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Coronary disease & ACSRandomised controlled trial

STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment–Elevation Myocardial Infarction: A Randomized, Open-Label Trial

CirculationPublished

  • Randomised controlled trial
  • investigator-initiated
  • open-label
  • multicentre
  • 2:1 randomisation
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Authors' conclusion

Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI.

Study context

Population
Patients ≥60 years with STEMI (≥2 mm ST elevation in 2 contiguous leads) unable to undergo primary percutaneous coronary intervention (PCI) within 1 hour
Participants
401 vs 203
Comparison
Pharmaco-invasive strategy with half-dose tenecteplase vs primary PCI
  • Pharmaco-invasiven = 401
  • Primary PCIn = 203reference
Primary endpoint
ST resolution and composite of death, shock, HF or reinfarction (efficacy end points of primary interest)
Follow-up
30 days (composite)

Primary result

As reported in the abstract

Relative risk

0.96

95% CI 0.62–1.48

By group

Pharmaco-invasive

85.2%

≥50% ST resolution after last angiography · Residual median sum of ST deviations 4.5 mm · 30-day composite 12.8% (51/400)

Primary PCI

78.4%

≥50% ST resolution after last angiography · Residual median sum of ST deviations 5.5 mm · 30-day composite 13.3% (27/203)

Pharmaco-invasive vs Primary PCI
relative risk 0.96 (95% CI 0.62–1.48)

Further findings

Median time from randomization to tenecteplase or sheath insertion

TIMI flow grade 3 at last angiography

≈87% in both groups

Safety

OutcomePharmaco-invasivePrimary PCI
Intracranial haemorrhage1.5%Not reported in the abstract
  • Intracranial haemorrhage: 3 were protocol violations (excess anticoagulation in 2, uncontrolled hypertension in 1)

Intracranial haemorrhage

No intracranial bleeding in the primary PCI arm

Major nonintracranial bleeding

Low in both groups
<1.5%

Original publication

STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment–Elevation Myocardial Infarction: A Randomized, Open-Label Trial. Circulation. Published 13 July 2023. doi:10.1161/circulationaha.123.064521
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Summarised from the published abstract; every number is checked against it