Summary
Increases in thrombin activity occur in patients treated with streptokinase, but conjunctive
therapy with intravenous heparin does not appear to improve either the rate of early
infarct artery patency or survival in patients with acute myocardial infarction. In
a recent study we found that concentrations of fibrinopeptide A, a marker of thrombin-mediated
fibrin formation, were lower in the first 3 h in patients treated with intravenous
heparin (5000 U bolus followed by a fixed-dose 1000 U/h infusion, n = 14) compared
with subcutaneous (12,500 U every 12 h, started 4 h after streptokinase, n = 14) administration,
but were increased in both groups of patients, consistent with persistent thrombin
activity. To determine whether the differential effects of the intensity of heparinization
on thrombin formation were reflected in differences in fibrin degradation, we measured
cross-linked fibrin degradation products (XL-FDP) before and 1,2,3,8,12, and 24 h
after streptokinase in the same cohort of patients, with a new ELISA with a D-dimer-specific
capture antibody (MAb 3B6) and a fibrin-specific tag antibody (MAb 1D2, Agen, Brisbane,
Australia). The incidence of early coronary recanalization assessed by creatine-kinase
MM isoforms (increase in activity ≥0.18%/min), was similar in both groups (79 vs 86%).
Concentrations of XL-FDP were similar in patients with and without recanalization,
but were lower in patients treated with intravenous compared with subcutaneous heparin
at 8 h, but the results did not reach statistical significance (627 ±151 ng/ml versus
1007 ± 157 ng/ ml, p = 0.06), and were significantly lower at 12 h (327 ± 72 versus
781 ± 162 ng/ml, p = 0.03 at 12 h) (mean ± SEM). Concentrations of cross-linked fibrin
degradation products were also lower in patients in whom the activated partial thromboplastin
time was greater than two times the control, compared with those with inadequate anticoagulation
(498 ± 105 versus 1084 ± 179 ng/ml; p = 0.02) (mean ± SEM). Thus, more effective inhibition
of thrombin with conjunctive intravenous heparin therapy results in less cross-linked
fibrin turnover in the first 12 h after thrombolysis with streptokinase. This probably
reflects decreased fibrin formation with therapeutic anticoagulation.
