SnackableHealth™ | STRIVE: Low-Dose r-tPA Shows Promising Early Reperfusion in STEMI With High Thrombus Burden

In this SnackableHealth™ discussion recorded at TCT 2025, Dr. Shamir R. Mehta and Dr. C. Michael Gibson reviewed the results of the STRIVE trial, which investigated the role of low-dose recombinant tissue plasminogen activator (r-tPA) versus placebo in patients with ST-segment elevation myocardial infarction (STEMI) and large thrombus burden undergoing primary PCI.

Dr. Mehta explained that despite advances in primary PCI, microvascular obstruction and impaired distal flow remain persistent challenges, particularly in patients with heavy thrombus load. The STRIVE trial tested whether administering a small, intracoronary dose of r-tPA could improve microvascular perfusion without increasing bleeding risk.

According to the findings, patients who received low-dose r-tPA exhibited higher rates of complete ST-segment resolution and improved TIMI flow post-PCI compared to placebo, with no significant increase in major bleeding or intracranial hemorrhage. “These results suggest that targeted pharmacologic thrombolysis can complement mechanical reperfusion when thrombus burden is high,” Dr. Mehta observed.

Dr. Gibson added that the concept of “facilitated microvascular reperfusion” revives interest in combining pharmacologic and mechanical strategies. “While large-scale trials are needed, STRIVE reopens the door to using low-dose fibrinolytics selectively — not systemically — to optimize outcomes in difficult STEMI cases,” he emphasized.

Both experts agreed that this precision-based approach could eventually refine STEMI management, particularly in centers with advanced cath lab capabilities and imaging-guided thrombus assessment.