Pain, heat, and emotion with functional MRI.

n engl j med 368;15 nejm.org april 11, 2013 1447 reduce mortality in patients undergoing primary PCI.7 Second-generation drug-eluting stents have increased the durability of primary PCI and may even have lowered rates of stent thrombosis, as compared with first-generation drug-eluting stents or bare-metal stents.8 Thus, since the start of the STREAM trial, the results of primary PCI have gotten better and safer, creating an even higher bar for prehospital fibrinolysis. The findings of this trial could have a major effect on clinical practice and further highlight the prominence of timely PCI as the treatment of choice for STEMI (Fig. 1). Health care systems can be reconfigured to provide such care, but there are a variety of practical barriers.9 When primary PCI cannot be performed, prompt fibrinolysis should be administered, with transfer to a PCI-capable center in the next several hours, especially in high-risk patients.10 A pharmacoinvasive approach, including initial half-dose fibrinolysis in the elderly, may be an option in selected circumstances, though it does not represent optimal care as compared with timely primary PCI. The STREAM trial shows us that the best therapy for STEMI remains rapid mechanical restoration of coronary flow with a stent.