Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction

Study Questions:

Can fibrinolysis combined with early angiography provide benefits similar to primary percutaneous coronary intervention (PCI) in patients presenting early after onset of ST-segment elevation myocardial infarction (STEMI) when delay to PCI is anticipated?

Methods:

The STREAM (Strategic Reperfusion Early After Myocardial Infarction) trial investigators randomized 1,892 patients presenting within 3 hours of symptom onset who could not undergo PCI within 1 hour of medical contact to primary PCI or fibrinolysis before transport to a PCI-capable hospital. Patients in the fibrinolytic arm received tenecteplase, clopidogrel, and enoxaparin and underwent angiography 6-24 hours after randomization except in the event of failed reperfusion, in which case, emergency angiography was recommended. The primary endpoint was a composite of death, shock, congestive heart failure, and reinfarction up to 30 days.

Results:

There was no difference in the primary endpoint between those randomized to immediate primary PCI (14.3%) versus fibrinolysis (12.4%, p = 0.21). There was no difference in 30-day mortality (4.6% vs. 4.4%). Time from symptom onset to reperfusion therapy was 100 minutes in the fibrinolysis arm and 178 minutes in the PCI arm. Emergency angiography was required in 36% of the patients in the fibrinolysis arm and the rest of the patients underwent angiography at a median of 17 hours after randomization. There were more intracranial bleeds with fibrinolysis (1% vs. 0.2%, p = 0.05). The protocol was amended after 21% of the patients had been randomized and the dose of tenecteplase was reduced in the elderly by 50%. Following this, there was a reduction in the incidence of intracranial bleeding with fibrinolysis, and no difference was noted between the two arms (0.5% vs. 0.3%).

Conclusions:

A strategy of prehospital fibrinolysis with early angiography resulted in outcomes similar to transfer for primary PCI in patients who could not undergo PCI within 1 hour after medical contact.

Perspective:

Primary PCI remains the pre-eminent strategy for treatment of STEMI. This study suggests that in patients in whom PCI cannot be provided in a timely fashion, fibrinolysis followed by rapid transfer to a PCI-capable hospital may provide similar benefits.

Clinical Topics: Anticoagulation Management, Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Intracranial Hemorrhages, Enoxaparin, Fibrinolysis, Percutaneous Coronary Intervention


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