Timing is more important than choice of agent

EDITOR,--Marc Verstraete states incorrectly1 that the accelerated tissue plasminogen activator regimen used in the global utilisation of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO) trial2 “lowered the 30 day mortality to 6.3%, compared with 7.2% achieved with streptokinase, aspirin, and intravenous heparin.” The 30 day mortality for the latter combination was found to be 7.4%. The figures quoted are for the combination of aspirin, streptokinase, and subcutaneous heparin in the same trial.

To quote this trial without mentioning the discussion that it has generated is misleading. By doing so Verstraete implies that streptokinase is good but that tissue plasminogen activator is better. This has by no means been proved to be the case. Many of the controversial issues surrounding the trial were summarised in a recent review.3 The authors helped put the debate in perspective by emphasising that the timing of thrombolysis is much more important than the choice of thrombolytic agent.