@article{3128023,
    title = "Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction",
    author = "Armstrong, P.W. and Gershlick, A.H. and Goldstein, P. and Wilcox, R. and Danays, T. and Lambert, Y. and Sulimov, V. and Ortiz, F.R. and Ostojic, M. and Welsh, R.C. and Carvalho, A.C. and Nanas, J. and Hans-Richard Arntz, S.H. and Huber, K. and Grajek, S. and Fresco, C. and Bluhmki, E. and Regelin, A. and Vandenberghe, K. and Bogaerts, K. and Van De Werf, F.",
    journal = "The New England journal of medicine",
    year = "2013",
    volume = "368",
    number = "15",
    pages = "1379-1387",
    publisher = "Massachussetts Medical Society",
    doi = "10.1056/NEJMoa1301092",
    keywords = "acetylsalicylic acid;  clopidogrel;  enoxaparin;  tenecteplase, adult;  aged;  angiocardiography;  article;  bleeding;  bolus injection;  brain hemorrhage;  congestive heart failure;  controlled study;  death;  drug dose reduction;  emergency care;  female;  fibrinolytic therapy;  heart reinfarction;  human;  loading drug dose;  major clinical study;  male;  multicenter study;  open study;  parallel design;  percutaneous coronary intervention;  priority journal;  prospective study;  randomized controlled trial;  shock;  ST segment elevation myocardial infarction",
    abstract = "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), clopi;dogrel, 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; ClinicalTrials.gov number, NCT00623623.) Copyright © 2013 Massachusetts Medical Society."
}