Interv Akut Kardiol. 2013;12(4):215-218

The STREAM (Strategic Reperfusion Early After Myocardial Infarction) Study.

Karel Dvořák

Kardiologická ambulance

Fibrinolysis – alternative reperfusion strategy for STEMI

The STREAM study was open-label, prospective, randomized, international and multicenter trial. Ninety nine centers from 15 countries

participated in the study. Two therapeutic approaches were compared in patients with STEMI that had the first medical contact within 3

hours after symptom onset preferably in pre-hospital period, and that were unable to undergo a primary percutaneous coronary intervention

(PPCI) within 1 hour, but not longer interval than 3 hours. Patients were assigned in part to the PPCI group, with immediate transfer to

7/24 PCI center, and prehospital therapy was performed according to a guideline-based local practice or to the fibrinolytic therapy (FT)

group. This procedure consisted of bolus tenecteplase according to body weight, clopidogrel 300 mg orally, enoxaparin 30 mg i.v. with

following subcutaneous application and aspirin 75 – 325 mg. In patients over 75 years old i.v. doses of enoxaparin were left out and

clopidogrel dose was lowered to 75 mg. After the implementation of protocol addition the dose of tenecteplase in these old patients was

halved. Cases with insufficient effect of FT after 90 minuts (clinical signs, continuing elevation of ST segment, shock, hemodynamic and

rhythm instability) were immediately transported to PCI center and a “rescue” coronary angiography was performed, the others from FT

group underwent coronary angiography 6 to 24 hours after the first medical contact, and PPCI as needed. The primary endpoint included

death, shock, congestive heart failure or reinfarction up to 30 days. Altogether 1915 patients were enrolled from March 2008 to July 2012.

The primary endpoint occurred in 116 of 939 patients (12.4%) in FT group, and 135 of 943 patients (14.3%) in PPCI group. The difference

between groups was not significant (0.68 vs. 1.09, P = 0.21). In the FT group the “rescue” coronary angiography was performed in 36.3%,

and in this group significantly more intracranial hemorrhage occurred (1.0% in FT group vs. 0.2 in PPCI group, P = 0.02). The FT with timely

coronary angiography resulted in effective alternative reperfusion strategy in patients with early STEMI, when presumed transfer to PCI

center could take several hours. A disadvantage is a comparatively high danger of intracranial hemorrhage particularly in patients over

75 years old, where it is likely the best to administer a half of tenecteplase dose.

Keywords: STEMI, primary percutaneous coronary intervention, pharmacoinvasive strategy, fibrinolytic therapy

Published: December 1, 2013  Show citation