Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction.


Journal Article

BACKGROUND: It is not known whether prehospital fibrinolysis, coupled with timely coronary angiography, provides a clinical outcome similar to that with primary percutaneous coronary intervention (PCI) early after acute ST-segment elevation myocardial infarction (STEMI). METHODS: Among 1892 patients with STEMI who presented within 3 hours after symptom onset and who were unable to undergo primary PCI within 1 hour, patients were randomly assigned to undergo either primary PCI or fibrinolytic therapy with bolus tenecteplase (amended to half dose in patients ≥75 years of age), clopidogrel, and enoxaparin before transport to a PCI-capable hospital. Emergency coronary angiography was performed if fibrinolysis failed; otherwise, angiography was performed 6 to 24 hours after randomization. The primary end point was a composite of death, shock, congestive heart failure, or reinfarction up to 30 days. RESULTS: The primary end point occurred in 116 of 939 patients (12.4%) in the fibrinolysis group and in 135 of 943 patients (14.3%) in the primary PCI group (relative risk in the fibrinolysis group, 0.86; 95% confidence interval, 0.68 to 1.09; P=0.21). Emergency angiography was required in 36.3% of patients in the fibrinolysis group, whereas the remainder of patients underwent angiography at a median of 17 hours after randomization. More intracranial hemorrhages occurred in the fibrinolysis group than in the primary PCI group (1.0% vs. 0.2%, P=0.04; after protocol amendment, 0.5% vs. 0.3%, P=0.45). The rates of nonintracranial bleeding were similar in the two groups. CONCLUSIONS: Prehospital fibrinolysis with timely coronary angiography resulted in effective reperfusion in patients with early STEMI who could not undergo primary PCI within 1 hour after the first medical contact. However, fibrinolysis was associated with a slightly increased risk of intracranial bleeding. (Funded by Boehringer Ingelheim; number, NCT00623623.).

Full Text

Duke Authors

Cited Authors

  • Armstrong, PW; Gershlick, AH; Goldstein, P; Wilcox, R; Danays, T; Lambert, Y; Sulimov, V; Rosell Ortiz, F; Ostojic, M; Welsh, RC; Carvalho, AC; Nanas, J; Arntz, H-R; Halvorsen, S; Huber, K; Grajek, S; Fresco, C; Bluhmki, E; Regelin, A; Vandenberghe, K; Bogaerts, K; Van de Werf, F; STREAM Investigative Team,

Published Date

  • April 11, 2013

Published In

Volume / Issue

  • 368 / 15

Start / End Page

  • 1379 - 1387

PubMed ID

  • 23473396

Pubmed Central ID

  • 23473396

Electronic International Standard Serial Number (EISSN)

  • 1533-4406

Digital Object Identifier (DOI)

  • 10.1056/NEJMoa1301092


  • eng

Conference Location

  • United States