Patients with a myocardial infarction with ST-segment elevation who present to hospitals

that do not have the capability of performing percutaneous coronary intervention

(PCI) often cannot undergo timely primary PCI and therefore receive fibrinolysis.

The role and optimal timing of routine PCI after fibrinolysis have not been

established.

We randomly assigned 1059 high-risk patients who had a myocardial infarction with

ST-segment elevation and who were receiving fibrinolytic therapy at centers that did

not have the capability of performing PCI to either standard treatment (including

rescue PCI, if required, or delayed angiography) or a strategy of immediate transfer

to another hospital and PCI within 6 hours after fibrinolysis. All patients received

aspirin, tenecteplase, and heparin or enoxaparin; concomitant clopidogrel was recommended.

The primary end point was the composite of death, reinfarction, recurrent

ischemia, new or worsening congestive heart failure, or cardiogenic shock within

30 days.

Cardiac catheterization was performed in 88.7% of the patients assigned to standard

treatment a median of 32.5 hours after randomization and in 98.5% of the

patients assigned to routine early PCI a median of 2.8 hours after randomization.

At 30 days, the primary end point occurred in 11.0% of the patients who were assigned

to routine early PCI and in 17.2% of the patients assigned to standard treatment

(relative risk with early PCI, 0.64; 95% confidence interval, 0.47 to 0.87;

P = 0.004). There were no significant differences between the groups in the incidence

of major bleeding.

Among high-risk patients who had a myocardial infarction with ST-segment elevation

and who were treated with fibrinolysis, transfer for PCI within 6 hours after

fibrinolysis was associated with significantly fewer ischemic complications than

was standard treatment. (ClinicalTrials.gov number, NCT00164190.)