Rescue percutaneous coronary intervention in the pharmaco-invasive era of ST-elevation myocardial infarction: insights from the STREAM-2 trial
Authors' conclusion
Contemporary PI with half-dose tenecteplase in older patients requiring rescue intervention led to less ST resolution and worse 30-day outcomes compared with those with successful fibrinolysis receiving scheduled angiography. Notably, delays to deploying rescue PCI in CH patients were shortened over those previously achieved thereby resulting in similar outcomes to those randomized in the ambulance. Our results reinforce the benefits of functional hub and spoke models with rapid transfer to a PCI-capable facility.
Study context
- Population
- Patients with ST-elevation myocardial infarction randomized to pharmaco-invasive (PI) treatment with half-dose tenecteplase or to primary percutaneous coronary intervention (PCI) (primary PCI (pPCI)) in STREAM-2patients in the current study
- Participants
- 583 patients
- Comparison
- Rescue PCI vs scheduled angiography after successful fibrinolysis; site of randomization, community hospital (CH) vs. ambulance
- Rescue PCIn = 168
- Scheduled angiographyn = 218
- pPCIn = 197
Primary result
As reported in the abstract
Rescue PCI
76.3
%
Scheduled angiography
92.5%
pPCI
78.7%
P < 0.001
Further findings
| Outcome | Values | RR (95% CI) | |
|---|---|---|---|
| Rescue intervention by site of randomization (CH vs ambulance) · 30 daysCHvs ambulance30-day composite outcome | 0.97 (0.50–1.87) | ||
| Primary PCI by site of randomization (CH vs ambulance) · 30 daysCHvs ambulance30-day composite outcome | 1.57 (0.72–3.41) | ||
| 0.20.5125Relative risk (log scale) |
| Outcome | Values | P value |
|---|---|---|
| Composite of all-cause death, shock, heart failure, and reinfarction · 30 daysRescue PCI vs scheduled angiography · worse with rescue PCI | Rescue PCI 16.7 % · scheduled angiography 6.0% · pPCI 12.2% | P < 0.001 |
| Rescue intervention by site of randomization (CH vs ambulance) · 30 daysCH vs ambulance · ST resolution ≥50% | CH ST resolution ≥50% 72.2 · 30-day composite outcome 17.6 · ambulance ST resolution ≥50% 80.5% · 30-day composite outcome 15.7% | P = 0.219 |
| Primary PCI by site of randomization (CH vs ambulance) · 30 daysCH vs ambulance · ST resolution ≥50% | CH ST resolution ≥50% 77.0 · 30-day composite outcome 9.3 · ambulance ST resolution ≥50% 80.2% · 30-day composite outcome 15.6% | P = 0.595 |
min
- Rescue intervention by site of randomization (CH vs ambulance) — Rescue intervention deployed in CH patients required longer compared with ambulance patients
- 10
- Primary PCI by site of randomization (CH vs ambulance) — Primary PCI required longer in CH patients
- 48
Safety
Intracranial haemorrhage · higher risk with rescue PCI
Original publication
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