Discussant Dr. Freek Verheugt called STREAM "an important step forward" and applauded the investigators for pursuing "a courageous trial to do in this era of primary PCI."
"This was the first trial to show that early fibrinolysis followed by mandatory timely angiography is as effective as primary PCI in patients who are more than 1 hour away from a PCI hospital. The strength of this study is two-thirds of patients don’t need urgent intervention when they have the lytic before. I think that’s very important because we know that off-hours primary PCI procedures have a worse outcome than daytime procedures. And you have more patients getting deferred intervention and CABG with the lytic strategy. It’s good for the patients, good for their relatives, and good for the interventional cardiologists and the cath lab personnel," said Dr. Verheugt, professor of cardiology at Nijmegen (the Netherlands) University.
"I don’t think STREAM will change the guidelines because it is within the guidelines, but I think it will change practice in certain parts of the world with long drive times to PCI hospitals," he predicted.
Dr. C. Michael Gibson noted that out of more than a dozen prespecified patient subgroups analyzed in STREAM, the outcomes for the two treatment strategies differed significantly in only one: patients with an inferior infarct location. They accounted for roughly half of study participants, and their primary endpoint rate was 7.3% with fibrinolysis compared with 12.3% with primary PCI. It seems counterintuitive that they would do significantly better with the pharmacoinvasive strategy, observed Dr. Gibson, professor of medicine at Harvard University, Boston.
Dr. Van de Werf replied that while the explanation for this finding is unclear, there is some evidence from earlier studies that fibrinolysis is more effective in reperfusing an occluded right rather than left coronary artery.
ACC conference cochair Dr. Neal Kleiman of Methodist Hospital, Houston, declared STREAM "a fantastic study on a very important issue. I think you’ve provided a beacon of light in the fog here."
Simultaneous with his presentation of the STREAM data in San Francisco, the study results were published online (N. Engl. J. Med. 2013 March 10 [doi: 10.1056/NEJMoa1301092]).
STREAM was funded by Boehringer Ingelheim. Dr. Van de Werf is a consultant to the company.