Effect of the initial bolus volume of recombinant tissue-type plasminogen activator on coronary recanalization and infarct size in Japanese acute myocardial infarction patients. Kumamoto University Myocardial Infarction Study (KUMIS) Group

Association between antithrombotic treatments and prognosis of patients with acute pulmonary thromboembolism in Japan

The utility of thrombolysis in patients with acute pulmonary thromboembolism (APTE) remains controversial, although anticoagulation therapy for APTE is well-established in Western countries. Nonetheless, large clinical trials of antithrombotic treatments for APTE have yet to be performed in Japan. In the present study, the association between antithrombotic treatments (thrombolysis and anticoagulation) and the clinical outcomes was retrospectively investigated in 225 APTE patients. In-hospital mortality was significantly lower in hemodynamically stable patients who received anticoagulation therapy than in those who received no adequate therapy (0% vs 33%). Thrombolysis in patients with or without cardiogenic shock failed to improve the in-hospital outcomes compared with those who received anticoagulation treatment (8% vs 3%). There was no significant difference in the bleeding rate between patients receiving thrombolysis and anticoagulation (3% vs 3%). These results indicate that anticoagulation could reduce the mortality of hemodynamically stable APTE patients and that the outcome after thrombolysis or anticoagulation treatment was similar. However, this study was limited because it was executed retrospectively. Further prospective randomized trials to investigate the efficacy of thrombolysis in Japan should be performed to completely address this issue.

Association of plasma levels of activated protein C with recanalization of the infarct-related coronary artery after thrombolytic therapy in acute myocardial infarction

Protein C is one of the most important antithrombotic components. After activation by the thrombin-thrombomodulin complex on endothelial cells, activated protein C (APC) inactivates factors Va and VIIIa, which leads to the inhibition of thrombin formation. We examined the association of plasma levels of APC with the responsiveness to coronary thrombolytic therapy of the infarct-related coronary artery in patients with acute myocardial infarction (AMI). Plasma levels of APC, thrombin-antithrombin III complex (TAT), and plasminogen activator inhibitor (PAI) activity were measured in 32 consecutive AMI patients who underwent coronary angiography followed by thrombolytic therapy, and compared to the measurements in 23 control subjects. On admission, APC levels (ng/mL) were significantly elevated in patients with AMI, as compared with controls (2.5+/-0.4 vs. 1.2+/-0.2, 1.3+/-0.2, respectively, p<0.01). At discharge, plasma levels in AMI patients decline to values not significantly different from those in controls. (1.2+/-0.2, 1.3+/-0.2, respectively). TAT levels (ng/mL) were different among the groups in a fashion similar to that of APC (14.1+/-3.1 on admission vs. 3.3+/-0.4 at discharge, 1.8+/-0.1 in the control subjects, respectively, p<0.01). PAI activity levels (IU/mL) were higher on admission than at discharge and higher than the control subjects (19.7+/-1.8 vs. 10.5+/-1.0, 5.4 +/- 0.7, respectively, p<0.01). Thirty-two patients with AMI were classified into two groups according to the results of thrombolysis: the success group (24 patients) and the failure group (eight patients). APC levels were higher in the failure group than in the success group (5.1+/-0.7 vs. 1.6+/-0.2, p<0.01). TAT levels were also higher in the failure group than in the success group (30.8+/-9.6 vs. 8.6+/-1.7, p<0.01). PAI activity levels (IU/mL) were lower in the failure group than in the success group (13.5+/-3.1 vs. 21.7+/-2.1, p<0.05). There were correlations between APC and TAT levels both on admission (r=0.75, p<0.0001) and at discharge (r=0.71, p<0.0001). Elevated APC was thought to correlate with increased thrombin generation in patients with AMI. This study demonstrated that there was a significant relation between plasma APC level and the responsiveness to thrombolytic therapy of the infarct artery. This study may also indicate that increased thrombin generation is a cause of the resistance to thrombolytic therapy.

New strategy of thrombolysis. Conjunctive effect of plasminogen activators with different pharmacokinetic profile

Combined actions of native and prolonged thrombolytics allow the use of lower doses and simplified schemes of administration, thus yielding significant results in experimental therapy regarding the efficacy and safety of thrombolysis. Development of prolonged forms of plasminogen activators and testing their effect in combination with the thrombolysis trigger are well founded and of current interest. Thrombolytic compositions on the basis of short- and long-term-acting plasminogen activators appear to be promising and potentially eligible for bolus administration.

Comparison of thrombolytic therapies with mutant tPA (lanoteplase/SUN9216) and recombinant tPA (alteplase) for acute myocardial infarction

The fibrinolytic capacity of patients with acute myocardial infarction (AMI) is known to be impaired. The primary regulatory element of the fibrinolytic system is plasminogen activator inhibitor (PAI). It has been previously observed that there are 2 peaks in the plasma PAI level of AMI patients at 4h and 16h after thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Lanoteplase/SUN9216 is a mutant tPA with a biological half-life longer than that of rtPA. Thrombolytic therapy with mutant tPA or rtPA was carried out consecutively in 21 patients with AMI (8 patients as the mutant tPA group, and 13 patients as the rtPA group). The recanalization time of the mutant tPA group was significantly faster than that of the rtPA group (16.1 +/- 3.9 min vs 39.6 +/- 4.8 min, p<0.01). The PAI activity at 4h after the initiation of thrombolysis was significantly lower in the mutant tPA group than in the rtPA group (8.74 +/- 5.46IU/L vs 26.74 +/- 3.35 IU/L, p<0.01). There was a one mild peak in serial plasma PAI activity levels 24h after the initiation of thrombolysis. The results suggest that thrombolytic therapy with mutant tPA reduced the impairment of fibrinolytic capacity. The mutant tPA gives faster recanalization and lower PAI activity after successful thrombolysis, compared with rtPA.