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

• Published in: Circulation. Cardiovascular interventions Vol. 17; no. 12; p. e014251
• Main Authors: Bainey, Kevin R., Welsh, Robert C., Zheng, Yinggan, Arias-Mendoza, Alexandra, Ristic, Arsen D., Averkov, Oleg V., Lambert, Yves, Kerr Saraiva, José F., Sepulveda, Pablo, Rosell-Ortiz, Fernando, French, John K., Musić, Ljilja B., Temple, Tracy, Ly, Eric, Bogaerts, Kris, Sinnaeve, Peter R., Danays, Thierry, Westerhout, Cynthia M., Van de Werf, Frans, Armstrong, Paul W.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 01.12.2024
• Subjects: Age Factors; Aged; Aged, 80 and over; Coronary Angiography; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - adverse effects; Humans; Intracranial Hemorrhages - chemically induced; Male; Percutaneous Coronary Intervention - adverse effects; Percutaneous Coronary Intervention - mortality; Randomized Controlled Trials as Topic; Risk Assessment; Risk Factors; ST Elevation Myocardial Infarction - diagnosis; ST Elevation Myocardial Infarction - diagnostic imaging; ST Elevation Myocardial Infarction - drug therapy; ST Elevation Myocardial Infarction - mortality; ST Elevation Myocardial Infarction - therapy; Tenecteplase - administration & dosage; Tenecteplase - adverse effects; Thrombolytic Therapy - adverse effects; Time Factors; Tissue Plasminogen Activator - administration & dosage; Tissue Plasminogen Activator - adverse effects; Treatment Outcome; fibrinolysis; percutaneous coronary intervention; reperfusion; intracranial hemorrhages; myocardial infarction
• ISSN: 1941-7640; 1941-7632; 1941-7632
• DOI: 10.1161/CIRCINTERVENTIONS.124.014251

BACKGROUND: 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. METHODS: 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. RESULTS: 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%; P=0.277) and comparable composite end points (23.4% versus 28.0%; relative risk, 0.90 [95% CI, 0.62-1.30]; P=0.567) without occurrence of intracranial hemorrhage. CONCLUSIONS: 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. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00623623. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02777580.