It is not clear so far whether pre-hospital fibrinolysis with early angiography could provide a clinical outcome similar to primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). This study included 1,892 patients who presented within three hours of symptom onset and who could not undergo primary angioplasty within the first hour. Patients were randomized to primary angioplasty or fibrinolytic therapy with tenecteplase, (half dose in patients ≥ 75 years old), plus enoxaparin and clopidogrel before transport to a hospital capable of performing primary angioplasty. Angioplasty was performed as an emergency in case fibrinolysis failure, otherwise angiography was performed six to twenty-four hours after randomization. The primary outcome was a composite of death, shock, congestive heart failure or re-infarction at thirty days.
The primary outcome occurred in 116 of 939 patients (12.4%) of the fibrinolysis group and in 135 of 943 patients (14.3%) of the primary angioplasty group, (relative risk in the fibrinolysis group, 0.86, confidence interval 95%, 0.68 to 1.09, P = 0.21). Emergency angiography was required in 36.3% of patients of the fibrinolysis group, while the remaining patients underwent angiography seventeen hours after randomization on average. Intracranial hemorrhages were more frequent in the primary fibrinolysis group than in the angioplasty group, (1.0% versus 0.2%, p = 0.04, after the protocol change, 0.5% versus 0.3%, P = 0.45).
Conclusion: In brief, the STREAM study showed that pre-hospital fibrinolytic with early coronary angiography as necessary, is effective in AMI patients who could not undergo primary angioplasty within one hour after the first physician contact. However, fibrinolysis was associated with a slightly increased risk of intracranial hemorrhage.
Frans Van de Worf
2013-03-12
Original title: The STREAM Trial: Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction.
