Pharmaco-Invasive Strategy With Half-Dose Tenecteplase in Patients With STEMI: Prespecified Pooled Analysis of Patients Aged ≥75 Years in STREAM-1 and 2

<jats:sec> <jats:title>BACKGROUND:</jats:title> <jats:p>In STREAM-1 (Strategic Reperfusion Early After Myocardial Infarction), excess intracranial hemorrhage occurred in patients aged ≥75 years receiving full-dose tenecteplase as part of a pharmaco-invasive strategy, whereas no further intracranial hemorrhage occurred after halving the tenecteplase dose. In STREAM-2 (Second Strategic Reperfusion Early After Myocardial Infarction), half-dose tenecteplase was an effective and safe pharmaco-invasive strategy in older patients with ST-segment–elevation myocardial infarction presenting within <3 hours, compared with primary percutaneous coronary intervention (PCI). We prespecified evaluating the efficacy and safety of a half-dose versus full-dose pharmaco-invasive strategy and compared the half-dose pharmaco-invasive strategy to primary PCI in patients aged ≥75 years.</jats:p> </jats:sec> <jats:sec> <jats:title>METHODS:</jats:title> <jats:p>We pooled data sets in patients aged ≥75 years from STREAM-1 and STREAM-2 receiving a pharmaco-invasive strategy versus primary PCI. Resolution of ST-segment–elevation after fibrinolysis and angiography was assessed, as was the relative risk of the primary composite of 30-day all-cause death, myocardial infarction, heart failure, and shock, along with bleeding.</jats:p> </jats:sec> <jats:sec> <jats:title>RESULTS:</jats:title> <jats:p> A total of 390 patients were included: 42 patients were randomized to full-dose pharmaco-invasive treatment, 205 patients to half-dose pharmaco-invasive treatment, and 143 patients to primary PCI. Half-dose versus full-dose pharmaco-invasive treatment resulted in similar proportions of patients achieving ≥50% ST-segment resolution posttenecteplase (63.2% versus 62.6%), with reduced intracranial hemorrhage (7.1% versus 0%, respectively). Half-dose pharmaco-invasive treatment and primary PCI also had similar proportions of patients with ≥50% ST-segment resolution postangiography (77.9% versus 72.4%; <jats:italic>P</jats:italic> =0.277) and comparable composite end points (23.4% versus 28.0%; relative risk, 0.90 [95% CI, 0.62–1.30]; <jats:italic>P</jats:italic> =0.567) without occurrence of intracranial hemorrhage. </jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS:</jats:title> <jats:p>Comparable efficacy exists between half- and full-dose tenecteplase pharmaco-invasive treatments with improved safety in patients with ST-segment–elevation myocardial infarction aged ≥75 years. Half-dose pharmaco-invasive therapy is a legitimate therapeutic option for elderly patients with ST-segment–elevation myocardial infarction unable to access timely primary PCI.</jats:p> </jats:sec> <jats:sec> <jats:title>REGISTRATION:</jats:title> <jats:p> URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.clinicaltrials.gov">https://www.clinicaltrials.gov</jats:ext-link> ; Unique identifier: NCT00623623. URL: <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" ext-link-type="uri" xlink:href="https://www.clinicaltrials.gov">https://www.clinicaltrials.gov</jats:ext-link> ; Unique identifier: NCT02777580. </jats:p> </jats:sec>

Authors
Bainey K.R. 1, 2 , Welsh R.C. 1, 2 , Zheng Yinggan 1 , Arias-Mendoza Alexandra 3 , Ristic A.D. 4 , Averkov O.V. 5 , Lambert Yves 6 , Kerr Saraiva J.F. 7 , Sepulveda Pablo 8 , Rosell-Ortiz Fernando 9 , French J.K. 10, 11, 12 , Musić L.B. 13 , Temple Tracy 1 , Ly Eric 1 , Bogaerts Kris 14 , Sinnaeve P.R. 15, 16 , Danays Thierry 17 , Westerhout C.M. 1 , Van De Werf Frans 15 , Armstrong P.W. 1
Journal
Circulation: Cardiovascular Interventions
Issue number
12
Language
English
State
Published
Volume
17
Year
2024
Organizations
  • 1 Canadian VIGOUR Centre (K.R.B., R.C.W., Y.Z., T.T., E.L., C.M.W., P.W.A.), University of Alberta, Edmonton, Canada.
  • 2 Mazankowski Alberta Heart Institute (K.R.B., R.C.W.), University of Alberta, Edmonton, Canada.
  • 3 Coronary Care Unit, National Institute of Cardiology, Mexico City, Mexico (A.A.-M.).
  • 4 Department of Cardiology, University Clinical Center of Serbia, University of Belgrade, Serbia (A.D.R.).
  • 5 Pirogov Russian National Research Medical University and City Clinical Hospital, Moscow (O.V.A.).
  • 6 Centre Hospitalier de Versailles, Service d'aide Médicale Urgente 78 and Mobile Intensive Care Unit, Le Chesnay, France (Y.L.).
  • 7 Cardiology Discipline, Pontifical Catholic University of Campinas School of Medicine, Brazil (J.F.K.S.).
  • 8 Pontifica Universidad Católica de Chile, Santiago (P.S.).
  • 9 Servicio de Urgencias y Emergencias 061 de La Rioja, Logroño, Spain (F.R.-O.).
  • 10 School of Medicine, University of New South Wales, Sydney, Australia (J.K.F.).
  • 11 Department of Cardiology, Liverpool Hospital, Sydney, Australia (J.K.F.).
  • 12 School of Medicine, Western Sydney University, Australia (J.K.F.).
  • 13 Cardiology Clinic, Medical Faculty, University Clinical Center of Montenegro, University of Podgorica (L.B.M.).
  • 14 Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven and University Hasselt, Belgium (K.B.).
  • 15 Department of Cardiovascular Sciences, KU Leuven, Belgium (P.R.S., F.V.d.W.).
  • 16 Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium (P.R.S.).
  • 17 TDC, Aix en Provence, France (T.D.).
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