STREAM trial (New Engl J Med 2013) was a sort of paradigm-creating study, that made Pharamco-Invasive approach – PIA an authentic via-media strategy, trying to accure benefits from both lysis and PCI in the management of STEMI.
However, one question remained. Does PIA work safely in the elderly, where bleeding risks are higher? Do they tolerate the double whammy of P and I ? Both procedures keep the blood clotting process tentative for a prolonged period of time.
Emprical usage of half dose lysis is not new, is existingn, for more than 4 decades, right from streptokinase days.
Now the multi-center STREAM-2 trial , released from Belgium , Published in the current issue of Circulation, asked this specific query on the efficacy of half dose Tenecteplace in PIA.
Both strategies had almost similar outcome with 87 % TIMI flow, implying elderly people , are reciveing twice the dose of lytics without any true benefits, but enhancing other risk.
Final message
The conclusions are not surprising. Our empirical thoughts have now, become acceptable sort of evidence. So , let us go ahead with this renewed PIA strategy and proceed with half dose of Tenecteplase ln elderly ( A liberal cut off of >60 years) without any guilt.
Meanwhile, the STREAM team has one more important job to do. So far, no one has the guts to test “P” vs “PIA” in the current era, in a large scale ( ie proceed with “I” if and only if “P“has failed. After all , if P is successful, that has resulted in good TIMI 3, and normal LV function there is no need for I )
Hope, somebody or institution get that courage and funds to design a STREAM- -3 trial comparing three distinct strategies, ie stand-alone TNK vs PIA, & pPCI and make it a reality. I am sure, it will bring surprise and very likely a pleasant one for all stake holders.