Fibrinolytic / Thrombolytic Agents in Acute Myocardial Infarction

The thrombolytic agents approved for use in the UK by the National Institute of Clinical Excellence (NICE) are streptokinase, reteplase, tenecteplase and alteplase.


How they are given

Streptokinase is given as an iv infusion over 1 hour.
Tenecteplase is given as a single bolus injection.
Alteplase is given either as an accelerated regimen (one bolus followed by two iv infusions) or as a standard regimen (one bolus and five infusions). 
Reteplase is given as two iv boluses 30 minutes apart.


If streptokinase had been given more than 5 days ago, neutralising antibodies may prevent the efficacy of a second dose and another agent should be used.


Clinical trials

Clinical trials have shown that the maximum 90-minute patency rate is obtained with reteplase.

Most trials have shown no significant difference in mortality rates between the various thrombolytic agents.

However, GUSTO 1 showed that the accelerated alteplase regimen was superior to streptokinase.

ASSENT 2 found almost equal 30-day mortality rates associated with the tenecteplase and accelerated alteplase regimens.

Thus accelerated alteplase and tenecteplase are believed to be superior to streptokinase.


The thrombolytic agent with the minimum risk of causing haemorrhagic stroke is streptokinase.

Heparin is co-administered with reteplase and alteplase, but not with streptokinase.

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Further reading

• Thrombolysis in Elderly Patients With Acute Myocardial Infarction (Medscape)
• Fibrinolytic (thrombolytic) agents in acute ST elevation myocardial infarction: Therapeutic use (UpToDate)
• Fibrinolytic (thrombolytic) agents in unstable angina and acute non-ST elevation myocardial infarction (UpToDate)