Another key finding of the analysis was that the addition of glycoprotein IIB/IIIA inhibitors to fibrinolytic administration was consistently associated with higher major bleeding rates (RR 1.47, 95% CI 1.10–1.98, for tenecteplase; and RR 1.88, 95% CI 1.24–2.86, for reteplase). A tenecteplase-based regimen tended to be associated with lower risk of major bleeding compared with other regimens (RR 0.79 [95% CI 0.63-1.00]).
The authors of a related comment note that this research is most relevant to settings in which access to cardiac catheterisation is absent, as studies assessing acute pharmaco-invasive strategies or early transfers for catheterisation after initial fibrinolytic administration were excluded. The latter is a preferred approach when available given its association with improved clinical event rates.
NICE published a clinical guideline on the acute management of myocardial infarction with ST-segment elevation in July 2013 (CG167). This states that coronary angiography, with follow-on primary PCI if indicated, is the preferred coronary reperfusion strategy for people with acute STEMI if presentation is within 12 hours of onset of symptoms and primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given. Fibrinolysis should be offered to those presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within this timeframe.