Survival outcomes 1 year after reperfusion therapy with either alteplase or reteplase for acute myocardial infarction: Results from the global utilization of streptokinase and t-PA for occluded coronary arteries (GUSTO) III trial

Eric J. Topol, E. Magnus Ohman, Paul W. Armstrong, Robert Wilcox, Alan M. Skene, Philip Aylward, John Simes, Anthony Dalby, Amadeo Betriu, Christoph Bode, Harvey D. White, Judith S. Hochman, Hakan Emanuelson, Alec Vahanian, Shelly Sapp, Amanda Stebbins, David J. Moliterno, Robert M. Califf

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65 Citations (Scopus)


Background - New recombinant plasminogen activators have been developed to simulate the fibrinolytic action of the physiological serine protease tissue plasminogen activator (alteplase, t-PA), and have prolonged half-life features permitting bolus administration. One such activator, reteplase (r-PA), was compared with t-PA in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-III Trial. Methods and Results - At 1-year follow-up, survival status was ascertained in 97.4% of the 15 059 patients enrolled in the GUSTO-III trial. At 1 year, the mortality rate for the t-PA-assigned group was 11.06%, and for r-PA it was 11.20% (P=0.77). The absolute mortality difference of 0.14% has 95% CIs of -1.21% to 0.93%. There were no significant differences in outcome by intention-to-treat for the 2 different plasminogen activators in the prespecified groups (age, infarct location, time-to-treatment). The absolute difference in mortality rates between t-PA and r-PA progressively narrowed over the predetermined observation times after random assignment; it was 0.31% at 24 hours, 0.26% at 7 days, 0.23% at 30 days, and 0.14% at 1 year. Of note, mortality rate in the trial between 30 days and 1 year in 13 883 patients was 4.02% and did not differ between the treatment groups. However, this mortality rate was substantially greater than in GUSTO-I, in which mortality rate for t-PA versus streptokinase between 30 days and 1-year was 2.97% (heart rate 1.36, 95% CI 1.23, 1.50, P<0.001). Conclusions - The r-PA and t-PA strategies yielded similar survival outcomes after 30 days in this trial. The increase in mortality rate during extended follow-up compared with previous trials may reflect higher-risk patients and highlights the need for improved secondary prevention strategies.

Original languageEnglish
Pages (from-to)1761-1765
Number of pages5
Issue number15
Publication statusPublished - 10 Oct 2000
Externally publishedYes


  • Myocardial infarction
  • Plasminogen activators
  • Reperfusion

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