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Background: Bolus fibrinolytic therapy facilitates early efficient institution of reperfusion therapy. Tenecteplase is a genetically engineered variant of alteplase with slower plasma clearance, better fibrin specificity, and high resistance to plasminogen-activator inhibitor-1. We did a double-blind, randomised, controlled trial to assess the efficacy and safety of tenecteplase compared with alteplase., Methods: In 1021 hospitals, we randomly assigned 16,949 patients with acute myocardial infarction of less than 6 h duration rapid infusion of alteplase (< or = 100 mg) or single-bolus injection of tenecteplase (30-50 mg according to bodyweight). All patients received aspirin and heparin (target activated partial thromboplastin time 50-75 s). The primary outcome was equivalence in all-cause mortality at 30 days., Findings: Covariate-adjusted 30-day mortality rates were almost identical for the two groups--6.18% for tenecteplase and 6.15% for alteplase. The 95% one-sided upper boundaries of the absolute and relative differences in 30-day mortality were 0.61% and 10.00%, respectively, which met the prespecified criteria of equivalence (1% absolute or 14% relative difference in 30-day mortality, whichever difference proved smaller). Rates of intracranial haemorrhage were similar (0.93% for tenecteplase and 0.94% for alteplase), but fewer non-cerebral bleeding complications (26.43 vs 28.95%, p=0.0003) and less need for blood transfusion (4.25 vs 5.49%, p=0.0002) were seen with tenecteplase. The rate of death or non-fatal stroke at 30 days was 7.11% with tenecteplase and 7.04% with alteplase (relative risk 1.01 [95% CI 0.91-1.13])., Interpretation: Tenecteplase and alteplase were equivalent for 30-day mortality. The ease of administration of tenecteplase may facilitate more rapid treatment in and out of hospital.

The two current criteria for diagnosis of left anterior fascicular block (LAFB) were evaluated; they are marked left axis deviation (LAD) and a delay in the time of inscription of the intrinsicoid deflection (ID) in lead aVL asynchronous to V6. From 400 electrocardiograms with a LAD of --30 degrees or greater, 62 percent showed asynchronous activation of the left ventricle. There was only a general relationship between the degree of LAD and delayed ID in aVL. The incidence of delayed ID in aVL was as follows: 2 percent with mean frontal QRS axis at 0 degrees; 9 percent at --15 degrees; 41 percent at --30 degrees; 69 percent at --45 degrees; 82 percent at --60 degrees; and 100 percent at --75 degrees or greater. The lack of correlation between both criteria in many instances questions their validity. The LAD alone should not be considered synonymous with LAFB. Recognition of delayed inscription of the ID in aVL is a useful supplemental criterion for diagnosis.

A new radiologic index indicative of pulmonary artery hypertension is presented. It was obtained by measuring the horizontal distances from the midline to the first divisions of the right and left pulmonary arteris, and dividing the sum of these distances by the maximum transverse diameter of the thorax. The index was significantly different in groups with and without pulmonary hypertension and was abnormal (above 38 percent in 111 of 150 patients with cardiovascular disease and pulmonary arterial hypertension (PAH). None of the cases with increased pulmonary flow from cardiac shunts but normal PAP had an anbormal index. Thus, an abnormal index suggested PAH but correlated poorly with the extent of hypertension.

Although pulmonary artery disease in Takayasu's arteritis has been described since 1940, it has received little attention. The clinical, hemodynamic, and angiographic features of the pulmonary involvement were studied in 22 patients with systemic arterial disease. Pulmonary involvement was found in 50 percent of the cases. Moderate pulmonary hypertension was a common finding (73 percent). Lesions were generally localized to the large and medium pulmonary vessels. None of the patients had pulmonary symptoms, but in 63 percent there were clinical, radiologic and electrocardiographic findings suggesting pulmonary hypertension or right heart strain. We believe that the pulmonary circulation should be routinely studied in patients with Takayasu's arteritis and that pulmonary involvement should be included in the classification of the disease.