ST–Segment-Elevation Myocardial Infarction Patients Randomized to a Pharmaco-Invasive Strategy or Primary Percutaneous Coronary Intervention

Abstract

G uidelines recommend a primary percutaneous coronary intervention (pPCI) as the preferred reperfusion modality in patients presenting with ST-segment-elevation myocardial infarction (STEMI).1,2 Because most STEMI patients initially present to hospitals without PCI facilities, performing a pPCI in a timely fashion constitutes a significant logistic challenge in many healthcare systems across the world. Despite Background-In the Strategic Reperfusion Early After Myocardial Infarction (STREAM) trial, a pharmaco-invasive (PI) strategy was compared with primary percutaneous coronary intervention (pPCI) in ST-segment-elevation myocardial infarction patients presenting within 3 hours after symptom onset but unable to undergo pPCI within 1 hour. At 30 days, the PI approach was associated with a nominally but nonstatistically significant lower incidence of the composite primary end point of death, shock, congestive heart failure, and reinfarction when compared with pPCI. The aim of the present study was to determine the effect of these strategies on 1-year mortality. Methods and Results-Vital status at 1 year was available in 936 of 944 (99.2%) and 941 of 948 (99.3%) patients in the PI and pPCI arm, respectively. At 1 year, all-cause mortality rates (6.7% versus 5.9%) were similar for PI and pPCItreated patients (P=0.49; risk ratio, 1.13; 95% confidence interval, 0.79-1.62). Cardiac mortality rates were similar as well (4.0% versus 4.1%, P=0.93; risk ratio, 0.98; 95% confidence interval, 0.62-1.54). Overall, only 34 patients died between day 30 and 1 year, 20 in the PI arm and 14 in the pPCI arm, of whom 20 died of noncardiac reasons (13 in the PI and 7 in the pPCI arm). There was no significant difference in 1-year all-cause mortality between the 2 groups among the prespecified key subgroups. Conclusions-At 1 year, mortality rates in the PI and pPCI arms were similar in ST-segment-elevation myocardial infarction patients presenting within 3 hours after symptom onset and unable to undergo pPCI within 1 hour. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00623623.

Prehospital fibrinolysis versus primary percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials

“…The increased risk of intracranial bleeding in patients ≥75 years old in the STREAM study [7] led to a dose reduction of tenecteplase in such patients. After the subsequent protocol amendment, no cases of intracranial hemorrhage were reported, and rates of mortality significantly dropped in the FL arm [11]. Moreover, rates of major bleeding did not significantly differ between the two strategies in our analysis.…”

“…Ultimately, three trials [6, 7, 9], comprising two long-term follow-up studies of the latter [10, 11] and a post hoc analysis of one trial [12], were selected for the meta-analysis. The review process is depicted in Fig.…”

Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction

“…At 1 year, mortality rates were similar in both groups. 16 These results suggest that pharmacoinvasive strategy may be an effective alternative option for STEMI treatment when PPCI is not readily available, especially in early presenters. Our results in an Asian population confirm the FASTMI2015 results in a European population and the STREAM results in a North American population.…”

Acute coronary syndromes

“…23 If this cannot be achieved, fibrinolytic treatment-using agents such as alteplase or reteplase that can be given by a bolus intravenous injection-with coronary stenting in the next 6-24 hours is an effective alternative. 24 Radial access for primary percutaneous coronary intervention is associated with fewer bleeding complications and reduced all cause mortality compared with femoral access. 25 Whether complete revascularisation, with…”