STREAM: Early fibrinolysis as effective as angioplasty

Issue: April 2013

SAN FRANCISCO — Clot-busting medications may equally benefit patients with MI ineligible for immediate PCI when compared with PCI.

Perspective from Neal S. Kleiman, MD

Presented as a late-breaking clinical trial at the American College of Cardiology Scientific Sessions, the STREAM trial studied 1,915 patients from 15 countries first seen in community hospitals or by emergency medical personnel for STEMI. Unable to receive immediate PCI until major medical center transfer (<3 hours after symptom onset), patients were randomly assigned for PCI or received tenecteplase (half dose in patients ≥ 75 years) plus enoxaparine, (30 mg IV bolus and/or subcutaneous injections based on age ≥75 years) clopidogrel and aspirin (300 mg loading dose, 75 mg in patients ≥ 75 years) before arrival.

Researchers found that patients receiving tenecteplase were more likely to have normal blood flow on an angiogram compared with patients who received PCI only (58% vs. 21%). Patients receiving tenecteplase were less likely to have complete blockage of an artery (16% vs. 59%) and were more likely to have CABG than PCI-only patients. More patients treated with tenecteplase eventually underwent CABG compared with PCI-only patients.

The dose of tenecteplase was halved in patients aged >75 years to minimize cranial bleeding during the course of the trial, researchers report. Bleeding in the total study population was 0.5% after dose reduction, according to study data published in The New England Journal of Medicine.

"It is clear we were able to see the patients very early after onset of symptoms," Frans J. J. Van de Werf, MD, PhD, professor of cardiology at University of Leuven, Belgium, said at a press conference. "If you look at the total population of patients studied, there was a significant rate of total stroke and hemorrhagic stroke in the invasive arm. We haven't observed a single case of intracerebral bleed in the elderly.”

In a press release, Van de Werf added that “drug therapy before transfer is at least as effective as [angioplasty], and an urgent catheterization was avoided in two-thirds of patients. It gives [clinicians] time to consider other options, such as [CABG] and medical therapy.”

For more information:

Van de Werf F. Late-breaking clinical trials III: Chronic CAD/stable ischemic heart disease and acute coronary syndromes. Presented at: American College of Cardiology Scientific Sessions; March 9-11, 2013; San Francisco.

Armstrong RA. N Engl J Med. 2013;doi:10.1056/nejmoa1301092.

Disclosure: Van de Werf reports receiving funding from Boehringer Ingelheim.

Perspective

Neal S. Kleiman, MD

This is a fantastic study. This is an issue that we've been dancing around for 2 decades: we are not as fast with getting patients to the cath lab as we would like to tell people we are. Between 6 hours to the cath lab and 6 minutes, where is the tipping point? These guys very intelligently selected 1 hour and tested it. It's very promising and I would love to see it done on a larger scale.

Neal S. Kleiman, MD

Professor of Medicine

Weill Cornell Medical College, N.Y.

Disclosures: Kleiman reports receiving consulting fees/honoraria from Eli Lilly and performing research for/receiving research grants from Merck-Schering Plough.