The latter group of patients also received clopidogrel, low molecular weight heparin, or glycoprotein IIb/IIIa inhibitors less frequently than the group PLK inhibition selleck referred for PPCI. Among patients treated with fibrinolysis, 96% underwent subsequent coronary angiography (38% within 3 hours of fibrinolysis, 23% between 3 and 24 hours, and 39% beyond 24 hours), with most of them (84%) undergoing PCI. 32% of patients in the fibrinolysis group required urgent referral for “rescue”

PCI. Survival at 5 years was 88% in patients receiving fibrinolysis and 84% for those undergoing PPCI (HR, 0.73; CI, 0.50–1.06; p = 0.1). When the timing of administration of fibrinolysis was considered, prehospital fibrinolysis was associated with lower 5-year mortality (HR, 0.57; CI, 0.36–0.88), while in-hospital fibrinolysis was associated with a trend toward increased 5-year mortality (HR, 1.19; CI, 0.72–1.96) compared to PPCI. The investigators also studied the subgroup of patients who sought medical attention within 180 minutes from the onset of symptoms (STREAM-like population). 5-year survival in this population was 88% and 81% in the fibrinolysis and PPCI groups

respectively (HR, 0.63; CI, 0.41–0.98; p = 0.039). However, in a propensity score-adjusted matched analysis, the benefit seen with prehospital fibrinolysis and with fibrinolysis (pre- or in-hospital) in the STREAM-like population did not remain statistically significant. Discussion In agreement with several recent studies 10–13 as well as the current American and European practice guidelines, 2,3 both STREAM and FAST-MI support the current recommendation of performing a coronary angiogram within 3–24 hours after successful fibrinolysis when timely PPCI is unavailable. However, extrapolating these findings

to other healthcare systems around the world should be done with caution for the following reasons: • STREAM randomized a very specific group of STEMI patients, namely those with a symptom onset-to-FMC of less than 3 hours. It is well recognized that the fibrinolytic agents are more effective early in the course Drug_discovery of STEMI because of the absence of fibrin cross-linking in the fresh thrombus, and this effect progressively declines after the first 3 hours. 14 Similarly, two-thirds of the FAST-MI patients receiving fibrinolysis did so prior to hospital admission. It remains unclear whether these finding are also applicable to late presenters. • The fibrinolytic agent used in STREAM and in the majority of FAST-MI patients was tenecteplase (TNK) which has an extended half-life allowing for a single bolus administration. TNK is more fibrin-specific, is associated with less intracranial hemorrhage, and higher rates of infarct artery patency compared to streprokinase – which remains the most frequently administered fibrinolytic agent worldwide.