Τίτλος:
Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction
Γλώσσες Τεκμηρίου:
Αγγλικά
Περίληψη:
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.
Συγγραφείς:
Armstrong, P.W.
Gershlick, A.H.
Goldstein, P.
Wilcox, R.
Danays, T.
Lambert, Y.
Sulimov, V.
Ortiz, F.R.
Ostojic, M.
Welsh, R.C.
Carvalho, A.C.
Nanas, J.
Hans-Richard Arntz, S.H.
Huber, K.
Grajek, S.
Fresco, C.
Bluhmki, E.
Regelin, A.
Vandenberghe, K.
Bogaerts, K.
Van De Werf, F.
Περιοδικό:
The New England journal of medicine
Εκδότης:
Massachussetts Medical Society
Λέξεις-κλειδιά:
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
DOI:
10.1056/NEJMoa1301092
