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Title: Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction
Authors: Armstrong, Paul W.
Gershlick, Anthony H.
Goldstein, Patrick
Wilcox, Robert
Danays, Thierry
Lambert, Yves
Sulimov, Vitaly
Rosell Ortiz, Fernando
Ostojic, Miodrag
Welsh, Robert C.
Carvalho, Antonio C. [UNIFESP]
Nanas, John
Arntz, Hans-Richard
Halvorsen, Sigrun
Huber, Kurt
Grajek, Stefan
Fresco, Claudio
Bluhmki, Erich
Regelin, Anne
Vandenberghe, Katleen
Bogaerts, Kris
Van de Werf, Frans
STREAM Investigative Team
Univ Alberta
Univ Hosp Leicester Trust
Univ Nottingham
Lille Univ Hosp
Boehringer Ingelheim GmbH & Co KG
Ctr Hosp Versailles
Mobile Intens Care Unit
First Moscow State Med Univ
Empresa Publ Emergencias Sanitarias
Univ Belgrade
Universidade Federal de São Paulo (UNIFESP)
Univ Athens
Benjamin Franklin Med Ctr
Univ Oslo
Poznan Univ Med Sci
Azienda Osped Univ Udine
Katholieke Univ Leuven
Univ Hasselt
Issue Date: 11-Apr-2013
Publisher: Massachusetts Medical Soc
Citation: New England Journal of Medicine. Waltham: Massachusetts Medical Soc, v. 368, n. 15, p. 1379-1387, 2013.
Abstract: BACKGROUNDIt 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).METHODSAmong 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.RESULTSThe 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.CONCLUSIONSPrehospital 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.)
ISSN: 0028-4793
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