Author Affiliations: Division of Cardiology, Department of Medicine (Drs Ohman, Granger, and Harrington) and Department of Community and Family Medicine (Dr Lee), Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
Management of acute coronary syndromes has advanced considerably during
recent years, similar to the evolution in treatment of acute myocardial infarction
(MI) in the 1980s. Then, fibrinolytic and aspirin therapy were shown to reduce
mortality substantially.1 Although these therapies
first were applied to all patients with suspected MI,1
those with ST-segment elevation or left bundle-branch block were shown to
derive most, if not all, of the benefit.2 Accelerated
tissue-type plasminogen activator (tPA) then was found to be superior to streptokinase
in the Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries
(GUSTO-I) trial, with a relative 14% reduction in 30-day mortality.3 Mortality models suggested that tPA treatment independently
predicted better outcomes, consistent across patient subgroups regardless
of absolute risk.4 Without a heterogeneous
treatment effect, the interpretation was that almost all patients with MI
would benefit from tPA treatment.
Ohman EM, Granger CB, Harrington RA, Lee KL. Risk Stratification and Therapeutic Decision Making in Acute Coronary Syndromes. JAMA. 2000;284(7):876–878. doi:10.1001/jama.284.7.876