Platelet function during and after thrombolytic therapy for acute myocardial infarction with reteplase, alteplase, or streptokinase

BACKGROUND

Changes in platelet aggregation (PA) and platelet surface receptor expression induced by thrombolytic therapy for acute myocardial infarction may influence the rate of initial reperfusion and early reocclusion.

METHODS AND RESULTS

In the RAPID-1 (Reteplase Angiographic Phase II International Dose-finding study), RAPID-2 (Reteplase vs Alteplase Patency Investigation During myocardial infarction), INJECT (INternational Joint Efficacy Comparison of Thrombolytics), and GUSTO-3 (Global Use of Strategies To Open occluded coronary arteries) trials, 126 patients were enrolled in a single center. Patients were treated with either conventional alteplase (100 mg/180 min; n=15), accelerated alteplase (100 mg/90 min; n=21), reteplase 10+10-U double bolus (n=50), reteplase 10+5-U double bolus (n=15), reteplase 15-U single bolus (n=15), or streptokinase (1.5 MU/60 min; n=10). PA (after stimulation with ADP), P-selectin expression and fibrinogen binding to glycoprotein (GP) IIb/IIIa (determined by flow cytometry with and without stimulation with ADP), and levels of soluble P-selectin, prothrombin fragments F1 and F2, thrombin-antithrombin complexes (TAT), and antithrombin III (ATIII) were determined. PA decreased significantly at 1 and 2 hours in patients treated by 10+10-U reteplase or by streptokinase. Fibrinogen binding to platelet GP IIb/IIIa followed a similar pattern. Significant thrombin generation and significantly elevated thrombin levels during thrombolysis were reflected by increased F1 and F2 fragments and TAT levels in all treatment groups. ATIII levels decreased significantly during thrombolytic therapy.

CONCLUSIONS

A decrease in PA in patients treated by reteplase or streptokinase compared with alteplase could be observed in the early phase. Double bolus (10+10 U) reteplase and streptokinase resulted in lower PA at 1 and 2 hours than therapy with accelerated alteplase. Total fibrinogen and fibrinogen binding to GP IIb/IIIa tended to be lower during the first 2 hours after reteplase than after accelerated alteplase.

Mechanical alterations in smooth muscle from mice lacking desmin

Mice with a null mutation introduced in the desmin gene were used to study the mechanical role of intermediate filaments in smooth muscle cells. Vas deferens (VD), urinary bladder (UB) and portal vein (PV) preparations were obtained from adult animals lacking desmin (Des -/-) and from age- and weight-matched wild-type animals (Des +/+). Active force per cross-sectional area was decreased in the smooth muscle of the Des -/- compared with Des +/+ mice (VD to 42%; UB to 34%). Quantitative gel electrophoresis suggests a marginally lower cellular content of myosin, but the organization of the contractile apparatus appeared unchanged by electron microscopy. A similar reduction in stress was measured in Des -/- skinned fibres showing that altered activation mechanisms were not involved. The results indicate that the reduced active force is caused by low intrinsic force generation of the contractile filaments or subtle modifications in the coupling between the contractile elements and the cytoskeleton. The relationship between length and passive stress was less steep in the Des -/- samples and a second length force curve after maximal extension revealed a loss of passive stress. The maximal shortening velocity was reduced in Des -/- skinned VD and UB preparations by approximately 25-40%. This was associated with an increased relative content of the basic essential myosin light chain, suggesting that alterations in the contractile system towards a slower, more economical muscle had occurred. PV preparations showed no difference in mechanical properties in Des +/+ and Des -/- animals, a result that was consistent with the predominance of vimentin instead of desmin in this vascular tissue. In conclusion, the results show that, although intermediate filaments in smooth muscle are not required for force generation or maintenance of passive tension, they have a role in cellular transmission of both active and passive force.

Reteplase (r-PA): a new plasminogen activator

Reteplase (r-PA) is a genetically engineered deletion mutant of wild-type tissue-type plasminogen activator. The structural differences lead to different functional properties, such as a prolonged half-life. The compound demonstrated good thrombolytic efficacy in in vitro as well as in animal studies. In angiographically controlled patency studies (GRECO, GRECO-2 RAPID-1, RAPID-2), the double-bolus application scheme was established, and a superior patency profile for reteplase in comparison to alteplase was demonstrated. Mortality studies established reteplase as a safe drug with a 30-day mortality at least equivalent to streptokinase (INJECT) and very similar to alteplase (GUSTO-3). A possible advantage may be the double-bolus application without a need for weight adjustment, especially in a prehospital setting. Thus, reteplase can be regarded as an excellent alternative to streptokinase or alteplase for thrombolytic therapy in acute myocardial infarction.