EARLY Routine Catheterization After Alteplase Fibrinolysis vs. PPCI in ST-Segment-Elevation MYOcardial Infarction

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

PHASE4

Total Enrollment

344 participants

Study Classification

INTERVENTIONAL

Study Start Date

2014-01-13

Study Completion Date

2016-09-12

Brief Summary

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The EARLY-MYO (EARLY routine catheterization after alteplase fibrinolysis vs. primary PCI in acute ST-segment elevation MYOcardial infarction) is an investigator-initiated, prospective, multicenter, randomized (1:1), open-label, actively-controlled, parallel group, non-inferiority trial comparing the efficacy and safety of a PhI strategy with half-dose fibrinolysis versus PPCI in STEMI patients presenting within 6 hours after symptom onset and with an expected PCI-related delay of ≥60 min.

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Detailed Description

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Early, successful restoration of myocardial perfusion after a ST-elevation myocardial infarction (STEMI) is the most effective way to reduce final infarct size and improve clinical outcome. Reperfusion for STEMI treatment in the modern era encompasses mechanical and pharmacological strategies. It is generally well-accepted that primary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy for all STEMI patients when it can be performed within the guideline-recommended timeframe at PPCI-capable facilities. However, PPCI is not universally available, and delays in performing percutaneous coronary intervention (PCI) are common in real-world practice. Even in some large cities, patients have a high chance of presenting to hospitals not providing around-the-clock PPCI service. Given this background, in recent years there has been great interest and progress in creating triage strategies for STEMI patients who cannot receive timely PPCI.

Pharmaco-invasive (PhI) strategy, an early reperfusion strategy by initial prompt fibrinolysis with subsequent early catheterization (with either routine early PCI after successful fibrinolysis or rescue PCI as needed), has been proposed as a therapeutic option for STEMI patients when timely PPCI is not feasible. However, current evidence on the efficacy and safety of PhI strategy in STEMI patients is limited, and the role of PhI strategy in STEMI continues to be debated. Given that no randomized clinical trial is available to compare a PhI strategy with half-dose fibrinolytic regimen versus PPCI in STEMI patients, investigators plan to perform a controlled, randomized trial to evaluate the efficacy and safety of a PhI strategy with half-dose alteplase fibrinolysis versus PPCI in STEMI patients.

Conditions

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Acute ST-segment Elevation Myocardial Infarction

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

TREATMENT

Blinding Strategy

SINGLE

Outcome Assessors

Study Groups

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Early post-fibrinolytic catheterisation

For STEMI Patients, alteplase is given as a intravenous bolus (8-mg) followed by 42 mg iv gtt in 90 min.Early routine catheterization after 3 hours but within 24 hours of the start of fibrinolytic therapy is performed, if required, PCI or, in case of insufficient ST resolution at 90 min,rescue PCI. The decision on rescue PCI will, however, be taken 90 min (or earlier if clinically indicated) after injection of alteplase according to the ST resolution (less than 50% reduction in ST-segment elevation).

Group Type EXPERIMENTAL

Alteplase

Intervention Type DRUG

Alteplase is given as a intravenous bolus (8-mg) followed by 42 mg iv gtt in 90 min.

Early post-fibrinolytic catheterisation

Intervention Type PROCEDURE

Early post-fibrinolytic catheterisation after 3 hours but within 24 hours of the start of fibrinolytic therapy is performed, if required, PCI or, in case of insufficient ST resolution at 90 min,rescue PCI. The decision on rescue PCI will, however, be taken 90 min (or earlier if clinically indicated) after injection of alteplase according to the ST resolution (less than 50% reduction in ST-segment elevation).

Primary PCI

For STEMI Patients,primary PCI is performed without fibrinolytic therapy.

Group Type OTHER

Primary PCI

Intervention Type PROCEDURE

For STEMI Patients,primary PCI is performed within 12 hours after the onset.

Interventions

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Alteplase

Alteplase is given as a intravenous bolus (8-mg) followed by 42 mg iv gtt in 90 min.

Intervention Type DRUG

Early post-fibrinolytic catheterisation

Early post-fibrinolytic catheterisation after 3 hours but within 24 hours of the start of fibrinolytic therapy is performed, if required, PCI or, in case of insufficient ST resolution at 90 min,rescue PCI. The decision on rescue PCI will, however, be taken 90 min (or earlier if clinically indicated) after injection of alteplase according to the ST resolution (less than 50% reduction in ST-segment elevation).

Intervention Type PROCEDURE

Primary PCI

For STEMI Patients,primary PCI is performed within 12 hours after the onset.

Intervention Type PROCEDURE

Other Intervention Names

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rt-PA

Eligibility Criteria

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Inclusion Criteria

* Age: over 18 or 18 years old, less than 75 years old;
* Patents with myocardial infarction who have symptom onset within 6h before randomization;
* ECG: ≥2 mm ST-segment elevation in 2 contiguous precordial leads or ≥1 mm ST-segment elevation in 2 contiguous extremity leads ;
* Patents with an expected PCI-related delay \[expected time delay from FMC to first balloon dilation≥90 min, and difference between the time of FMC to balloon dilation minus the time from FMC to start of fibrinolysis ≥60 minutes)\];
* Signed informed consent form prior to trial participation.

Exclusion Criteria

1. Evidence of cardiac rupture;
2. ECG: new left bundle branch block;
3. "Diagnosis to balloon inflation" time over 3 hours;
4. Thrombolysis contradictions:

* Definite cerebral apoplexy history;
* Any history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery) or recent trauma to the head or cranium (i.e. \< 3 months);
* Active bleeding or known bleeding disorder/diathesis;
* Recent administration of any i.v. or s.c. anticoagulation within 12 hours including unfractionated heparin, enoxaparin and/or bivalirudin or current use of oral anticoagulation(warfarin or coumadin);
* Uncontrolled hypertension, defined as a single blood pressure measurement ≥ 180/110 mm Hg (systolic BP ≥ 180 mm Hg and/or diastolic BP ≥ 110 mm Hg) prior to randomisation;
* Major surgery, biopsy of a parenchymal organ, or significant trauma within the past 2 months (this includes any trauma associated with the current myocardial infarction); Prolonged or traumatic cardiopulmonary resuscitation (\> 10 minutes) within the past 2 Weeks Major surgery pending in the following 30 days;
5. Severe complication

* Other diseases with life expectancy ≤12 months;
* Any history of Severe renal or hepatic dysfunction(hepatic failure, cirrhosis, portal hypertension and active hepatitis); Neutropenia, thrombocytopenia ; Known acute pancreatitis;
* Known acute pericarditis and/or subacute bacterial endocarditis;
* Arterial aneurysm, arterial/venous malformation and aorta dissection;
6. Complex heart condition

* Cardiogenic shock(SBP \<90 mmHg after fluid infusion or SBP\<100 mmHg after vasoactive drugs);
* PCI within previous 1 month or Previous coronary-artery bypass surgery(CABG);
* Previously known multivessel coronary artery disease not suitable for revascularization;
* Hospitalisation for cardiac reason within past 48 hours;
7. Not suitable for clinical trial

* Inclusion in another clinical trial;
* Previous enrolment in this study or treatment with an investigational drug or device under another study protocol in the past 7 days;
* Pregnancy or lactating;
* Body weight \<40kg or \>125kg;
* Known hypersensitivity to any drug that may appear in the study;
* Inability to follow the protocol and comply with follow-up requirements or any other reason that the investigator feels would place the patient at increased risk.

Minimum Eligible Age

18 Years

Maximum Eligible Age

75 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No