Print Get Citation Citation AMA Citation Nam J, Fisher D. Nam J, Fisher D Nam, Jason, and Daniel Fisher. "Low-dose intracoronary alteplase unlikely to improve outcomes in STEMI patients treated with primary PCI." 2 Minute Medicine, 14 January 2015. McGraw-Hill, New York, NY, 2015. AccessCardiology. http://accesscardiology.mhmedical.com/updatesContent.aspx?gbosid=454158§ionid=208298240 MLA Citation Nam J, Fisher D. Nam J, Fisher D Nam, Jason, and Daniel Fisher.. "Low-dose intracoronary alteplase unlikely to improve outcomes in STEMI patients treated with primary PCI." 2 Minute Medicine New York, NY: McGraw-Hill, 2015, http://accesscardiology.mhmedical.com/updatesContent.aspx?gbosid=454158§ionid=208298240. Download citation file: RIS (Zotero) EndNote BibTex Medlars ProCite RefWorks Reference Manager Mendeley © Copyright Clip Full Chapter Figures Only Tables Only Videos Only Supplementary Content Top Low-dose intracoronary alteplase unlikely to improve outcomes in STEMI patients treated with primary PCI by Jason Nam, MD; Daniel Fisher Listen +Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission. +1. In this randomized controlled trial, low-dose intracoronary alteplase given early during primary percutaneous coronary intervention (PCI) for acute ST-Elevation Myocardial Infarction (STEMI) did not reduce microvascular obstruction. +2. Health related quality of life was not improved with low-dose intracoronary alteplase. +Evidence Rating Level: 1 (Excellent) Study Rundown: + +Acute coronary thrombosis causes ST-Elevation Myocardial Infarction (STEMI), and primary percutaneous coronary intervention (PCI) is used to emergently reopen the occluded coronary artery with a stent. However, thrombi often embolize to distal vasculature and failed microvascular reperfusion has been estimated to occur in 45% of all patients. It is unclear if addition of low dose alteplase may aid in treatment. In this randomized controlled trial including patients with acute STEMI presenting within 6 hours of symptom onset, adjunctive low-dose intracoronary alteplase given during primary PCI did not reduce microvascular obstruction compared to placebo. There was an increase in troponin T in the alteplase groups in addition to dose-related increases in fibrin D-dimer levels, suggesting clot lysis did occur. Health related quality of life scores were not improved with this intervention compared to placebo. +Though this treatment paradigm is unlikely to significantly reduce microvascular obstruction, some limitations should be noted. First, the duration of findings were limited to 3 months and so longer term benefits of this intervention cannot be excluded. The trial was also discontinued when pre-specified futility criteria were met, and so a small effect size may have been missed. Finally, drug administration was focused at a single time point before stent implantation when coronary blood flow is variable, and it is unclear if different administration timing may have changed results. +Click to read the study in JAMA +Relevant Reading: Efficacy and Safety of a Pharmaco-Invasive Strategy With Half-Dose Alteplase Versus Primary Angioplasty in ST-Segment-Elevation Myocardial Infarction: EARLY-MYO Trial (Early Routine Catheterization After Alteplase Fibrinolysis Versus Primary PCI in Acute ST-Segment-Elevation Myocardial Infarction) In-Depth [randomized controlled trial]: + +The T-TIME study was a randomized, double-blind, clinical trial that recruited 440 patients from 11 UK hospitals and randomized them to receive alteplase 10mg, alteplase 20mg, or placebo with primary PCI. Patients with a clinical diagnosis of acute STEMI with persistent ST-segment elevation or recent left bundle-branch block with symptom onset to reperfusion time of 6 hours or less were potentially eligible for randomization. The primary outcome was the amount of microvascular obstruction (% of left ventricular mass) demonstrated by late gadolinium-enhanced magnetic resonance imaging (MRI) 10 to 15 minutes after administration of contrast media. Recruitment was discontinued early on recommendation of data and safety monitoring committee because a pre-specified futility criterion for efficacy was met. The amount of microvascular obstruction revealed by MRI did not differ between the 10-mg alteplase group (2.6% vs. 2.3%; CI95 -0.76 to 1.35%) or 20-mg alteplase group (3.5% vs. 2.3%; CI95 -0.08 to 2.41%) when compared to placebo. Compared with placebo, there was a dose-related increase in the systemic concentrations of fibrin D-dimer and prothrombin levels and a slight reduction in plasminogen in the alteplase groups (p < 0.05). Health-related quality of life scores were similar between the 20-mg alteplase and placebo groups (CI95 -0.04 to 0.04). +©2019 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.