From the Guidelines
The Stream, Clarity Timi 28, and Gusto trials have significantly impacted the management of acute myocardial infarction, with the most recent and highest quality evidence from the Clarity Timi 28 trial 1 demonstrating that adding clopidogrel to aspirin and fibrinolytic therapy in STEMI patients reduces cardiovascular events without increasing major bleeding risks.
Key Findings
- The Stream trial evaluated early fibrinolytic therapy versus primary percutaneous coronary intervention (PCI) in STEMI patients when PCI couldn't be performed promptly, finding that early fibrinolysis followed by angiography was a reasonable alternative when primary PCI was delayed 1.
- The Clarity Timi 28 trial demonstrated that adding clopidogrel to aspirin and fibrinolytic therapy in STEMI patients significantly reduced cardiovascular events without increasing major bleeding risks 1.
- The Gusto trial compared different thrombolytic strategies in acute myocardial infarction, establishing that accelerated tissue plasminogen activator (tPA) with intravenous heparin provided the best survival benefit compared to streptokinase regimens 1.
Clinical Implications
- The use of clopidogrel in addition to aspirin and fibrinolytic therapy is recommended for STEMI patients, as it has been shown to reduce cardiovascular events without increasing major bleeding risks 1.
- The choice of thrombolytic strategy in acute myocardial infarction should be based on the availability of primary PCI and the patient's individual risk factors 1.
- A pharmaco-invasive strategy, which includes early fibrinolytic therapy followed by angiography, is a reasonable alternative when primary PCI is delayed 1.
From the Research
Stream Trial
- The Stream trial is not directly mentioned in the provided evidence, however, trials such as CLARITY-TIMI 28 2, 3 and other studies 4, 5, 6 discuss the management and treatment of acute coronary syndromes (ACS) including ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI).
Clarity Timi 28
- The CLARITY-TIMI 28 trial was a randomized, double-blind, placebo-controlled study of clopidogrel in patients receiving fibrinolytic therapy for STEMI 2, 3.
- The trial found that the addition of clopidogrel to standard fibrinolytic therapy improved reperfusion and reduced the risk of cardiovascular death, recurrent MI, or recurrent ischemia requiring urgent revascularization 2.
- Among patients undergoing coronary artery bypass grafting (CABG), there was no excess bleeding in the clopidogrel group and a trend toward reduction in 30-day ischemic events 2.
Gusto
- The GUSTO trial is not directly mentioned in the provided evidence, however, other studies discuss the use of fibrinolytic therapy and primary percutaneous coronary intervention (PCI) in the treatment of ACS 4, 5, 6.
- The use of supersaturated oxygen therapy in patients with late-presentation anterior STEMI has been investigated as a potential new treatment for this high-risk patient group 6.