title: Fibrinolysis or primary PCI in 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), 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.
  
  
  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.).
authors.affiliation: Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research, University of Alberta, Edmonton, Canada
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: Anthony H
authors.initials: AH
authors.lastname: Gershlick
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.forename: Robert
authors.initials: R
authors.lastname: Wilcox
authors.forename: Thierry
authors.initials: T
authors.lastname: Danays
authors.forename: Yves
authors.initials: Y
authors.lastname: Lambert
authors.forename: Vitaly
authors.initials: V
authors.lastname: Sulimov
authors.forename: Fernando
authors.initials: F
authors.lastname: Rosell Ortiz
authors.forename: Miodrag
authors.initials: M
authors.lastname: Ostojic
authors.forename: Robert C
authors.initials: RC
authors.lastname: Welsh
authors.forename: Antonio C
authors.initials: AC
authors.lastname: Carvalho
authors.forename: John
authors.initials: J
authors.lastname: Nanas
authors.forename: Hans-Richard
authors.initials: HR
authors.lastname: Arntz
authors.forename: Sigrun
authors.initials: S
authors.lastname: Halvorsen
authors.forename: Kurt
authors.initials: K
authors.lastname: Huber
authors.forename: Stefan
authors.initials: S
authors.lastname: Grajek
authors.forename: Claudio
authors.initials: C
authors.lastname: Fresco
authors.forename: Erich
authors.initials: E
authors.lastname: Bluhmki
authors.forename: Anne
authors.initials: A
authors.lastname: Regelin
authors.forename: Katleen
authors.initials: K
authors.lastname: Vandenberghe
authors.forename: Kris
authors.initials: K
authors.lastname: Bogaerts
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D000077144:Clopidogrel; D017023:Coronary Angiography; D004359:Drug Therapy, Combination; D004562:Electrocardiography; D017984:Enoxaparin / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D005343:Fibrinolytic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D006333:Heart Failure / Q000517:prevention & control; D006801:Humans; D020300:Intracranial Hemorrhages / Q000209:etiology; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000628:therapy; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D012008:Recurrence; D000077785:Tenecteplase; D015912:Thrombolytic Therapy / Q000379:methods*; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives / Q000627:therapeutic use; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D017984:Enoxaparin; D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D010959:Tissue Plasminogen Activator; D013988:Ticlopidine; D000077785:Tenecteplase