Acute Coronary Intervention

recommend Neuroimmunomodulation to anyone interested in gaining an introduction to an exciting field with a long future. Treatment for the patient with an acute myocardial infarction (AMI) has changed considerably in the past 50 years. Initially, the treatment simply consisted of rest. With the introduction of antiarrhythmics and coronary care units, mortality from AMI decreased substantially. Over the past several years, the treatment of AMI has evolved further with the use of thrombolytic agents and emergency percutaneous transluminal angioplasty (PTCA). Acute Coronary Intervention deals with this rapidly advancing and exciting area. Edited by Eric J. Topol, this book provides a thorough discussion of both the basic science research and the clinical trials in the field. The first section of this volume concerns the thrombolytic agents. The biochemical aspects and pathophysiology of streptokinase (SK), urokinase (UK), and tissue-type plasminogen activator (tPA) are presented in depth. This section is very helpful because it clears up any confusion the reader may have had about the differences between these drugs. SK, by forming a plasminogen-streptokinase complex, which then activates plasminogen to form plasmin, causes a "systemic lytic state." Unlike SK, tPA is derived from human tissue and normally has a low affinity for circulating plasminogen. When bound to fibrin, however, tPA binds plasminogen tightly and causes a fibrin-specific thrombolysis and, in theory, avoids a systemic lytic state. With this background, Topol includes a section entitled "Lessons From Major Clinical Trials," which examines the following trials: the Western Washington, the GISSI (Italian Group for the Study of Streptokinase in Myocardial Infarction), the TIMI (Thrombolysis in Myocardial Infarction), the TAMI (Thrombolysis in Acute Myocardial Infarction), and the European Cooperative. For each trial, the author outlines the purpose of the study and provides a flow chart of the protocol. In general, this section is excellent. In the chapter discussing the GISSI trial, however, the author showed that short-term intravenous SK was effective in reducing mortality in AMI at one year. From this finding he goes on to add, however, "Thrombolysis with high dose intravenous SK can definitely be seen as a recommended treatment for the majority of patients admitted to CCUs within at least 6 hours of the onset of diagnostic pain; its beneficial effects on mortality are beyond question, and its overall risk profile is clinically acceptable." Comments such as this, which advocate an extremely aggressive approach to the treatment of AMI, are common throughout the …