What is the role of thrombolysis in ST-Elevation Myocardial Infarction (STEMI)?

From the Guidelines

Thrombolysis is only recommended for patients with ST-elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be performed within a reasonable time frame, ideally within 120 minutes of first medical contact, as primary PCI is the preferred treatment due to its superior outcomes in reducing morbidity, mortality, and improving quality of life 1.

Key Considerations for Thrombolysis in STEMI

• The decision to use thrombolysis should be based on the time from symptom onset and the availability of primary PCI, with a focus on minimizing delays in treatment.
• Thrombolysis is considered a viable alternative to primary PCI if it can be delivered within 3 hours after onset of chest pain or other symptoms, but primary PCI is preferred due to its lower risk of stroke and better preservation of myocardium 1.
• The preferred thrombolytic agents include fibrin-specific drugs, and all patients should receive adjunctive antithrombotic therapy including aspirin, clopidogrel, and anticoagulation with unfractionated heparin or enoxaparin.

Post-Thrombolysis Management

• After thrombolysis, patients should be transferred to a PCI-capable facility for either rescue PCI if thrombolysis fails or routine angiography within 24 hours, as this approach has been shown to improve outcomes 1.
• Routine post-thrombolysis coronary angiography and PCI, if applicable, is recommended up to 24 hours after thrombolysis, independent of angina and/or ischemia, to further reduce morbidity and mortality.

Prioritizing Primary PCI

• Primary PCI is the treatment of choice for STEMI when available in a timely manner, due to its superior clinical outcomes compared to thrombolysis, including reduced rates of stroke and improved myocardial salvage 1.
• The benefits of primary PCI over thrombolysis are particularly significant for patients presenting between 3 and 12 hours after symptom onset, highlighting the importance of prompt transfer to a PCI-capable facility when possible.

From the FDA Drug Label

TNKase is a tissue plasminogen activator, indicated to reduce the risk of death associated with acute ST elevation myocardial infarction (STEMI). Initiate treatment as soon as possible after the onset of STEMI symptoms. In patients with a large ST segment elevation myocardial infarction, physicians should choose either thrombolysis or PCI as the primary treatment strategy for reperfusion Rescue PCI or subsequent elective PCI may be performed after administration of thrombolytic therapies if medically appropriate.

Thrombolysis in STEMI is indicated with tenecteplase (IV) to reduce the risk of death associated with acute ST elevation myocardial infarction (STEMI).

• The treatment should be initiated as soon as possible after the onset of STEMI symptoms.
• Physicians should choose either thrombolysis or PCI as the primary treatment strategy for reperfusion in patients with a large ST segment elevation myocardial infarction.
• Rescue PCI or subsequent elective PCI may be performed after administration of thrombolytic therapies if medically appropriate 2, 2, 2.

From the Research

Thrombolysis in STEMI

• Thrombolysis is still indicated when primary percutaneous coronary intervention (PPCI) is not available within 90-120 minutes 3
• Fibrinolysis is associated with a considerable risk of death and recurrent MI, even when reperfusion is achieved 3
• Early PCI or pharmaco-invasive strategy has evolved from facilitated PCI, with improved cardiovascular events compared to standard therapy 4
• Meta-analysis showed improved cardiovascular events with early PCI compared to standard therapy, with no significant bleeding complications when doing early PCI 4 to 24 hours after successful thrombolysis 4

Comparison of Thrombolysis and PPCI

• PPCI is the treatment of choice for STEMI if performed within 90 minutes from first medical contact 4
• Thrombolytic administration and rescue or routine PCI leads to more initial infarct-related artery patency and less thrombectomy with similar clinical outcomes when PPCI cannot be performed in the "golden time" 5
• PPCI was superior to thrombolysis in early-arriving stable STEMI patients with regard to 30-day composite endpoint driven by a decreased incidence of post-infarction angina 6
• No 1-year survival benefit for PPCI over thrombolysis was observed in early-arriving stable STEMI patients 6

Safety and Efficacy of Additional Therapies

• The use of glycoprotein IIb/IIIa inhibitors (GPIs) in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome 7
• A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation 7