title: Reduced dose tenecteplase and outcomes in elderly ST-segment elevation myocardial infarction patients: Insights from the STrategic Reperfusion Early After Myocardial infarction trial.
abstract: BACKGROUND
  Elderly patients with ST-segment elevation myocardial infarction (STEMI) have worse outcomes and a greater risk of intracranial bleeding than nonelderly patients. Baseline characteristics, clinical outcomes, and the relationship of the tenecteplase (TNK) dose reduction to the efficacy, safety, and electrocardiographic indicators of reperfusion efficacy were evaluated in STEMI patients ≥75 years.
  
  
  METHODS
  The STREAM trial evaluated early presenting STEMI patients who could not undergo primary percutaneous coronary intervention within 1 hour of first medical contact. Because of excess intracranial hemorrhage (ICH) in patients ≥75 years, the dose of TNK was reduced by 50%.
  
  
  RESULTS
  Before dose amendment, there were 3 (7.1%) of 42 elderly patients with ICH; 2 of these were fatal, whereas no ICH occurred in the 93 elderly patients who received half-dose TNK postamendment. The median extent of ST-segment elevation resolution (≥50%) and proportion of patients with ≥2 mm in the electrocardiogram lead with greatest ST-segment elevation was comparable in elderly patients preamendment and postamendment (63.2% vs 56.0% and 43.6% vs 40.0%, respectively). Patients requiring rescue coronary intervention after TNK was also similar (42.9% vs 44.1%). The primary composite end point (30-day all-cause death, cardiogenic shock, congestive heart failure, and reinfarction) was 31.0% before versus 24.7% postamendment.
  
  
  CONCLUSIONS
  Our data, from a modest-sized population of elderly STEMI patients, indicate that half-dose TNK reduces the likelihood of ICH without compromising reperfusion efficacy. These observations are hypothesis generating and warrant further confirmation in randomized clinical trials in the elderly.
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada. Electronic address: paul.armstrong@ualberta.ca.
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Yinggan
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Cynthia M
authors.initials: CM
authors.lastname: Westerhout
authors.affiliation: Empresa Pública de Emergencias Sanitarias, Almería, Spain.
authors.forename: Fernado
authors.initials: F
authors.lastname: Rosell-Ortiz
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Peter
authors.initials: P
authors.lastname: Sinnaeve
authors.affiliation: Centre Hospitalier de Versailles, SAMU 78 and Mobile Intensive Care Unit, Versailles, France.
authors.forename: Yves
authors.initials: Y
authors.lastname: Lambert
authors.affiliation: Duke University Medical Centre, Duke Clinical Research Institute, Durham, NC.
authors.forename: Renato D
authors.initials: RD
authors.lastname: Lopes
authors.affiliation: Boehringer Ingelheim, Berkshire, UK.
authors.forename: Erich
authors.initials: E
authors.lastname: Bluhmki
authors.affiliation: Boehringer Ingelheim France, Reims France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Danays
authors.affiliation: Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium.
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004562:Electrocardiography; D005343:Fibrinolytic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D020300:Intracranial Hemorrhages / Q000517:prevention & control*; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000503:physiopathology; D011859:Radiography; D000077785:Tenecteplase; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage* / Q000009:adverse effects; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase