Inconclusive messages from equivalence trials in thrombolysis

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Abstract
#### Glossary COMPASS, : Comparison trial of saruplase and streptokinase GISSI, : Gruppo Italiano per lo studio della sopravvivenza nell’infarto GUSTO, : Global use of strategies to open occluded coronary arteries INJECT, : International joint efficacy comparison of thrombolytics ISIS, : International study of infarct survival Editor,—Since the mid-80s a series of large scale randomised clinical trials has progressively proved the effectiveness of thrombolytic treatment in acute myocardial infarction but, despite prodigious efforts, the superiority of intensive strategies based on tissue-type plasminogen activator (tPA) over the standard regimen with streptokinase has not been proved.1The certainty of the benefit has fuelled the search for new thrombolytic agents for a guaranteed market; however, the uncertainty of further benefits from new drugs has suggested testing their equivalence rather than superiority in impracticable trials. This approach has given poor results as demonstrated if one assesses the additional benefits (deaths avoided) and risks (excess of strokes) produced by single steps in the search for better or equivalent thrombolytic agents. We compared indirectly the efficacy and safety of tPA, reteplase, and saruplase by combining …