Int. J. Pharm. Sci. Rev. Res., 45(2), July - August 2017; Article No.
06, Pages: 29-32 ISSN 0976 – 044X
Review Article
A Review on Thrombolytic Therapy used in Myocardial Infarction
(Streptokinase vs Tenecteplase)
Giri Raja Sekhar.D1*, Ramya. N2, Poojitha. G2, Bhargavi. C2, Madhuri. R2
1 2
Associate Professor, Department of Pharmacy Practice, Pharm D student, Department of Pharmacy Practice, Annamacharya
college of Pharmacy-516115, Rajampet, Kadapa dist. A.P, India.
*Corresponding author’s E-mail: [Link]@[Link]
Received: 03-05-2017; Revised: 12-07-2017; Accepted: 28-07-2017.
ABSTRACT
The most severe form of Acute Coronary Syndrome is ST elevation myocardial infarction which requires immediate therapy.
Thrombolytic agents are the medications that are used widely for the treatment of myocardial infarction. Now day’s different types
of thrombolytic drugs recurrently available in market: alteplase, anisteplase, urokinase, streptokinase, tenecteplase. Thrombolytic
therapy should be given with maintaining proper safety in order to minimize the risk of clinically important bleeding as well as
enhance the chances of successfully thrombolysis of clot. Beside proper knowledge of contraindication, evolutionary factor and
combination of drug is essential for successful thrombolytic therapy. And also should know which drug may produce more efficacy in
thrombolytic therapy. Streptokinase may produce more bleeding complications and less resolution of st-segment when compared to
tissue-plasminogen activators such as tenecteplase. The mortality rate is very high in acute myocardial infarction. So, this can be
reduced by providing tissue plasminogen activator within the time.
Keywords: streptokinase, tenecteplase, myocardial infarction, safety, efficacy.
INTRODUCTION Thrombolytic therapy classification
A blood clot (thrombus) develops in the circulatory
system which consolidates a mechanism in human
body to repair the injured blood vessel. If
thrombus is formed when it is not needed, this can
produce significant consequence like embolism, ischemia,
Thrombolytic drugs are also called "plasminogen
activators" and "fibrinolytic drugs."3
Thrombolytics Used in Clinical Practice
Streptokinase
heart attack, stroke1 and thrombus is formed due to
Streptokinase is a non-fibrinogen-specific fibrinolytic
exposition of the lipid-rich core after atherosclerosis
agent and is a protein which is derived from group a
plaque rupture / erosion into the arterial lumen triggers
streptococci having a molar mass of 47 kDa and is made
the formation of unstable platelet aggregates, which may
up of 414 amino acid residues. The protein exhibits its
lead to intermittent reduction in coronary flow and Acute
maximum activity at a pH of approximately 7.5 and its
coronary thrombosis resulting in total occlusion of a
isoelectric pH is 4.7. Among thrombolytics, this indirect
coronary artery leads to ST segment elevation myocardial
2 fibrinolytic agent is the most commonly used and studied
infarction (STEMI). Myocardial infarction is mainly
due to its availability and lower cost in comparison to
treated by percutaneous coronary intervention and
other agents in this pharmacologic class. It has a short
thrombolytic therapy. In India, PCI centres are not
half-life and is delivered in a continuous infusion over 1
available in all hospitals. Due to this unavailability of PCI,
hour (administered both intravenously or intra coronary).
the use of thrombolytics are increased. So there is need
to know the safety and efficacy of thrombolytics in the
patients of myocardial infarction.
Table 1: Classification of Thrombolytics
Generation of
Fibrin specific Non fibrin specific
thrombolytic drug
Urokinase
First -
Streptokinase
Recombinanttissueplasminogenactivator(t-PA) Prourokinase (scum-PA) Sk-plasminogen
Second
Alteplase activatingcomplex(APSAC)
Tenecteplase (TNK-tPA)
Reteplase
Third Monteplase
Lanoteplase -
Pamiteplase
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Int. J. Pharm. Sci. Rev. Res., 45(2), July - August 2017; Article No. 06, Pages: 29-32 ISSN 0976 – 044X
indicated for the reduction of mortality associated with
Patients may develop antibodies following administration
acute myocardial infarction (AMI). TNK-tPA is a 527
of this agent. If a patient has antibodies, they are at
amino-acid glycoprotein derived by molecular
increased risk of an allergic reaction (including the most
modification of the native human t-PA. It has a prolonged
severe form, anaphylaxis) to streptokinase. Alternatively
half-life, increased fibrin specificity and increased
the presence of antibodies may diminish the thrombolytic
resistance to inhibition by plasminogen activator
effect of streptokinase. These effects mean that
inhibitors and the only thrombolytic agent that can be
streptokinase is used only once in any given patient, and
administered as a single bolus injection over 5 seconds.
repeated administration is discouraged. In some areas, up
Tenecteplase is currently listed as a black triangle drug
to 50% of patients presenting with AMI have already
indicating that the Committee on Safety of Medicines is
received streptokinase once and are therefore not
monitoring it to assess the frequency of adverse
suitable for this drug .4-7
reactions.6,9,10
Dose: 1.5million units over 60 minutes. 8
Dose: The dose is adjusted according to body weight.
Administration
Table 2: Doses of Tenecteplase according to body weight
Dilute two 75,000 unit vials of streptokinase with 5ml
dextrose 5% in water each, gently swirl to dissolve. Patient body
[Link] Dose
weight
Add this dose of the 1.5 million units to 150ml dextrose 1 <60kg 30mg
8
5% in water.
2 60-69kg 35mg
Tenecteplase 3 70-79kg, 40mg
Tenecteplase is the sixth thrombolytic to gain approval 4 80-90Kg 45mg
for manufacturing and marketing by the Food and Drug
5 >90Kg 50mg
Administration (FDA) . Is an altered form of human tissue
plasminogen activator (tPA)), a third-generation
thrombolytic recently manufactured in India since 2007 is
Mechanism Of Thrombolytics:8
Figure 1: Mechanism of Thrombolytics
Contraindications to thrombolytic therapy Active bleeding or bleeding diathesis (excluding
menses)
Absolute contraindications
Significant closed head trauma or facial trauma
Prior intracranial hemorrhage (ICH)
within 3 months
Known structural cerebral vascular lesion
Intracranial or intraspinal surgery within 2 months
Known malignant intracranial neoplasm
Severe uncontrolled hypertension (unresponsive
Ischemic stroke within 3 months to emergency therapy)
Suspected aortic dissection For streptokinase, prior treatment within the
previous 6 months
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Int. J. Pharm. Sci. Rev. Res., 45(2), July - August 2017; Article No. 06, Pages: 29-32 ISSN 0976 – 044X
Relative contraindications for the success of thrombolytic therapy. If the ST
segment elevation has decreased by ≥ 50%, this
History of chronic, severe, poorly controlled
is associated with a higher rate of coronary
hypertension
artery reperfusion. The available research has
Significant hypertension on presentation (systolic clearly shown that the more the ST segment is
blood pressure >180 mm Hg or diastolic blood decreased, the greater the improvement in
pressure >110 mm Hg mortality rates. Other indirect markers of
reperfusion such as the presence/absence of
Traumatic or prolonged (>10 minutes) chest pain, myoglobin levels don’t appear to be
cardiopulmonary resuscitation (CPR) or major very sensitive or reliable
16
surgery less than 3 weeks previously
CONCLUSION
History of prior ischemic stroke not within the last
3 months Streptokinase may produce more bleeding complications
and less resolution of st-segment when compared to
Dementia tissue-plasminogen activators such as tenecteplase. Now-
Recent (within 2-4 weeks) internal bleeding a-days mortality rate is very high in acute myocardial
infarction. So, this can be reduced by providing tissue
Noncompressible vascular punctures plasminogen activator within the time.
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Source of Support: Nil, Conflict of Interest: None.
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