Fibrinolysis or Primary PCI in ST-segment Elevation Myocardial Infarction

Selected in The New England Journal of Medicine by G. Harris

References

Authors

Paul W. Armstrong, Anthony H. Gershlick, Patrick Goldstein, Robert Wilcox, Thierry Danays, Yves Lambert, Vitaly Sulimov, Fernando Rosell Ortiz, M Miodrag Ostojic, Robert C. Welsh, Antonio C. Carvalho, John Nanas, Hans-Richard Arntz, Sigrun Halvorsen, Kurt Huber, Stefan Grajek, Claudio Fresco, Erich Bluhmki, Anne Regelin, Katleen Vandenberghe, Ph.D., Kris Bogaerts, Frans Van de Wer

Reference

N Engl J Med 2013; 368:1379-1387

Published

April 2013

Link

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My Comment

Background

The benefit of early fibrinolytic therapy in patients who present with STEMI, has been demonstrated in multiple trials.

The CAPTIM trial (prehospital fibrinolysis), demonstrated the benefit of rt-PA in patients presenting with STEMI within 6 hrs of symptom onset, with superior 5 year outcome in the fibrinolytic group vs. the primary PCI in the group of patients who received fibrinolysis within 2 hours of symptom onset.

The STREAM trial sought to establish whether patients with STEMI within 3 hours of symptom onset, who could not undergo primary PCI within 1 hour of the 1st medical contact would experience similar benefit from onsite fibrinolysis (tenecteplase), and angiography performed within 6-24hrs.

The primary endpoint was composite of death, shock, congestive heart failure or reinfarction up to 30 days.

Major findings

  1. There was no significant difference between the two groups. (1e endpoint occurred in12.4% of the patients in the fibrinolysis group and 14.3% in the 1e PCI group).
  2. Prior to the protocol amendment, there was a higher incidence of intracranial haemorrhage in the fibrinolysis group (1.0% vs. 0.2%, P=0.04), however thereafter there was no significant difference (0.5% vs. 0.3%, P=0.45).
  3. In 36% of patients in the fibrinolysis group, emergency angiography was needed.
  4. Nonintracranial events where similar between the two groups.

My comment

The STREAM trial demonstrated that in those patients who could not undergo primary PCI in one hour from first medical contact, prehospital fibrinolysis with coronary angiography, performed between 6-24 hrs after randomization, resulted in similar outcomes as angiography.

This trial is not a form of facilitated PCI as the patients who received fibrinolysis, did not undergo immediate angiography upon arrival at the hospital.

This trial dose provide another option to patients who present late to a hospital with PCI facilities, as well as those who present to hospitals with lower success rates for emergency PCI (there are a multitude of possible reasons for this).

3 comments

  • Rajeev Gupta 01 Aug 2013

    36% of the thrombolysed pts.( despite presented within 3 hours of the onset of the symptoms) needed rescue PCI is rather unusual. The most important message for me is reducing the dose of Thrombolytic agent to 50% above 75 years of age reduced intracranial hemorrhages markedly.This should be applied in the clinical practice.

  • Abdulkafi TASHANI 27 Oct 2013

    Thanks for highlighting these two trials as i am working in a hospital with limited facilities to work off hour PPCI and i noted similar out come for pci post lytic therapy as long as the pci is done within the period of hospital stay unless the pt experienced of angina were pci had to done within 24 hrs . Concerning intracerebral hemorrhage it was noted in the octrogenic and fragile ladies were PPCI becomes preferable.

  • George Harris 30 Oct 2013

    Thank you, Dr Tashani for your comment.