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• Early treatment aims to reduce the extent of myocardial damage. As
the myocardium is damaged by a diminished oxygen supply due to
the obstructed coronary artery, infarct size can be reduced in two
1. dissolution of the thrombus to restore coronary blood flow
2. decreasing myocardial oxygen consumption
Restoration Of Flow:
• This has become the main aim of treatment
as it reduces the mortality significantly.
Flow is normally restored using drug therapy -
fibrinolytic agents
(e.g. streptokinase, tissue plasminogen activator),
antiplatelet agents (e.g. aspirin) and antithrombins
(e.g. heparin). Recently, coronary angioplasty
(PTCA) has been used to restore flow mechanically.
• The speed at which the flow is restored is
important. For every hour of delay, the effect
of therapy diminishes and mortality increases.

• The mainstay of treatment is fibrinolytic therapy. This is given to
dissolve the thrombus in the artery and restore flow. There are two
fibrinolytic drugs commonly used in Australia - streptokinase and
tissue plasminogen activator (tPA).
• Streptokinase produces generalised systemic fibrinolysis. Streptokinase
creates an active complex which promotes the cleavage of the Arg/Val
bond in plasminogen to form the proteolytic enzyme plasmin. Plasmin
in turn degrades the fibrin matrix of the thrombus, thereby exerting
its thrombolytic action. This helps eliminate blood clots or arterial
blockages that cause myocardial infarction.
The indications for fibrinolytic therapy are symptoms of myocardial ischemia, of less than 12 hours'
duration, with ECG changes of ST elevation or left bundle branch block. Patients without these ECG
changes should not be given fibrinolytic therapy.3
Table 1
Indications and contraindications for
fibrinolytic therapy
•within 12 hours of onset of chest pain lasting for at least 30 minutes
•ECG changes of ST elevation of at least 1 mm in two or more contiguous leads, or left bundle
branch block
Øcerebral event within 6 months
Ømajor trauma including surgery within 1 month
Øbleeding peptic ulcer within 2 months
Øuncontrolled hypertension
Ønon-compressible vascular puncture
• Reocclusion of an infarct-related artery
• Occurs in a minority but significant number of patients following
fibrinolytic therapy. These patients also tend to have a poorer
• Can be difficult to diagnose.
• Re-infarction is more common in patients with diabetes mellitus or
previous myocardial infarction.

• Postinfarction angina
• Angina may occur from a few hours to 30 days after AMI.
• The incidence is highest in patients with non-ST-elevation myocardial
infarction and those treated with fibrinolytics compared with PCI.