TY - JOUR
TI - Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction
AU - Armstrong, P.W.
AU - Gershlick, A.H.
AU - Goldstein, P.
AU - Wilcox, R.
AU - Danays, T.
AU - Lambert, Y.
AU - Sulimov, V.
AU - Ortiz, F.R.
AU - Ostojic, M.
AU - Welsh, R.C.
AU - Carvalho, A.C.
AU - Nanas, J.
AU - Hans-Richard Arntz, S.H.
AU - Huber, K.
AU - Grajek, S.
AU - Fresco, C.
AU - Bluhmki, E.
AU - Regelin, A.
AU - Vandenberghe, K.
AU - Bogaerts, K.
AU - Van De Werf, F.
JO - The New England journal of medicine
PY - 2013
VL - 368
TODO - 15
SP - 1379-1387
PB - Massachussetts Medical Society
SN - null
TODO - 10.1056/NEJMoa1301092
TODO - 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
TODO - 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.
ER -