperfused group but none of the non reperfused group had ST segment resolution. No difference was observed in the levels of fibrinogen and thrombin clotting time between the reperfused 0.25 +/- 0.3 g/l; 6.9 +/- 4, and the non reperfused group 0.4 +/- 0.6 g/l; 7.9 +/- 2.6. No difference was observed in the levels of antistreptokinase antibody between the reperfused (median = 168 U/ml and the non reperfused (median = 177 U/ml). Failure to reperfuse with Streptokinase is not due to failure to achieve a lytic state. Therefore increased or accelerated dosages of streptokinase are unlikely to increase the rate of reperfusion.
Collapse
Affiliation(s)
- N el Gaylani
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK
| | | | | | | | | | | |
Collapse
|
10
|
Urdahl KB, Mathews JD, Currie B. Anti-streptokinase antibodies and streptokinase resistance in an Aboriginal population in northern Australia. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1996; 26:49-53. [PMID: 8775528 DOI: 10.1111/j.1445-5994.1996.tb02906.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Thrombolytic treatment with streptokinase in acute myocardial infarction has proven to be safe and effective in Caucasian populations with relatively low levels of anti-streptokinase IgG and streptokinase resistance. Higher levels of antibodies, as seen in previous recipients of streptokinase therapy, cause more adverse reactions and may result in lower efficacy. AIMS To examine the levels of anti-streptokinase IgG and streptokinase resistance in a population subjected to endemic streptococcal infections. METHODS AND RESULTS Thirty Aboriginal adults from a remote community in Northern Australia with endemic streptococcal infections and 15 non-Aboriginal adults from an urban community without endemic infections participated in this study. Aboriginal adults exhibited levels of anti-streptokinase IgG and streptokinase resistance that, respectively, were almost 20 and 15 times greater than the values of non-Aboriginal adults. At least 23% of Aboriginal adults had sufficiently high levels of streptokinase resistance to neutralise a standard 1.5 million unit dose of streptokinase. CONCLUSIONS Aboriginal adults from a remote community had dramatically elevated levels of anti-streptokinase IgG and in vitro streptokinase resistance. Prospective studies are needed to assess the clinical relevance of streptokinase resistance in populations from areas with endemic streptococcal infection.
Collapse
Affiliation(s)
- K B Urdahl
- Department of Microbiology, University of Minnesota Medical School, Minneapolis, USA
| | | | | |
Collapse
|
11
|
Marzilli M. From the experimental myocardial infarction to the clinical acute myocardial infarction: limitations of thrombolytic therapy. Int J Cardiol 1995; 49 Suppl:S71-5. [PMID: 7591319 DOI: 10.1016/0167-5273(95)02341-s] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Early administration of thrombolytic agents in acute myocardial infarction lowers mortality and preserves left ventricular function. Currently, only one third of infarct patients receive this treatment, the vast majority being excluded because of restrictive criteria and delayed hospital admission. When correctly administered, thrombolytic therapy achieves reperfusion in 50-85% of occluded vessels. Five to 15% of these initially recanalized vessels eventually reocclude. Possible mechanisms of failure of thrombolytic therapy to induce stable coronary reperfusion include thrombus formation during thrombolysis, platelet activation by thrombolysis, fibrin deposition during thrombolysis, and resistance to thrombolysis. Bleeding complications including intracranial haemorrhage remain a major complication. New therapeutic regimens, new thrombolytic agents and more effective anti-thrombotic drugs, together with intervention strategies that anticipate the time of treatment, promise a significant increase of the overall benefits obtainable with thrombolysis in acute myocardial infarction.
Collapse
Affiliation(s)
- M Marzilli
- University of Pisa Medical School, Institute of Clinical Physiology CNR, Pisa, Italy
| |
Collapse
|
12
|
|
13
|
Abstract
Acute myocardial infarction is the result of an acute interruption of myocardial blood flow resulting in ischemic myocardial necrosis. The pathogenesis of this phenomenon nearly always involves acute thrombosis superimposed on a disrupted atherosclerotic plaque. Thrombolytic agents have been conclusively shown to reduce mortality in many patient subgroups with myocardial infarction, including the elderly, patients with inferior myocardial infarction, and patients with systolic hypertension. Nearly all patients with acute myocardial infarction of less than 6 h in duration with S-T segment elevation should receive thrombolysis unless significant contraindications exist and outweigh the potential benefits. Aspirin should be given to almost all patients regardless of whether they receive thrombolysis. Angioplasty and coronary artery bypass surgery are useful as primary or secondary modes of reperfusion in selected patients with infarction.
Collapse
Affiliation(s)
- J R Gossage
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn 37232-2650
| |
Collapse
|
14
|
Gemmill JD, Hogg KJ, Dunn FG, Rae AP, Hillis WS. Pre-dosing antibody levels and efficacy of thrombolytic drugs containing streptokinase. Heart 1994; 72:222-5. [PMID: 7946770 PMCID: PMC1025505 DOI: 10.1136/hrt.72.3.222] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To evaluate the influence of pretreatment streptokinase resistance titre and the concentration of IgG antibodies to streptokinase on the efficacy of thrombolytic drugs containing streptokinase in restoring coronary patency in acute myocardial infarction. DESIGN Comparative observational study. SETTING City general hospital. PATIENTS One hundred and twenty four previously unexposed patients presenting within six hours of onset of acute myocardial infarction. INTERVENTIONS Streptokinase, 1.5 MIU as intravenous infusion over 60 minutes (60 patients), or anistreplase, 30 units as intravenous injection over five minutes (64 patients). MAIN OUTCOME MEASURES Pretreatment streptokinase resistance titre and concentration of IgG antibodies to streptokinase were measured in 96 and 124 patients respectively and coronary patency assessed angiographically at 90 minutes and 24 hours. RESULTS Pretreatment streptokinase resistance titre and concentrations of IgG antibodies to streptokinase were low and skewed towards higher values. Those patients with coronary occlusion at 24 hours had a significantly higher median streptokinase resistance titre (100 v 50 streptokinase IU ml-1, P = 0.02). There were trends towards a higher streptokinase resistance titre in those patients with coronary occlusion at 90 minutes (50 v 20 streptokinase IU ml-1, P = 0.06) and higher concentrations of IgG antibodies to streptokinase in those with coronary occlusion at both 90 minutes and 24 hours (1.53 v 0.925, P = 0.03; 1.65 v 1.04 micrograms streptokinase binding ml-1, P = 0.06). Coronary patency rates were similar in the two treatment groups. CONCLUSIONS In the range measured in previously unexposed patients the streptokinase resistance titre has a small, but significant, negative influence on the efficacy of streptokinase and anistreplase. This effect should be considered if retreatment with streptokinase or anistreplase is proposed.
Collapse
Affiliation(s)
- J D Gemmill
- Department of Medicine and Therapeutics, University of Glasgow, Western Infirmary
| | | | | | | | | |
Collapse
|
15
|
Brügemann J, van der Meer J, Bom VJ, Lie KI. Streptokinase antibodies are of clinical importance and they can be measured in half an hour by a simple enzyme-linked immunosorbent assay. Heart 1994; 72:209-10. [PMID: 7980840 PMCID: PMC1025494 DOI: 10.1136/hrt.72.2.209-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
|
16
|
Shaila G, Chandrashekhar YS, Kumar N, Ganguly NK, Anand IS. Antistreptokinase antibodies before and after streptokinase therapy in patients with acute myocardial infarction from areas endemic for streptococcal infection and influence on reperfusion rates. Am J Cardiol 1994; 74:187-9. [PMID: 8023789 DOI: 10.1016/0002-9149(94)90099-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- G Shaila
- Departments of Cardiology & Experimental Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | | | | | | | | |
Collapse
|
17
|
Abstract
Antibodies to streptokinase (SK) are widespread in the population, but reports of their effect on the action of SK are conflicting. Specific anti-SK IgG was purified from the sera of 10 patients, five with low titres of anti-SK IgG and five with high titres. The effect of increasing specific anti-SK IgG antibodies on the action of SK was evaluated in vitro using a fluorimetric assay for plasmin and by a fibrin plate lysis assay. The inhibition of SK by whole plasma from a further group of patients was also assessed by the fibrin plate assay. There was a positive correlation between the serum antibody concentration and the quantity of specific anti-SK eluted (r = 0.797; P < 0.005). The addition of specific anti-SK IgG caused a dose-related decrease in SK activity (fluorimetric assay r = -0.93; P = 0.02; fibrin plate assay r = -0.98; P < 0.001). The addition of patient plasma to the fibrin plate assay also resulted in decreased lysis, which was dependent upon antibody titre (r = -0.95; P < 0.0001). Significant in vitro reduction of the activity of SK by specific antibody was demonstrated, and this was similar with plasma containing comparable amounts of antibody. The findings suggest that treatment with SK would be unlikely to induce an effective thrombolytic state when antibody titres are high (such as those seen within 2 years of an initial dose of SK).
Collapse
Affiliation(s)
- M Lynch
- General Hospital, Birmingham, UK
| | | | | | | |
Collapse
|
18
|
Musselman DR, Tate DA, Oberhardt BJ, Abruzzini AF, Blauwet MB, Koch G, Dehmer GJ. Differences in clot lysis among patients demonstrated in vitro with three thrombolytic agents (tissue-type plasminogen activator, streptokinase and urokinase). Am J Cardiol 1994; 73:544-9. [PMID: 8147298 DOI: 10.1016/0002-9149(94)90330-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This study compares the ability of 3 thrombolytic drugs to promote clot lysis using a new in vitro testing procedure. Whole blood samples from 132 patients were tested using 5 different concentrations of tissue-type plasminogen activator (t-PA), streptokinase (SK) and urokinase. A mixture of blood and thrombolytic drug was placed on a dry-reagent test card containing reptilase, buffers and paramagnetic particles where clot formation occurred. Analysis of the motion of the clot-embedded paramagnetic particles caused by an oscillating magnetic field was used to define the lysis onset time. The slope of the linear regression plot of lysis onset time versus 1/[drug concentration] defined the kinetic rate constant (k) for each drug in each patient. Higher values of k indicated greater resistance to in vitro clot lysis. In the patients studied, there was a large range of k values for t-PA and SK (coefficient of variation 143 and 137%, respectively) but a smaller range of k for urokinase (coefficient of variation 32%). The coefficients of variation for t-PA and SK observed in the study group were five- to 10-fold greater than the coefficients of variation determined for replicate test measurements. Resistance to all SK concentrations tested was found in 9% of the patients. In vitro sensitivity to thrombolysis was compared among the drugs by correlating the derived k values. These comparisons indicated no relation for any of the drugs; many patients had a relatively low k value for 1 drug, while having a relatively high k value for a different drug.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- D R Musselman
- C. V. Richardson Cardiac Catheterization Laboratory, University of North Carolina Hospitals, Chapel Hill 27514
| | | | | | | | | | | | | |
Collapse
|
19
|
Bom VJ, Brügemann J, van der Schaaf W, van Wijk RT, van der Meer J. Rapid enzyme immunoassay of anti-streptokinase antibodies in human plasma. Clin Chim Acta 1993; 218:121-9. [PMID: 8306437 DOI: 10.1016/0009-8981(93)90176-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A simple enzyme immunoassay for determination of anti-streptokinase antibodies (aSKa) in plasma is described. Commercially available reagents have been used for the assay, which is calibrated with a reference preparation of aSKa containing 100 AU/ml. The assay is specific and reproducible with a variation coefficient of 4.8%. In healthy individuals a broad range of values between 4 and 291 AU/ml was observed with a large difference between the mean and median value (55 AU/ml and 27 AU/ml, respectively). Data from a study on 21 patients with myocardial infarction treated with the streptokinase derivative antistreplase suggest that a high titre of aSKa before treatment is associated with failure of thrombolytic therapy. The assay procedure can be shortened to 0.5 h to screen patients for a high aSKa level. This assay allows a more routine assessment of aSKa in the clinic.
Collapse
Affiliation(s)
- V J Bom
- Department of Haemostasis, Thrombosis & Rheology, University Hospital Groningen, The Netherlands
| | | | | | | | | |
Collapse
|
20
|
Brügemann J, van der Meer J, Bom VJ, van der Schaaf W, de Graeff PA, Lie KI. Anti-streptokinase antibodies inhibit fibrinolytic effects of anistreplase in acute myocardial infarction. Am J Cardiol 1993; 72:462-4. [PMID: 8352192 DOI: 10.1016/0002-9149(93)91143-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- J Brügemann
- Department of Cardiology (Thoraxcenter), University Hospital Groningen, The Netherlands
| | | | | | | | | | | |
Collapse
|
21
|
Elliott JM, Cross DB, Cederholm-Williams SA, White HD. Neutralizing antibodies to streptokinase four years after intravenous thrombolytic therapy. Am J Cardiol 1993; 71:640-5. [PMID: 8447258 DOI: 10.1016/0002-9149(93)91003-z] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Neutralization antibodies to streptokinase increase to high levels within several days of administration. It is not known how long these high levels persist. The time course of antibody levels needs to be further characterized owing to the increasing need to readminister thrombolytic therapy, and to the possibility that these antibodies may compromise the safety and efficacy of a further dose of streptokinase or streptokinase-containing compounds. In this study, paired streptokinase neutralization titers (in vitro functional assay) and specific antistreptokinase immunoglobulin G (IgG) antibody levels were measured in 145 patients who received streptokinase between 10 and 48 months previously. Serologic evidence of recent streptococcal infection was also sought. Neutralization titers sufficient to inactivate a conventional dose of 1,500,000 units of streptokinase were still present in 50% of patients (95% confidence interval 36-64) at 24 months, 48% (34-62) at 36 months, and 51% (37-71) at 48 months after streptokinase administration. Levels of specific antistreptokinase IgG antibodies also remained constant over the 1- to 4-year period. Neutralization titers were weakly correlated with specific IgG levels (r = 0.35). Antistreptolysin titers > or = 250 and > or = 333 IU/ml were present in 30% (24-38) and 12% (8-18) of these patients, respectively. Neutralization titers were not correlated with antistreptolysin titers. Neutralizing antibodies (assessed by an in vitro functional assay) remained high in 51% of patients 4 years after intravenous streptokinase administration. It is not known whether persisting high in vitro neutralization titers affect the efficacy and safety of repeat administration of streptokinase or streptokinase-containing compounds.
Collapse
Affiliation(s)
- J M Elliott
- Cardiovascular Research Unit, Green Lane Hospital, Auckland, New Zealand
| | | | | | | |
Collapse
|
22
|
Flores ED, Lange RA, Cigarroa RG, Hillis LD. Therapy of acute myocardial infarction in the 1990s. Am J Med Sci 1990; 299:415-24. [PMID: 2113353 DOI: 10.1097/00000441-199006000-00009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- E D Flores
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235
| | | | | | | |
Collapse
|
23
|
Affiliation(s)
- M Nidorf
- Department of Cardiovascular Medicine, Sir Charles Gairdner Hospital, Nedlands, WA
| | | |
Collapse
|
24
|
Significance of antibodies to streptokinase in coronary thrombolytic therapy with streptokinase or APSAC. ACTA ACUST UNITED AC 1988. [DOI: 10.1016/0268-9499(88)90014-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
25
|
Lange RA, Hillis LD. Evolving concepts in the treatment of acute myocardial infarction. Am J Med Sci 1988; 296:143-52. [PMID: 3041833 DOI: 10.1097/00000441-198808000-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Recent studies in patients with transmural acute myocardial infarction have demonstrated that intravenous thrombolytic therapy with streptokinase or tissue plasminogen activator improves left ventricular function and reduces mortality. To accomplish this, these agents must be infused early, ie, within 3 to 4 hours of the onset of chest pain; later administration of the agents exerts no significant beneficial effect. Tissue plasminogen activator appears to be the most effective and safest of the available thrombolytic agents: its intravenous administration is followed by coronary reperfusion in about 70% of patients, and its use is not associated with allergic reactions, a systemic fibrinolytic state, or a prolonged fibrinolytic effect. Once reperfusion has been established with an intravenous thrombolytic agent, intravenous heparin is given for several days, followed by oral aspirin to prevent reocclusion. Since many of these patients have a residual high-grade coronary artery stenosis in the infarct-related artery, mechanical alleviation of the residual stenosis with angioplasty or bypass surgery is an attractive therapy 2 to 4 days after reperfusion, and preliminary data indicate that elective coronary angioplasty 3 days after thrombolytic therapy is beneficial. However, further studies are needed to assess more definitively the use of such an aggressive therapeutic strategy.
Collapse
Affiliation(s)
- R A Lange
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas 75235
| | | |
Collapse
|
26
|
Vaughan DE, Kirshenbaum JM, Loscalzo J. Streptokinase-induced, antibody-mediated platelet aggregation: a potential cause of clot propagation in vivo. J Am Coll Cardiol 1988; 11:1343-8. [PMID: 3130418 DOI: 10.1016/0735-1097(88)90302-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The administration of intracoronary streptokinase to a patient with a prior history of rheumatic fever was associated with the retrograde propagation of thrombus from the left anterior descending coronary artery into the left main coronary artery with near catastrophic consequences. The addition of streptokinase to platelet-rich plasma from the patient initiated platelet aggregation and secretion in vitro. Platelet aggregation was also seen in 1 of 15 control subjects after the addition of streptokinase, and the addition of plasma or immunoglobulin G (IgG) from the index patient supported platelet aggregation in the presence of streptokinase in all of the previously nonreactive control subjects. This in vitro platelet aggregation was specific for streptokinase and not initiated by either urokinase or tissue plasminogen activator. Streptokinase-induced platelet aggregation was not inhibited by aprotinin, but was completely attenuated by the addition of an excess of antihuman IgG Fab. These findings suggest that streptokinase can initiate specific antibody-mediated platelet aggregation in vitro and may be more than coincidentally related to clot propagation or thromboembolism in vivo.
Collapse
Affiliation(s)
- D E Vaughan
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts 02115
| | | | | |
Collapse
|
27
|
Nazari J, Davison R, Kaplan K, Fintel D. Adverse reactions to thrombolytic agents. Implications for coronary reperfusion following myocardial infarction. MEDICAL TOXICOLOGY AND ADVERSE DRUG EXPERIENCE 1987; 2:274-86. [PMID: 3306267 DOI: 10.1007/bf03259869] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The use of thrombolytic agents to dissolve coronary artery thrombi causing acute transmural myocardial infarctions has been shown to decrease short term mortality, and improve left ventricular function, in patients with acute transmural myocardial infarction. Several thrombolytic agents are currently available which differ mainly in cost, antigenicity, and mechanism of action. Current investigations are being directed at finding safer, more effective thrombolytic agents and at developing optimal therapy following thrombolysis. The complications of thrombolytic therapy are for the most part minor and reversible. Immediate and delayed hypersensitivity to streptokinase is rare. Hypotension and arrhythmias commonly accompany myocardial reperfusion and are usually benign and self-limited. Haemorrhagic complications are the most frequent and serious problems following the use of thrombolytic agents. They can be lessened by the proper selection of patients to avoid those at high risk of bleeding. The avoidance of unnecessary arterial and venous punctures will decrease the incidence of minor but annoying local bleeding. Those agents which are activated at the site of thrombi will hopefully cause fewer bleeding episodes, but early experience with these agents has not been able to demonstrate a lower rate. With careful attention to patient selection and follow-up, thrombolytic agents can be safely and effectively used in the management of patients with acute myocardial infarction.
Collapse
|
28
|
Chien KR, Meidell R, Gerard R. Tissue plasminogen activator: from molecular biology to myocardial infarction. Am J Med Sci 1987; 293:201-7. [PMID: 3105313 DOI: 10.1097/00000441-198703000-00009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The recent development of recombinant tissue plasminogen activator as a therapeutic agent during acute myocardial infarction is one of the most lucid examples of the potential impact of recombinant DNA technology in clinical medicine. This remarkable achievement would not have been possible without several key discoveries in molecular biology and clinical cardiology and exemplifies the synergistic relationship between basic and clinical research. This article chronicles this journey from molecular biology to myocardial infarction.
Collapse
|
29
|
Abstract
Thrombolytic therapy is becoming an important addition to the care of patients with transmural (Q-wave) myocardial infarction. In this review, the authors analyze the mechanisms of effect and thrombolytic capabilities of several currently used thrombolytic interventions and review the influence of reperfusion in reducing mortality and protecting segmental ventricular function in animal models and patients. The problems related to thrombolytic therapy also are discussed and patient subgroups most likely to benefit from thrombolytic therapy identified. Finally, the authors speculate concerning future alterations in thrombolytic agents and additions to thrombolytic therapy as they might be usefully applied in the care of patients with acute transmural myocardial infarcts.
Collapse
|
30
|
|
31
|
Fears R, Ferres H, Hibbs M, Standring R. Consequences of antibody binding in vitro on the pharmacological properties of anisoylated plasminogen streptokinase activator complex. Drugs 1987; 33 Suppl 3:64-8. [PMID: 3315614 DOI: 10.2165/00003495-198700333-00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- R Fears
- Beecham Pharmaceuticals Research Division, Great Burgh, Epsom
| | | | | | | |
Collapse
|
32
|
Six AJ, Brommer EJ, Müller EJ, Kerkhoff HF. Activation of the fibrinolytic system during intracoronary streptokinase administration. J Am Coll Cardiol 1987; 9:189-96. [PMID: 3794096 DOI: 10.1016/s0735-1097(87)80100-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Serial biochemical studies were performed in 12 patients treated with intracoronary streptokinase infusion for acute myocardial infarction, in order to study the method of activation of the fibrinolytic system during local administration of a relatively low dose of this drug and to determine correlations between systemic effects and reperfusion. Plasma samples were obtained before and every 15 minutes during the infusion of streptokinase and after completion of the therapy. Streptokinase dosage in this study was 211,000 +/- 88,000 IU (+/- SD). The average time from the onset of symptoms to the start of infusion was 2 hours 50 minutes (range 1 hour 10 minutes to 3 hours 30 minutes). Reperfusion occurred in six patients and temporary recanalization in three; in three patients no recanalization was achieved. Fibrinolytic assays of pretreatment plasma samples revealed elevated levels of plasminogen activators, presumably caused by the release of tissue-type plasminogen activator after a condition of stress. Plasminogen concentrations decreased from 94 +/- 17% to 44 +/- 30%. Alpha 2-antiplasmin fell from 84 +/- 27% to 12 +/- 19%; in seven patients no plasmin inhibitor activity was measurable at the completion of the infusion. Free plasmin occurred in samples only when this inhibitor had disappeared. This resulted in a lytic state leading to degradation of fibrinogen, the levels of which fell from 2.9 +/- 0.7% to 1.5 +/- 1.1%. Fibrinogen degradation products, measured in plasma with monoclonal antibodies, increased exponentially during streptokinase infusion in at least four patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
33
|
Lew AS, Cercek B, Hod H, Shah PK, Ganz W. Usefulness of residual plasma fibrinogen after intravenous streptokinase for predicting delay or failure of reperfusion in acute myocardial infarction. Am J Cardiol 1986; 58:680-5. [PMID: 3766409 DOI: 10.1016/0002-9149(86)90337-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The relation between the level of residual plasma fibrinogen and coronary artery reperfusion after 750,000 IU of intravenous (i.v.) streptokinase (SK) was examined in 76 patients with acute myocardial infarction. Both the frequency and rapidity of reperfusion were greater in the 53 patients in whom the residual fibrinogen level was 50 mg/dl or less (low fibrinogen) than in the 23 patients in whom it was more than 50 mg/dl (high fibrinogen). Reperfusion occurred in all 53 patients in the low-fibrinogen group, compared with only 15 patients in the high-fibrinogen group (p less than 0.001). The interval from initiation of SK to clinical signs of reperfusion was 50 +/- 34 minutes in the low-fibrinogen group and 110 +/- 54 minutes in the high-fibrinogen group (p less than 0.001). A high fibrinogen level occurred in 58% of patients who weighed more than 85 kg and in 25% of patients who weighed 85 kg or less (p less than 0.05). No patient who weighed 60 kg or less had a high fibrinogen level. The high-fibrinogen group also had a greater incidence of a high anti-SK antibody titer: 8 of 13 patients (62%) tested, compared with none of the 8 patients tested in the low-fibrinogen group (p less than 0.01). Our data indicate that a high residual fibrinogen level after administration of i.v. SK identifies patients in whom SK is relatively ineffective, probably because of inadequate dosage of inactivation of the drug.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
34
|
Lew AS, Laramee P, Cercek B, Shah PK, Ganz W. The hypotensive effect of intravenous streptokinase in patients with acute myocardial infarction. Circulation 1985; 72:1321-6. [PMID: 4064276 DOI: 10.1161/01.cir.72.6.1321] [Citation(s) in RCA: 70] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
We studied the hypotensive effect of a rapid intravenous infusion of high-dose streptokinase in 98 patients with an acute myocardial infarction. The systolic blood pressure fell from 132 +/- 20 (range 90 to 174) to 97 +/- 21 mm Hg (range 58 to 152) at 15 +/- 8 min (range 4 to 40) after the commencement of the streptokinase infusion (p less than .001). A fall in diastolic blood pressure from 80 +/- 16 (range 51 to 105) to 61 +/- 15 mm Hg (range 32 to 92) accompanied the fall in systolic pressure (p less than .001). The fall in blood pressure was associated with an increase in heart rate (73 +/- 14 to 78 +/- 17 beats/min, p less than .001), preceded the appearance of clinical signs of reperfusion by 37 +/- 38 min and was similar in magnitude and timing in patients with anterior and inferior infarction. There were direct relationships between the rate of infusion of streptokinase and both the magnitude (r = .49, p less than .001) and the rate of fall of systolic blood pressure (r = .67, p less than .001) as well as both the magnitude and rate of fall of diastolic blood pressure. In most patients, the fall in blood pressure was transient (9 +/- 6 min, range = 2 to 30) and easily managed by slowing or stopping the infusion, placing the patient in the Trendelenburg position, or by administering an infusion of low-dose norepinephrine or dopamine. However, in four patients with severe left ventricular dysfunction, severe hypotension persisted for more than 60 min.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
|
35
|
|