An 88-year-old man with diabetes mellitus and hypertension presents with an ST elevation myocardial infarction (STEMI) to a rural community hospital. He presents within one hour of symptom onset. There is no percutaneous coronary intervention (PCI) capable center able to initiate primary invasive reperfusion within guideline based recommendations. There are no contraindications to fibrinolysis reperfusion.
Which of the following is the best treatment option for this patient?
The correct answer is: D. Half dose TNK with 75 mg clopidogrel, routine aspirin, and dose reduced enoxaparin.
The results of The Strategic Reperfusion Early after Myocardial Infarction (STREAM) trial demonstrated that half dose TNK with 75 mg clopidogrel, routine aspirin, and dose reduced enoxaparin reduced the likelihood of intracranial hemorrhage without compromising reperfusion efficacy. However, these observations are hypothesis generating and warrant further confirmation in randomized clinical trials in the elderly. See associated expert opinion piece.
Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment
elevation yocardial infarction. N Engl J Med 2013;368:1379–87.
Armstrong PW, Zheng Y, Westerhout CM, et al. Reduced dose tenecteplase and outcomes in elderly ST-segment elevation myocardial infarction patients: Insights from the Strategic Reperfusion Early After Myocardial infarction trial. Am Heart J 2015;169:890–8.