A 74 year old man was admitted at 9.30 am with a two hour history of central, crushing chest pain radiating to the throat and left arm associated with dyspnoea and vomiting. The patient's general practitioner had diagnosed angina pectoris some months previously. The rest of the past medical history was blameless. The patient had a sinus tachycardia andblood pressure of 150/100 mm Hg. There was a fourth heart sound but no evidence of cardiac failure. The ECG showed changes of an extensive acute anterior myocardial infarction.  Recombinant tissue plasminogen activator (Actilyse, Boehringer Ingelheim) by an accelerated regimen was administered within three hours of the onset of symptoms together with aspirin and heparin.  At 8.00 pm the patient became agitated and disoriented in place and time. There was no focal neurological deficit. Temazepam was prescribed. The following morning the patient complained of headache and his mental state was unchanged. A computed tomographic head scan was arranged which demonstrated numerous recent intracerebral haemorrhages. The patient had a prolonged convalescence complicated by depression and patchy cognitive loss.  Despite numerous clinical trials and guidelines the choice of thrombolytic agent in the setting of acute myocardial infarction remains a matter of clinical judgement. In this case tissue plasminogen activator was chosen because of the extent of electrocardiographic change in an otherwise healthy patient. This case serves as a graphic reminder that the improved rates of coronary patency with tissue plasminogen activator compared to streptokinase are partly offset by an increased risk of serious bleeding.

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