Melissa Walton-Shirley

November 19, 2013

Many of us have spent the better part of the past decade trying to become the "haves" instead of the "have-nots." Although we survived the "lytic-only" era at our facility, several of our patients did not, namely my Uncle Gordon. He was one of the intracranial-bleed statistics like we mention in the cohort description of every randomized trial of PCI vs lytics. He died a victim of geography. It is in his memory that I examine carefully these trials that laud pharmacoinvasive strategies, like STREAM. I celebrate primary-PCI programs without surgery on-site and take comfort that hospitals with no option for a timely PCI just a decade ago have now saved thousands from heart failure and death. And now, are we to believe that thrombolytic therapy has made a comeback with this quarterback sneak?

I'm no longer in the cath lab after hand surgery two years ago, because I drop pencils, mugs of coffee, and plates. More important, I recognized that I could no longer sense wire resistance—the kind you feel before you can see on flouro. Although my 21 years in the lab as an angiographer ended, it doesn't make me any less passionate about the ongoing quest to extend what is the best ACS-STEMI care on the planet to everyone who needs it. The best care is still a primary PCI, without question, and I believe that despite the fact that I have never made a living performing PCI.

But STREAM champions the unwilling "have-nots." Those who will benefit are the landlocked, so to speak, with no hope for a timely primary PCI. Their STs are up and the roads are closed. The bridge is broken. The helicopter won't fly. For them, there is no way of getting into a cath lab anywhere in time for myocardial salvage. STREAM studied patients who could not get a PCI within 60 minutes. There were 1891 STEMI sufferers randomized to either a primary PCI or the fibrin-specific lytic TNK. Patients received usual care with aspirin, clopidogrel, and enoxaparin as background therapy.

At 90 minutes, the lytic recipients were evaluated for signs of successful reperfusion and then underwent angiography at six to 24 hours. Rescue PCI was performed only if patients demonstrated signs of shock or inadequate revascularization. At just 20% of enrollment, the steering committee was notified of patients over the age of 75 who had experienced an intracranial bleed. A 50% reduction in TNK dose was implemented in that age group. At one year, there was no statistical difference in mortality, with the death rate for the TNK-treated patients at 6.7% and for PCI patients at 5.9%.

The success of this study stands, like all others, on the shoulders of history. Clearly, through trial and error, we have better antiplatelet regimens and anticoagulants. We have fibrin-specific lytic. We have developed a healthy respect for body weight, age, and renal function. This integration of knowledge that culminated in the STREAM trial should be celebrated, but we should never let down our guard.

Despite the success of this study, continual honing of our transport systems is imperative. We must make primary PCI available to as many patients as possible, if for nothing else than the nearly 40% of STEMI patients who aren't lytic eligible. There is no greater buzzkill for a standard order for thrombolytic like an active ulcer, a recent stroke, polypectomy, or orthopedic or gallbladder surgery. Despite these issues, just as soon as we convince ourselves that thrombolytics are great, some stubborn white-clot–laden vessel won't recanalize. We'll realize quickly that those STs won't ever come down without a wire, a coil, and a cocktail, and then we'll fall in love with primary PCI all over again.

Despite my total avoidance of lytic utilization over the past decade, I did appreciate the STREAM trial. It is a most benevolent study. It reminds us that our brothers and sisters who work in the trenches of STEMI care deserve to have something available that works. Most of all, patients clutching their chests lying on gurneys in emergency departments of non-PCI–capable hospitals around the world deserve something that works. Delivering TNK might not be the best option, but we now know that this particular "second best" is safe. Certainly STREAM bullies us into admitting that for many, thrombolytic therapy is far better than nothing at all. For desperate patients, "good enough" is even better.

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