nnnnnnnnnnCartoons by Jim Storey Waiheke Island NZ
Please read this review article and tell me what you make of it. The more I read the more my mind goes into contortions. How am I to work out the truth? Click on the title above. It's a bit of a tough read but when you arrive in hospital with a heart attack do you want clot busting drugs or wot. Maybe staying at home, taking an
asprin and having an
AED at the ready might be better.
Conclusion
The theoretical basis of thrombolysis (ie, the open-artery hypothesis) does not account for survival differences in randomized studies. Results of randomized trials of thrombolysis in AMI may have been confounded by lack of uniform use of aspirin, higher control group AMI mortality than prevalent today, and psychological influences due to lack of blinding in some studies. AMI registry statistics do not support the efficacy of thrombolysis in AMI. The NRMI-2 registry suggests that a significant percentage of suspected AMI patients may be inappropriately receiving thrombolytics.
Given the significant morbidity, mortality, and expense of thrombolysis in AMI, an independent analysis of the statistical data of the more than 1 million patients in the NRMI studies should be done, including adjustments for age and all the known poor prognostic factors, in order to better determine whether thrombolysis for AMI improves survival.
Streptokinase is a clot busting drug.
From the ISIS2 trial, using streptokinase and aspirin after myocardial infarction had an NNT of 20 to prevent 1 death at 5 weeks compared with doing nothing. Here is prophylaxis against a serious event, by definition not treatable if it occurs. The NNT for the adverse effect of haemorrhagic stroke with streptokinase was 1000.
From the less dramatic end of the spectrum is prophylaxis after dog bite. If no prophylactic antibiotics are given any subsequent infection (10%) should be treatable. The NNT for antibiotic prophylaxis was 16, so that only one patient out of 16 receiving prophylaxis actually avoids infection as a result. The other 15 have antibiotics that they did not need, and which may have adverse effects. And then there is cost.
I got the quotes above from
Bandolier. Great medical site full of evidence based stuff. NNT is a useful concept. Is treating 20 people to save one life worthwhile - most people are going to says yes. At what cost?
Is it worthwhile treating 16 people with dog bites to prevent one infection. I'd say no. What would you say?
With regards to streptokinase I'd prefer to know the results at a year and even five years. Many people lived for many years after having a heart attack prior to clot busting drugs. Could giving clot busting drugs have a deleterious effect on long term survival? If for sake of argument they save 1 in 20 at five weeks but at a year 2 extra treated persons are dead compared to non treated, what choice would you make? Does anyone know what the figures are two or more years out.
