STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With...

Area of Science:

• Cardiology
• Emergency Medicine
• Pharmacology

Background:

• ST-segment-elevation myocardial infarction (STEMI) management guidelines suggest pharmaco-invasive treatment when primary percutaneous coronary intervention (PCI) is not timely.
• Full-dose tenecteplase increases intracranial hemorrhage risk in elderly patients.
• The safety and efficacy of half-dose tenecteplase in this population remain unestablished.

Purpose of the Study:

• To evaluate the effectiveness and safety of a pharmaco-invasive strategy using half-dose tenecteplase in elderly patients with STEMI.
• To compare this strategy against primary PCI when timely intervention is unavailable.

Main Methods:

• The STREAM-2 study randomized patients aged ≥60 with STEMI to either half-dose tenecteplase followed by angiography/PCI or primary PCI.
• Efficacy endpoints included ST resolution and a 30-day composite of death, shock, heart failure, or reinfarction.
• Safety endpoints focused on stroke and non-intracranial bleeding.

Main Results:

• Pharmaco-invasive treatment with half-dose tenecteplase showed comparable ST resolution (85.2% vs. 78.4%) and similar 30-day composite clinical outcomes (12.8% vs. 13.3%) to primary PCI.
• Intracranial hemorrhage occurred in 1.5% of the pharmaco-invasive group versus 0% in the primary PCI group.
• Major non-intracranial bleeding was infrequent (<1.5%) in both groups.

Conclusions:

• A half-dose tenecteplase pharmaco-invasive strategy offers comparable efficacy to primary PCI in older STEMI patients when timely PCI is unavailable.
• This approach is a reasonable alternative, provided contraindications to fibrinolysis are respected and anticoagulation is managed carefully.
• The risk of intracranial hemorrhage is higher with this strategy compared to primary PCI.