OBJECTIVE: to perform cost-effectiveness analysis of alteplase compared with streptokinase and absence of thrombolytical therapy for myocardial infarction (MI) in Russia. METHODS: Data on effectiveness of treatment and resource use were extracted from hospital medical charts randomly selected from 10 city hospitals in a retrospective study. A total of 133 patients received alteplase, 97 patients received streptokinase and 131 patients did not receive thrombolytical therapy. Effectiveness was assessed by death rate, presence of anginal pains, arrhythmia and heart failure at discharge. Direct medical costs were calculated on the basis of price-lists for medical services of an insurance company and median prices for drugs given in a wholesale pharmaceutical informational bulletin. Incremental cost-effectiveness ratio (ICER) was calculated for alteplase vs streptokinase and no thrombolytical therapy and for streptokinase vs no thrombolytical therapy. . RESULTS: There was no significant difference in death rate between 3 groups. Patients from alteplase group significantly less often had heart failure by the end of hospital treatment as well as anginal pains. Rate of arrhythmia at discharge was minimal in streptokinase group. Alteplase required much more costs than streptokinase or treatment without thrombolytical therapy. ICER was 252,454.31 rubles ($7,889.20) per absence of heart failure at discharge for alteplase vs streptokinase, and 166,720.5 rubles ($5,210.02) for alteplase vs treatment without thrombolytical therapy. Still streptokinase was more cost-effective vs treatment without thrombolytical therapy: ICER was 4,038.76 rubles ($126.21) per absence of heart failure at discharge. CONCLUSION: Alteplase is less cost-effective thrombolytical strategy for MI than streptokinase in spite of higher effectiveness.