European Heart Journal Advance Access originally published online on June 6, 2006
European Heart Journal
2006 27(13):1530-1538; doi:10.1093/eurheartj/ehl088
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A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (Which Early ST-elevation myocardial infarction Therapy) study
Canadian VIGOUR Centre, 2-51 Medical Sciences Building, University of Alberta Edmonton, AB, Canada T6G 2H7
Received 11 May 2006; revised 23 May 2006; accepted 24 May 2006; online publish-ahead-of-print 6 June 2006.
* Corresponding author. Tel: +780 492 0591; fax: +780 492 9486. E-mail address: paul.armstrong{at}ualberta.ca
See page 1511 for the editorial comment on this article (doi:10.1093/eurheartj/ehl107)
Aims Uncertainty exists as to which reperfusion strategy for ST-elevation myocardial infarction (MI) is optimal. We evaluated whether optimal pharmacologic therapy at the earliest point of care, emphasizing pre-hospital randomization and treatment was non-inferior to expeditious primary percutaneous coronary intervention (PCI).
Methods and results Which Early ST-elevation myocardial infarction Therapy (WEST) was a four-city Canadian, open-label, randomized, feasibility study of 304 STEMI patients (>4 mm ST-elevation/deviation) within 6 h of symptom onset, emphasizing pre-hospital ambulance treatment and participation of community and tertiary care centres. All received aspirin, subcutaneous enoxaparin (1 mg/kg), and were randomized to one of three groups: (A) tenecteplase (TNK) and usual care, (B) TNK and mandatory invasive study 
24 h, including rescue PCI for reperfusion failure, and (C) primary PCI with 300 mg loading dose of clopidogrel. Time from symptom onset to treatment was rapid (to TNK for A=113 and B=130 min and for PCI in C=176 min). The primary outcome, a composite of 30-day death, re-infarction, refractory ischaemia, congestive heart failure, cardiogenic shock, and major ventricular arrhythmia, was 25% (Group A), 24% (Group B), and 23% (Group C), respectively. However, there was a higher frequency of the combination of death and recurrent MI in Group A vs. Group C (13.0 vs. 4.0%, respectively, P-logrank=0.021), yet no difference between Group B (6.7%, P-logrank=0.378) and C.
Conclusion These data suggest that a contemporary pharmacologic regimen rapidly delivered, coupled with a strategy of regimented rescue and routine coronary intervention within 24 h of initial treatment, may not be different from timely expert PCI.
Key Words: ST-elevation myocardial infarction • Percutaneous coronary intervention • Fibrinolytic pharmacologic reperfusion
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