Home > Journal Club, ST elevation myocardial infarction > Journal Club 27 March 2013

Journal Club 27 March 2013


Fibrinolysis or Primary PCI in ST-Segment Elevation Myocardial Infarction





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).


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.


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.


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.

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