A new comparative analysis from the STREAM-1 and STREAM-2 trials published in American Heart Journal offers evidence that a half-dose pharmaco-invasive (PI) strategy using tenecteplase (TNK) is just as effective—and potentially safer—as full-dose therapy or primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients aged 60 to under 75 years.
STREAM-2 was specifically designed to address the safety concerns around administering full-dose TNK in elderly patients. While earlier results had shown comparable outcomes between half-dose TNK and PPCI in patients aged ≥75, this analysis focuses on those in the 60–74 age range who present within 3 hours of symptom onset.
The analysis covered 1,103 patients across the two trials. Among them, 327 received full-dose PI treatment (STREAM-1), 289 half-dose (STREAM-2), and 487 underwent PPCI. ST resolution ≥50% was similar between full-dose and half-dose groups (71.2% vs. 68.7%; P = .519). The rates of intracranial hemorrhage (ICH) were low and statistically similar between the two groups (2.1% vs. 1.5%; P = 0.605).
Patients receiving PI therapy actually showed slightly better ST resolution after angiography than those treated with PPCI in both STREAM-1 and STREAM-2. The 30-day composite outcome—covering death, myocardial infarction, heart failure, and shock—was also similar across treatment arms.
Major (non-ICH) bleeding significantly dropped in the half-dose PI group (0.3%) compared to the full-dose group (7.1%). These findings highlight the potential of half-dose TNK as a frontline strategy when PPCI is not rapidly available, especially in semi-urban or resource-constrained settings.
• A half-dose TNK in the primary intervention (PI) strategy was as effective as full-dose TNK in STEMI patients aged 60–74.
• ST resolution ≥50% was comparable between half-dose and full-dose groups.
• Intracranial hemorrhage rates were low and not significantly different.
• Patients with PCI had nominally better post-angiography ST resolution than those with PPCI.
• 30-day outcomes (death, MI, heart failure, shock) were similar across treatment strategies.
• Major non-ICH bleeding was significantly reduced with half-dose TNK.
• The half-dose PI strategy offers a safe and effective alternative when PPCI is not promptly available.
Bainey KR, Welsh RC, Zheng Y, et al. Pharmaco-invasive strategy and dosing of tenecteplase in STEMI patients 60 to <75 years: An inter-trial comparison of the STREAM-1 and STREAM-2 trials. Am Heart J. 2025;284:20-31. doi:10.1016/j.ahj.2025.02.002
A half-dose pharmaco-invasive (PI) strategy using tenecteplase (TNK) is just as effective, and potentially safer,, as full-dose therapy or primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) patients aged 60 to under 75 years.