Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Elevation Myocardial Infarction: STREAM-2 1-Year Mortality Follow-Up
Bibliographic record
Abstract
on behalf of the STREAM-2 Investigators D elays in achieving reperfusion with either fibrinoly-sis or primary percutaneous coronary intervention (PPCI) are associated with excess mortality. ST-elevation myocardial infarction guidelines recommend a pharmacoinvasive (PI) treatment strategy if timely PPCI is unavailable. 1,2 However, PI treatment with full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. 3 In STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction [URL: https://clinicaltrials.gov; Unique identifier: NCT02777580]), we tested a half-dose, tenecteplase-based PI strategy in patients ≥60 years with ST-elevation myocardial infarction, presenting <3 hours of symptom onset and unable to undergo PPCI <1 hour. Because of similar angiographic and clinical 30-day outcomes-except for an excess of intracra-nial bleedings in the PI arm, in part because of protocol violations including excessive anticoagulation 4-we performed a prespecified exploratory analysis of mortality and cardiac rehospitalization rates at 1 year. As previously reported, institutional review boards approved STREAM-2 (n=604) and informed consent was obtained. 3,4 After 2 years from the time of the publication , requests for STREAM-2 trial data will be considered by the executive committee provided that the data are requested in writing by qualified researchers with an outline of proposed objectives that address any potential conflicts of interest. Data sharing will be accompanied by an expectation that any outcomes will be shared with the STREAM-2 executive committee, which reserves the right to review any proposed publication of the work. Patients were randomized (2:1) to either a PI strategy or PPCI. Patients assigned to PI treatment received half-dose, weight-adjusted bolus tenecteplase, 150 to 325 mg aspirin, 300 mg clopidogrel, and subcutane-ous enoxaparin 0.75 mg/kg, with patients ≤75 years receiving an additional IV dose of 30 mg. Depending on successful reperfusion 60 to 90 minutes after bolus tenecteplase, coronary angiography was undertaken 6 to 24 hours after randomization. All-cause and cardiac mortality were estimated using Kaplan−Meier curves. Cardiac rehospitalizations ≤1 year were calculated using competing risk methodology. In a prespecified per-protocol analysis, 31 patients (24 PI; 9 PPCI) were excluded. One-year vital statuses for 399 of 401 (99.5%) patients in the PI arm and 201 of 203 (99.0%) patients in the PPCI arms were available. The mean age was 70±8 years, and 27% were ≥75 years of age. The median time from symptom onset to start of reperfusion was relatively short in both arms, and 80 minutes shorter in the PI versus PPCI arm (Figure [A]). The median delay between
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.003 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.000 | 0.001 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.004 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".