Introduction

Coronary artery occlusion is responsible for 180 000 admissions to hospital each year in the United Kingdom. Vessel obstruction is commonly caused by the formation of a thrombus, and timely treatment with thrombolytic drugs such as streptokinase has improved the immediate and longer term outlook after acute myocardial infarction.1 2 3 4 5 Mortality in patients given thrombolytic drugs sufficiently early is 10% to 12%—a third less than mortality in untreated patients. The benefits of thrombolytic treatment have been shown clearly in clinical trials, but there are limitations. We review current practice and the research that is currently under way to improve outcome in patients who have had acute myocardial infarction.

Current practice

Current clinical practice is based on considerable research and debate over the past 10 years. Thrombolytic drugs should be given as soon as possible, although benefit may occur for up to 12 hours after onset of symptoms.6 Use of audit review to ensure that thrombolysis is given early is a priority. An electrocardiogram should be done within 15 minutes and thrombolysis started within 30 minutes of the patient's arrival in hospital.

The global utilisation of streptokinase and tPA for occluded arteries (GUSTO-I) trial showed that tissue plasminogen activator may be better than streptokinase in those patients who are younger, present earlier, have anterior infarction, and who have been given streptokinase for a previous myocardial infarction.5 Aspirin seems to be as beneficial as thrombolytic drugs, although its action is unclear and may not be entirely related to its anticoagulant effects.3 Lifelong treatment with aspirin after myocardial infarction seems to be generally accepted.7 Early treatment with angiotensin converting enzyme inhibitor drugs in people with impaired ventricular function, and ß blocking drugs in those whose ventricular function is not severely impaired, improve the outcome in the longer …