Which fibrinolytic agent is safest and most effective in STE
According to the results of a recently published study in the journal Annals of Emergency Medicine, in patients with ST-segment elevation myocardial infarction (STEMI), when percutaneous coronary intervention is not an option, reperfusion therapy with the fibrinolytic agents tenecteplase, reteplase, or accelerated alteplase (90 minutes of infusion) plus parenteral anticoagulation has better overall safety and efficacy than other regimens.

Randomized controlled trials comparing fibrinolytic agents with an approved indication of reperfusion therapy in adults with STEMI, whether administered alone or in combination with adjunctive anticoagulant therapy, were included in the reveiw.

Studies assessing primary or facilitated percutaneous intervention versus fibrinolytics were excluded. Primary outcomes included all-cause mortality within 30 to 35 days (efficacy) and major bleeding (safety).

This systematic review found that in STEMI patients, tenecteplase, reteplase, and accelerated alteplase (90-minute infusion) plus parenteral anticoagulation were the most effective regimens (ie, lower mortality), with an acceptable safety profile (ie, lower risk of bleeding), compared with streptokinase or nonaccelerated alteplase with or without parenteral anticoagulation.

The network meta-analysis showed that monotherapy fibrinolytics (streptokinase and nonaccelerated alteplase) had increased risk of mortality compared with guideline-recommended accelerated alteplase with parenteral anticoagulation.

The addition of glycoprotein IIb or IIIa inhibitors to any fibrinolytic regimen significantly increased the risk of major bleeding and therefore should be avoided.

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