Key result
Intracoronary alteplase shows no benefit over placebo for MACE or poor reperfusion outcomes.
Why the study?
In patients undergoing primary PCI for STEMI, distal thrombus embolization often causes microvascular obstruction, and targeted intracoronary low-dose alteplase might improve microvascular obstruction without increasing systemic bleeding risk.
Does adjunctive intracoronary delivery of low-dose alteplase reduce microvascular obstruction or major adverse cardiovascular events in patients undergoing primary PCI for STEMI and high thrombus burden?
Population
210 patients undergoing primary PCI for large territory STEMI and high thrombus burden
Comparison
Intracoronary alteplase 10 mg vs alteplase 20 mg vs placebo
Design
Multicenter, randomized, double-blind trial
Follow-up
30 days
Authors
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“We could not have any more of a neutral result. Regardless of how you look at microvascular obstruction, whether you look at it angiographically with myocardial blush grade or whether you look at it with ST-segment resolution at 30 minutes, it is completely neutral.”
“Microvascular obstruction after primary PCI remains the single most important unresolved issue limiting the efficacy of primary PCI in STEMI patients. STRIVE does not support the routine administration of alteplase and it joins the growing list of previously promising therapies that have not succeeded in improving this important issue.”
“Every time we see a trial of something that seems promising for microvascular disease, and then I hear a presentation like [STRIVE], I just want to say a four-letter word. It's like, man, really?”
Adjunctive intracoronary alteplase confers no benefit in high-thrombus STEMI; challenges prior observational signals for routine use.
RCT (n=210)
double-blind
randomized
Yes
Does adjunctive intracoronary delivery of low-dose alteplase reduce microvascular obstruction or major adverse cardiovascular events in patients undergoing primary PCI for STEMI and high thrombus burden?
Effect estimate: RR 1.00 (95% CI 0.76-1.31)
Absolute Event Rate: 53.3% vs 52.9%
p-value: p=>0.99
Intracoronary administration of low-dose alteplase during primary PCI for STEMI with large thrombus burden does not improve microvascular obstruction or 30-day clinical outcomes and may increase the risk of ventricular fibrillation.
Mehta et al. (2025) conducted an RCT in ST-segment elevation myocardial infarction (STEMI) and large thrombus burden (n=210). alteplase vs. placebo (saline) was evaluated on composite of major adverse cardiovascular events (MACE), myocardial blush grade (MBG) 0/1, distal embolization or failure to achieve ≥ 50% ST-segment resolution at 30 minutes post-PCI (RR 1.00, 95% CI 0.76-1.31, p=>0.99). Intracoronary alteplase was not superior to placebo in reducing the composite of MACE, MBG 0/1, distal embolization, or failure of ST-segment resolution (RR 1.00; 95% CI 0.76-1.31; P>0.99).
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