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(Circulation. 1996;94:863-865.)
© 1996 American Heart Association, Inc.

Articles

Thrombin Inhibitors in Fibrinolysis

A Hobson's Choice of Alternatives

Joseph Loscalzo, MD, PhD

Whitaker Cardiovascular Institute and Evans Department of Medicine, Boston University School of Medicine, Boston, Mass.

Correspondence to Dr Joseph Loscalzo, Boston University Medical Center Hospital, 88 E Newton St, Boston, MA 02118-2394.

Key Words: Editorials • thrombolysis • thrombosis • coronary disease

	Introduction

 

Where to elect there is but one Take Hobson's choice-take that or none. -England's Reformation. Chapter IV, p 326.

Legend holds that Tobias Hobson, the first Englishman to rent horses for hackney use, offered potential customers one of two choices: take the horse nearest the door of his establishment or take none at all. More often than not, the horse offered was surpassed in appearance and quality by others further down the line, and the nature of the purchaser's dilemma has since become a metaphor for anyone given a difficult choice between two suboptimal alternatives. Adjunctive anticoagulant use in patients treated with fibrinolytic therapy for acute coronary syndromes presents a Hobsonian choice to cardiologists: administering them increases the risk of significant bleeding, yet withholding them increases the risk of acute rethrombosis.

The adjunctive use of thrombin inhibitors with thrombolytic therapy for the treatment of acute Q-wave myocardial infarction is predicated on activation of the coagulation system during fibrinolysis.¹ Both plasmin-mediated platelet activation² and plasmin-mediated prothrombinase activity³ lead to the generation of thrombin during fibrinolytic therapy and, thereby, to the conversion of fibrinogen to fibrin.⁴

Preclinical studies confirmed the view that thrombin inhibitors administered with plasminogen activators potentiate fibrinolysis.^{5 6} The use of heparin as an adjunct to thrombolytic therapy in patients with acute Q-wave myocardial infarction is not, however, universally accepted. Hemorrhagic risk is believed to be excessive, especially when heparin is used in conjunction with streptokinase; thus, current guidelines suggest that heparin be administered with tissue plasminogen activator but that . . . [Full Text of this Article]

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