GUSTO-I Trial

GUSTO-I

Global Utilization of Streptokinase and t-PA for Occluded coronary arteries – I
   
Author(s)   

• The GUSTO investigators
• Califf RM, White HD, Van de Werf F, Sadowski Z, Armstrong PW, Vahanian A, Simoons ML, Simes RJ, Lee KL, Topol EJ
• White HD, Barbash GI, Califf RM, Simes RJ, Granger CB, Weaver WD, Kleiman NS, Aylward PE, Gore JM, Vahanian A, Lee KL, Ross AM, Topol EJ
• Lesnefsky EJ, Lundergan CF, Hodgson JMcB, Nair R, Reiner JS, Greenhouse SW, Califf RM, Ross AM

Title(s)   

• An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction
• One-year results from the global utilization of streptokinase and TPA for occluded coronary arteries (GUSTO-I) trial
• Age and outcome with contemporary thrombolytic therapy. Results from the GUSTO-I trial
• Increased left ventricular dysfunction in elderly patients despite successful thrombolysis: The GUSTO-I angiographic experience

Reference(s)

• N Engl J Med 1993;329:673-82
• Circulation 1996;94:1233-8
• Circulation 1996;94:1826-33
• J Am Coll Cardiol 1996;28:331-7

Disease   

• AMI

Purpose   

• To compare aggressive thrombolytic strategies with standard thrombolytic regimens in the treatment of AMI

Study design   

• Randomised, parallel-group

Follow-up   

• 30 days and 1 year

Patients   

• 41,021 patients with AMI < 6 h after onset of symptoms

Treatment regimen   

• Streptokinase, 1.5 x 106 U over 60 min, plus sc heparin, 12,500 U bid; or
• streptokinase, 1.5 x 106 U over 60 min, plus iv heparin as a bolus of 5000 U, then 1000-1200 U/h adjusted to an activated partial thromboplastin time of 60-85 s; or
• accelerated tissue rt-PA as a 15 mg bolus, then 0.75 mg/kg up to 50 mg over 30 min, and 0.5 mg/kg up to 35 mg over the next 60 min, with iv heparin as above; or
• rt-PA, 1.0 mg/kg iv over 60 min, up to 90 mg, and streptokinase, 1.9 x 106 U over 60 min given simultaneously, and iv heparin as above

Concomitant therapy   

• Aspirin, 160-325 mg/day. Atenolol, 5 mg iv in 2 divided doses, then oral atenolol, 50-100 mg once daily. Other medication or treatment at the discretion of the physician

Results   

• Mortality at 30 days was 7.2% in the streptokinase and sc heparin group, 7.4% for streptokinase and iv heparin, 6.3% for accelerated rt-PA and iv heparin, and 7% for the combination of rt-PA and streptokinase plus iv heparin. This corresponds to a 14% reduction in mortality for accelerated rt-PA compared to the two streptokinase only regimens (p = 0.001). 1-year mortality rates remained in favour of accelerated rt-PA (9.1%) over streptokinase with sc heparin (10.1%; p = 0.011) and streptokinase with iv heparin (10.1%, p = 0.009). Combination therapy showed an intermediate 1-year mortality of 9.9%, which was statistically indistinguishable from streptokinase (p = 0.47) but was marginally different from accelerated rt-PA (p = 0.05). There was a significant excess of haemorrhagic strokes at 30 days in the accelerated rt-PA group (p = 0.03) and for the combination group (p < 0.001), compared to streptokinase only. However, a consistent pattern of fewer complications was seen in the accelerated rt-PA group. The combined endpoint of death or disabling stroke was significantly lower in the accelerated rt-PA group (6.9%) than in the streptokinase only groups (7.8%; p = 0.006). Accelerated rt-PA treatment resulted in a lower 1-year mortality in all but the oldest patients (47% rt-PA vs 40.3% streptokinase). Patients > 75 years had higher mortality rate at 30 days than patients ≤ 75 years, but absolute net benefit was still greater with accelerated rt-PA. Older patients had a higher baseline risk profile for both clinical and angiographic characteristics. 30-day mortality increased markedly with age (3.0% in patients aged < 65, 9.5% in those aged 65-74, 19.6% in those aged 75-85, and 30.3% in patients aged > 85), as did stroke, cardiogenic shock, bleeding, and reinfarction. Despite patency at 90 min, 30-day mortality in the elderly remained elevated (17.8% vs 4% in adults) (p ≤ 0.0001). Elderly patients were mainly female and showed more hypertension, multivessel coronary artery disease, previous MI, anterior MI, and later time to treatment (3-6 h). Combined death or disabling stroke occurred less often with accelerated rt-PA in all but the oldest patients who showed a weak trend towards a lower incidence with streptokinase and heparin (odds ratio 1.13, 95% CI 0.6-2.1)

source