Pulse Glucocorticoid Therapy in Patients With ST-Segment Elevation Myocardial Infarction
Phase: PHASE2
Conditions: ST Elevation Myocardial Infarction, Inflammatory Response, Myocardial Reperfusion Injury, Myocardial Injury
Sponsor: Thomas Engstrom

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Pulse Glucocorticoid Therapy in Patients With ST-Segment Elevation Myocardial Infarction 
PULSE-MI 
 
NCT05462730 
08-03-2023 
 
 

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A prospective randomized, double-blinded, placebo-controlled clinical trial to investigate whether 
single-dose pulse therapy with glucocorticoid treatment prior to primary PCI can reduce final in-
farct size in patients with STEMI.  
 
Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark 
Version: 4.0 (08.03.2023) 
EU-CT number: 2022-500762-10-00 
 
Principal Investigator 
Jacob Lønborg, MD, PhD, DMSc 
Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark 
 
Co-Principal Investigators 
Jasmine Melissa Madsen, MD 
Thomas Engstrøm, MD, PhD, DMSc, Professor of Cardiology 
 
Sponsor 
Thomas Engstrøm, MD, PhD, DMSc, Professor of Cardiology  
Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark 
 
Sub-Investigators 
Laust Obling, MD 
Charlotte Barfod, MD, PhD  
Lars Bredevang Andersen, MD 
Niels Vejlstrup, MD, PhD 
Lia Evi Bang, MD, PhD 
 
PULSE GLUCOCORTICOID THERAPY IN PATIENTS WITH ST-SEGMENT 
ELEVATION MYOCARDIAL INFARCTION 
 
 

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Table of Contents 
1. ABBREVIATIONS ........................................................................................................................ 6 
2. BACKGROUND ............................................................................................................................ 7 
2.1 PURPOSE OF THE STUDY ................................................................................................................... 7 
2.2 CLINICAL RELEVANCE ..................................................................................................................... 7 
2.3 REPERFUSION INJURY AND INFLAMMATION IN STEMI .................................................................... 7 
2.4 GLUCOCORTICOIDS AND STEMI ...................................................................................................... 8 
2.5 SAFETY AND RATIONALE ................................................................................................................. 9 
3. HYPOTHESIS .............................................................................................................................. 10 
4. OBJECTIVES OF THE STUDY ................................................................................................ 10 
4.1 OVERALL PRIMARY OBJECTIVE ..................................................................................................... 10 
4.2 SECONDARY OBJECTIVES ............................................................................................................... 11 
5. ENDPOINTS AND FOLLOW-UP ............................................................................................. 11 
5.1 ENDPOINT DEFINITION ................................................................................................................... 13 
5.2 EVENT RECORDING ........................................................................................................................ 13 
5.3 MONITORING ................................................................................................................................. 13 
6. STUDY SETUP ............................................................................................................................ 13 
6.1 STUDY DESIGN ............................................................................................................................... 13 
6.2 TARGET PATIENT POPULATION AND NUMBER OF PATIENTS ........................................................... 14 
6.3 STUDY SETTING ............................................................................................................................. 15 
6.4 ESTIMATED STUDY DURATION ....................................................................................................... 15 
6.5 INCLUSION AND EXCLUSION CRITERIA ........................................................................................... 16 
7. ETHICAL ASSESSMENT .......................................................................................................... 17 

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8. STUDY PROGRESS AND CONDUCT ..................................................................................... 17 
8.1 SCREENING AND INCLUSION ........................................................................................................... 17 
8.2 REGISTRATION .............................................................................................................................. 18 
8.3 RANDOMIZATION ........................................................................................................................... 19 
8.4 STUDY MEDICINE AND PLACEBO .................................................................................................... 19 
8.5 BLINDING ....................................................................................................................................... 20 
8.6 DOSAGE ADJUSTMENTS .................................................................................................................. 21 
8.7 DISCONTINUATION OF STUDY PARTICIPATION ............................................................................... 21 
8.8 RESEARCH BIOBANK ...................................................................................................................... 21 
8.9 CONCOMITANT PROCEDURES......................................................................................................... 22 
8.9.1 PRIMARY PCI PROCEDURE ...................................................................................................................... 22 
8.9.2 FOLLOW-UP MEDICAL TREATMENT ......................................................................................................... 22 
8.9.3 FOLLOW-UP INVESTIGATIONS .................................................................................................................. 22 
8.9.4 10 YEAR FOLLOW-UP ............................................................................................................................... 23 
9. ETHICAL CONSIDERATIONS ................................................................................................ 23 
9.1 ETHICAL CONDUCT OF THE STUDY ................................................................................................ 23 
9.2 INFORMED CONSENT ...................................................................................................................... 24 
9.2.1 IN THE EMERGENCY SITUATION ................................................................................................................ 25 
9.3 BENEFITS AND RISKS...................................................................................................................... 27 
10. STATISTICS .............................................................................................................................. 27 
10.1 POWER CALCULATIONS ............................................................................................................... 27 
10.2 STATISTICAL ANALYSIS................................................................................................................ 28 
10.3 PRE-SPECIFIED SUBGROUP ANALYSES .......................................................................................... 28 
11. SUB-STUDY ............................................................................................................................... 28 
12. DATA STORING AND HANDLING OF PERSONAL DATA ............................................ 29 
13. ASSESSMENTS OF SAFETY AND HARM .......................................................................... 29 
13.1 ADVERSE EVENTS (AES)............................................................................................................... 29 

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13.2 SERIOUS ADVERSE EVENTS (SAES) .............................................................................................. 30 
13.3 SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSARS) ........................................... 30 
14. FINANCE AND INSURANCE ................................................................................................. 30 
15. PUBLICATION ......................................................................................................................... 31 
16. ANNUAL SAFETY REPORT .................................................................................................. 31 
APPENDIX A (CARDIAC MAGNETIC RESONANCE PROTOCOL AND ENDPOINTS) . 37 
APPENDIX B (END-POINT DEFINITIONS) .............................................................................. 40 
APPENDIX C (THE PULSE-MI COMMITTEE MEMBERS AND INVESTIGATORS) ...... 43 
 
 
 
 

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1. Abbreviations  
AEs 
 
 
Adverse Events 
AMI 
 
 
Acute Myocardial Infarction 
CAG  
 
Coronary Angiography 
CABG  
 
Coronary Artery Bypass Graft 
CEC 
 
 
Clinical Event Committee 
CFR 
 
 
Coronary Flow Reserve  
CMR  
 
Cardiac Magnetic Resonance 
CRP 
 
 
C-Reactive protein 
ECG  
 
Electrocardiogram 
GCP  
 
Good Clinical Practice 
HF 
 
 
Heart Failure 
IRA 
 
 
Infarct-Related Artery 
ICF 
 
 
Informed Consent Form 
IMR 
 
 
Index of Myocardial Resistance  
LAD  
 
Left Anterior Descending Artery 
LGE 
 
 
Late Gadolinium Enhancement 
LVEF  
 
Left Ventricular Ejection Fraction 
MVO  
 
Microvascular Obstruction 
MSI 
 
 
Myocardial Salvage Index 
PCI 
 
 
Percutaneous Coronary Intervention 
PI 
 
 
Principal Investigator 
RD 
 
 
Referring Cardiology Fellow Doctor 
SAEs  
 
Serious Adverse Events 
SCAD  
 
Spontaneous Coronary Artery Dissection 
SD 
 
 
Standard Deviation 
STEMI 
 
ST-segment elevation myocardial infarction  
SUSARs 
 
Suspected Unexpected Serious Adverse Reactions 
TIA 
 
 
Transient Ischemic Attack 
TIMI  
 
Thrombolysis In Myocardial Infarction  
 
 

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2. Background 
2.1 Purpose of the Study  
The overall primary objective of the Pulse Glucocorticoid Therapy in Patients with ST-Segment El-
evation Myocardial Infarction (STEMI) trial (PULSE-MI) is to test the hypothesis that administra-
tion of single-dose glucocorticoid pulse therapy in the pre-hospital setting reduces final infarct size 
in patients with STEMI treated with primary percutaneous coronary intervention (PCI). 
 
2.2 Clinical Relevance 
STEMI remains one of the leading causes of mortality globally despite significant advances in 
reperfusion therapies with timely primary PCI1. One-year mortality following STEMI has decreased 
to around 10%, yet a substantial number of patients with STEMI develop heart failure (HF) (22%) 
which impairs prognosis significantly2-6. A main driver for mortality and heart failure following 
STEMI is infarct size that is the cause of ischemia and reperfusion injury7. Of note, inflammation is 
induced immediately after the onset of acute myocardial ischemia and is subsequently exacerbated 
following reperfusion8. Hence, inflammation in the setting of STEMI is an important factor in both 
acute myocardial ischemia and reperfusion injury, which is why inflammation per se is a feasible 
and desirable target for improving prognosis in these patients. 
 
2.3 Reperfusion Injury and Inflammation in STEMI 
Up to 60% of patients with STEMI have reperfusion in the pre-hospital setting due to effective an-
tithrombotic treatment with heparin and aspirin9. Yet, primary PCI including stent implantation is 
the preferred revascularization strategy in patients with STEMI to reduce the occurrence of re-in-
farction and improve the overall prognosis in these patients10, 11. However, an additional myocardial 
injury may occur when coronary blood flow is restored, a phenomenon called “reperfusion injury”7. 
The injury occurs immediately after the restoration of blood flow requiring early treatment and may 
account for up to 50% of the damaged myocardium (Figure 1)4, 6. Thus, the extent of myocardial 
damage and resulting final infarct size are major components in determining the clinical course fol-
lowing STEMI7, 12.  However, the phenomenon is not completely understood, and no preventive 
treatment exists. Multiple pathophysiological factors may contribute to reperfusion injury such as 
microvascular obstruction (MVO), oxidative stress, and inflammation.  
Following reperfusion, platelets are the first cells to migrate to the damage myocardium in-
ducing accumulation of leukocytes in the infarct-related-artery (IRA) prompting local inflammation 

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and release of pro-inflammatory cytokines inducing systemic inflammation13, 14. Hence, inflamma-
tion per se may drive excessive cardiomyocyte death resulting in decreased contractility and in-
creased infarct size post-acute myocardial infarction (AMI)15. Moreover, in the course following 
AMI and subsequently reperfusion, the myocardium starts healing and scarring resulting in remod-
eling of the ventricle potentially causing either compensatory hypertrophy or thinning of the myo-
cardium, which may lead to reduced left ventricular ejection fraction (LVEF) and HF16. Of note, in-
flammation plays a critical role in ventricular remodeling post-AMI, thus inflammation in relation 
to reperfusion injury may extend of myocardial damage following STEMI17.  
Figure 1. Microscopy of a rabbit cardiac myocyte. 
 
Engstrøm et al., Unpublished data. During 90 minutes of ischemia, the structure integrity of the car-
diomyocyte is preserved. Following 1-minute of reperfusion, the integrity and structure of the cardi-
omyocyte is lost.  
 
2.4 Glucocorticoids and STEMI 
Glucocorticoids are crucial in regulation of the systemic inflammatory response and may therefore 
be beneficial in limiting myocardial injury following STEMI18, 19. Glucocorticoids mediate two dif-
ferent mechanisms: the genomic effect mediated by glucocorticoid receptor occupation, gene tran-
scription, and translation within the cells which is induced within hours and the non-genomic effect, 
which is induced rapidly (<15 minutes) after administration via plasma membrane bound receptors 
and independent of cytosolic receptor occupation and genomic regulation20, 21. Some of the pro-
posed nongenomic effects of glucocorticoids on the cardiovascular system include decreased vascu-
lar inflammation and reduced infarct size by activating the endothelial nitric oxide synthase 
(eNOS), cardioprotection through membrane stabilization through nitric oxide (NO) production, 
and increasing the contractility of the vascular smooth muscle cells20. Taken altogether, the non-

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genomic actions secure that the anti-inflammatory effect is initiated quickly to protect the myocar-
dium immediately whereas, in addition, the genomic actions protects the tissue in the subsequent 
period.The use of glucocorticoid in relation to ischemia has therefore been investigated in experi-
mental, in-vivo, and clinical studies in the 1970’s and 1980’s. In experimental animal studies, glu-
cocorticoids showed beneficial effects on hemodynamics and infarct size following ischemia, how-
ever most studies were performed in non-reperfused animals16, 19, 22. Albeit this, clinical studies in 
patients with AMI have shown conflicting results16, 19, 22. Further, definitive conclusions on gluco-
corticoids’ efficacy in patients with STEMI are difficult to draw due to different study designs, in-
vestigational agents, and medicine dosage16. However, most importantly, all studies performed in 
patients with AMI were before the era of primary PCI16, and since the implementation of PCI in 
treatment of STEMI, the prognosis in these patients has improved significantly1. Considering these 
advances in reperfusion strategies, glucocorticoids may now add an additional beneficial role in 
limiting infarct size and improving prognosis in patients with STEMI19. Although questions have 
been raised of impaired infarct heeling in relation to glucocorticoid treatment in the setting of 
STEMI, the concern is not supported by randomized controlled clinical trials16, 23. Long-term use of 
glucocorticoids is, however, associated with adverse side-effects, but short-term use of glucocorti-
coids has only few side-effects24. None of the previous studies have investigated single-dose pulse 
therapy with glucocorticoids in patients with STEMI who were treated with primary PCI. Based on 
reperfusion advances, role of inflammation in both STEMI and reperfusion injury, and few side ef-
fects of short-term use of glucocorticoid, intravenous short-term treatment with glucocorticoid 
could add potential benefit and have an important therapeutic role in limiting the degree of myocar-
dial injury and thereby improving prognosis in patients with STEMI.  
 
2.5 Safety and Rationale  
In light of the above, we will investigate the well-known, widely used, and highly potent glucocorti-
coid, methylprednisolone, administrated as single pulse-dose therapy prior to primary PCI in pa-
tients with STEMI in a randomized clinical trial. 
 
Pulse glucocorticoid therapy was first used for acute rejection following kidney transplanta-
tion25,  and is defined as treatment with ≥250 mg prednisolone or equivalent for one or more 
days26. Pulse glucocorticoid therapy is now used as effective and safe treatment of a wide range of 
diseases such as rheumatic diseases, dermatologic diseases, optic neuritis, multiple sclerosis, acute 
disseminated encephalomyelitis, glomerulonephritis, and systemic vasculitis27. Doses up to 2500 

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mg methylprednisolone, depending on disease severity, are recommended and used in treating these 
inflammatory conditions27. The beneficial acute effects of pulse glucocorticoid therapy in these con-
ditions are thought to be mediated by the nongenomic effects of glucocorticoids via plasma mem-
brane bound receptors, and the estimated complete glucocorticoid receptor occupation is reached at 
approximately 100 mg methylprednisolone, reaching maximum activation around 250 mg27, 28. Ge-
nomic mechanisms cannot explain the beneficial effects of glucocorticoid doses >100 mg, and the 
extent of receptor activation is directly dependent on methylprednisolone dosage29. Despite concern 
of serious adverse events (SAEs) following high-dose methylprednisolone, intravenous pulse ther-
apy is not associated with increased risk of mortality, adverse events (AEs), or AEs leading to dis-
continuation of pulse methylprednisolone30, 31. The Norwegian “Summary of Product Characteris-
tics” (SPC) for Solu-Medrol (methylprednisolone) recommends doses up to 30 mg/kg. The Danish 
SPC for Solu-Medrol (methylprednisolone) recommends infusion of 250 mg methylprednisolone 
over a period of ≥5 minutes32. This is due to the potential side-effects of a rapid infusion of 
methylprednisolone. These potential side-effects are, however, not well supported by the literature. 
In fact, pulse glucocorticoid therapy administrated intravenously over a short period of time has few 
side effects compared with long-term oral treatment24, 30, 33. Considering this knowledge, safety, and 
potential beneficial dual effects in patients with STEMI undergoing primary PCI, administration of 
250 mg methylprednisolone administrated in the pre-hospital setting may well offer substantial ad-
vantages in these patients. The expected effect will then translate into reduced infarct size, better 
clinical outcomes including fewer patients with HF and subsequently reduced mortality following 
STEMI.  
3. Hypothesis  
In patients with STEMI undergoing primary PCI, 250 mg methylprednisolone administrated in the 
pre-hospital setting limits reperfusion injury and reduce final infarct size measured by late gadolin-
ium enhancement (LGE) on cardiac magnetic resonance (CMR) 3 months after STEMI.  
4. Objectives of the Study 
4.1 Overall Primary Objective 
To determine whether 250 mg methylprednisolone administrated in the pre-hospital setting reduces 
final infarct size on CMR in patients with STEMI undergoing primary PCI. 
 

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4.2 Secondary Objectives 
• To determine whether the response of methylprednisolone differs in pre-specified sub-
groups: age, gender, pre-PCI Thrombolysis in Myocardial Infarction (TIMI) flow, culprit in 
left anterior descending artery (LAD), time from first medical contact to primary PCI, and 
duration of symptoms prior to primary PCI. 
• To determine whether methylprednisolone improves LVEF within 48 hours and 3 months 
after primary PCI.  
• To determine whether methylprednisolone decreases acute infarct size and edema measured 
on CMR within 48 hours of primary PCI. 
• To determine whether methylprednisolone decreases degree of microvascular obstruction 
(MVO) and hemorrhage measured on CMR within 48 hours of primary PCI.  
• To determine whether methylprednisolone inhibits the inflammatory response at admis-
sion,24 hours after admission and after 3 months. Markers of inflammation: High sensitivity 
C-reactive protein (hsCRP), leucocyte- and differential count, plasma cytokine levels (IL-
1b, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12, IL-13, IL-17A, G-CSF, GM-CSF, 
MCP-1, MIP-1beta, INF-g and tumor-necrosis factor α (TNF-α)), and procalcitonin 
• To determine whether methylprednisolone increases myocardial salvage index (MSI) on 
CMR 
• To determine whether methylprednisolone increases coronary flow reserve (CFR) and de-
creases index of microcirculatory resistance (IMR). 
• To determine whether methylprednisolone improves clinical outcomes (all-cause mortality 
and hospitalization for HF) at one year after primary PCI.  
• To determine whether methylprednisolone decreases peak Troponin-T and creatine kinase 
myocardial band (CKMB) during admission. 
 
All these outcomes are relevant to patients with STEMI and have the potential to change the clinical 
course following STEMI and standard clinical practice.  
5. Endpoints and Follow-Up 
Primary and secondary endpoints are listed in Table 1.  
 
 

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Table 1. PULSE-MI endpoints 
 
Intervention with glucocorti-
coid vs. no intervention 
Timeframe 
Primary endpoint 
Final infarct size (% of ven-
tricular mass) measured by 
LGE on CMR 
3 months after primary PCI 
Secondary endpoints 
The extent of MVO on CMR 
Within 48 hours after primary 
PCI 
 
The extent of hemorrhage on 
CMR 
Within 48 hours after primary 
PCI 
 
Other CMR efficacy parame-
ters as specified in the appen-
dix A  
Within 48 hours and 3 months 
after primary PCI 
 
All-cause mortality and hospi-
talization for HF 
3 months after primary PCI 
 
Peak Troponin-T and CKMB 
During admission 
 
Safety: Incidence of adverse 
events the first seven days of 
index event 
Within 7 days of STEMI 
 
Exploratory endpoints: 
1. Pre-PCI and post-PCI TIMI flow 
2. C-reactive protein (CRP), leucocyte- and differential count, thrombocytes, HbA1c, p-Glu-
cose, pro-brain natriuretic peptide (BNP), creatine kinase, creatinine, potassium, and sodium 
at admission, during admission and after 3 months 
3. Arrhythmia (ventricular tachycardia/ventricular fibrillation) during transportation in the am-
bulance and peri-procedural during PCI 
4. Bolus CFR, IMR, absolute CFR, and microvascular resistance reserve (MRR) following pri-
mary PCI 
5. LVEF on transthoracic echocardiography during admission and one to three months follow-
ing primary PCI 
6. Killip Class at admission  

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7. Biomarkers of inflammation at admission, 24 hours after admission, and after 3 months 
8. All-cause mortality and hospitalization for HF after 1 and 10 years 
 
5.1 Endpoint Definition  
All clinical endpoints (all-cause mortality and hospitalization for HF) are defined in Appendix B. 
The CMR efficacy parameters are described in Appendix A. Secondary endpoints will be identified 
using hospital files in which all deaths and hospital referrals are reported. 
 
Events will subsequently be adjudicated by members of our clinical events committee 
(CEC), who will review all relevant medical records.  
 
5.2 Event Recording  
Violations of the protocol will be monitored continuously. The CEC is responsible for adjudicating 
the clinical secondary endpoints. No members of the CEC participate in recruitment or data collec-
tion or have access to any information regarding treatment allocation. A list of all CEC members is 
given in Appendix C.   
 
5.3 Monitoring  
Monitoring of the study will be done by a local Good Clinical Practice (GCP) unit. The trial will be 
conducted in compliance with the published trial protocol, the Helsinki Declaration, the GCP guide-
lines (ICH-GCP), and national laws. The Sponsor of the trial allows investigators and institutions 
involved in the trial to perform trial-related monitoring, audit, and inspection from the authorities 
including direct access to the data and documents related to the trial.  
The first monitoring meeting will be held after inclusion of 2 patients. The following meetings will 
be held as needed. A full monitoring plan will be elaborated and composed before initiation of the 
study by the local GCP unit. 
6. Study Setup  
6.1 Study Design 
This study is an investigator-initiated, 1:1 randomized, double-blinded, placebo-controlled prospec-
tive clinical proof-of-concept trial to investigate whether pulse therapy with 250 mg methylpredni-
solone in the pre-hospital setting limit reperfusion injury and reduce infarct size, and subsequently 
improve clinical outcomes in patients with STEMI undergoing primary PCI. The trial will be 

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chaired at the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Den-
mark.  
 
6.2 Target Patient Population and Number of Patients 
The target patient population is male and female patients aged 18 years and over with documented 
evidence of STEMI, eligible planned for primary PCI who had symptom onset within 12 hours be-
fore randomization who were initially managed by an ambulance paramedic and included by the re-
ferring and including doctor (on-call cardiology fellow doctor (RD) at Rigshospitalet) in the pre-
hospital setting. 
A total of 378 patients with STEMI (189 patients treated with intravenous infusion of 250 
mg methylprednisolone and 189 patients with intravenous placebo infusion) are included for the 
primary endpoint of final infarct size (% LGE of the LV) on CMR at 3 months. The inclusion will 
continue until this number has been reached and with an expected drop-out rate of 40%, 530 pa-
tients need to be included and randomized. All patients will be included in the pre-hospital setting 
from throughout the Capital Region and Region Zealand of Denmark (Figure 2).  
 
 
 
 
 
 
 
 
 
 
 
Figure 2. Flowchart of the study 
 

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6.3 Study Setting 
In all, patients with STEMI will be included in the pre-hospital setting throughout the Capital Re-
gion and Region Zealand of Denmark prior to primary PCI at Rigshospitalet, Copenhagen Univer-
sity Hospital, Denmark if eligible to participate in the study. Eligibility will be carefully screened 
by the RD at Rigshospitalet. Data collection and analysis will be undertaken through the Depart-
ment of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.  
 
6.4 Estimated Study Duration  
We expect the study to begin once the study has been approved by the government. Rigshospitalet 
performs approximately 1000 primary PCI procedures per year34. An inclusion is planned to be 
completed in 36 months, and the 3-months follow-up period will be completed after 39 months. 
However, the study will be stopped before when 378 patients have completed CMR at 3 months. 
Following completion of the trial, the hospital records will be accessed at 1 and 10 years to obtain 
information on mortality and hospitalization for HF (Figure 3). 
 
 
 
Figure 3. Timeline of the study 

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6.5 Inclusion and Exclusion Criteria 
Inclusion criteria for recruitment are listed below and must be fulfilled for the patient to be random-
ized:  
1. Age ≥18 years including fertile women*. 
2. Acute onset of chest pain with < 12 hours duration.  
3. STEMI as characterized on electrocardiogram (ECG) by one of the following:  
1) at least two contiguous leads with ST-segment elevation ≥2.5 mm in men < 40 
years, ≥2 mm in men ≥40 years, or ≥1.5 mm in women in leads V2-V3 and/or ≥1 mm 
in the other leads,   
2) presumed new left bundle branch block with ≥1 mm concordant ST-segment ele-
vation in leads with a positive QRS complex, or concordant ST-segment depression 
≥1 mm in V1-V3, or discordant ST-segment elevation ≥5 mm in leads with a negative 
QRS complex,  
3) Isolated ST depression ≥0.5 mm in leads V1-V3 and ST-segment elevation (≥0.5 
mm) in posterior chest wall leads V7-V9 indicating posterior acute myocardial infarc-
tion (AMI),  
4) ST-segment depression ≥1 mm in eight or more surface leads, coupled with ST-
segment elevation in aVR and/or V1 suggesting left main-, or left main equivalent- 
coronary obstruction.  
Exclusion criteria for recruitment are listed below and none of the criteria must be fulfilled for a pa-
tient to be eligible: 
1. Presentation with cardiac arrest (out of hospital cardiac arrest (OHCA)). 
2. Time from symptoms onset to primary PCI > 12 hours.  
3. Known allergy to glucocorticoid or known mental illness with maniac or psychotic episodes. 
 
* It is not possible to perform a pregnancy test (HCG urine test) in the pre-hospital setting. However, methylpredniso-
lone is not contraindicated in pregnant women. 

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4. Patients with previous AMI in the assumed culprit artery. 
5. Previous coronary artery bypass graft (CABG). 
6. Unable to read and understand Danish. 
7. Ethical Assessment  
The patient will be informed and treated according to the international guidelines (ICH-GCP) and 
protected under the General Data Protection Regulation (GDPR) including the processing of per-
sonal data (data protection law) and the Danish Health Act. As to the need for fast transportation 
and treatment (primary PCI), the main ethical issue that could arise from this trial is that informed 
consent cannot be obtained prior to intervention and treatment with primary PCI due to the acute 
setting of the study. Intervention before informed consent is done to secure initiation of the study 
treatment as soon as possible due to the need of acute intervention and treatment in STEMI and vul-
nerable patients. Moreover, the ability of the patient to provide informed consent in the pre-hospital 
setting is questionable due to vulnerability, chest pain and acute setting. This implies the following:  
• Recruitment and randomization in the pre-hospital setting will be performed by the par-
amedic in the ambulance. 
• The including doctor is the RD at Rigshospitalet. The including RD is continuously in 
touch with the paramedic in the ambulance by telephone from the time of screening until 
randomization has been done.  
• The patient will provide informed consent as soon as possible following the acute man-
agement of the patient (primary PCI), once the patient is stable.  
• The process of informed consent is described thorough in section 9.2. The process fol-
lows article 35 of Clinical Trial Regulation EU No 536/2014 and Law of Clinical Trials, 
§3.  
• The justification for providing informed consent following intervention due to the emer-
gency situation is described thorough in the section 9.2.1.  
8. Study Progress and Conduct  
8.1 Screening and Inclusion 
Screening, inclusion and registration will be done in the ambulance in the pre-hospital setting. The 
including RD at Rigshospitalet will carefully check the eligibility of the patient to participate in the 
study. The including RD is continuously in touch with the paramedic in the ambulance by telephone 

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from the time of screening until randomization has been done. The including RD has all the neces-
sary information about the patient including previous medical and psychotic history, actual medica-
tions, and clinical status. Clinical status includes patients’ general condition, blood pressure, heart 
rate, and ECG changes. As of the acute nature of STEMI and study design, the qualifying ECG will 
be performed in the pre-hospital settings as normal procedure. These data will be used for eligibil-
ity evaluation by the including doctor (RD) at Rigshospitalet. The RD that is responsible for inclu-
sion of the patient via telephone must ensure that there are no contraindications for administration 
of glucocorticoids (including history of known mental illness with maniac or psychotic episodes) as 
part of the eligibility check. This information is available via the patient charts that can be accessed 
by the RD. If the including RD find the patient eligible to participate in the study, the including RD 
will ask the paramedic to include the patient in the study in the pre-hospital setting.  
In the pre-hospital setting, the paramedic in the ambulance will do the following:  
1. Include the patient in the study following eligibility check by the RD at Rigshospitalet.  
2. Randomize the patient by picking a random box from a storage in the ambulance containing 
the study medicine (methylprednisolone or placebo). All boxes are identical, and the para-
medic is therefore blinded when randomizing.  
3. Register the patient in an electronic database, REDCap.  
All patients, or the legally designated representative must personally sign and date the informed 
consent form (ICF) as soon as possible following the primary PCI procedure (described in detail in 
section 9.2). The independent legally designated representative of patients who are enrolled and un-
able to provide informed consent will be Dr. Reza Jabbari. If patients remain unable to provide in-
formed consent 3 days following admission, the nearest relative to the patient will also sign the ICF 
on behalf of the patient as soon as possible. Informed consent from the patient will subsequently be 
obtained as soon as possible. The procedure of informed consent is described thorough in section 
9.2.  
 
8.2 Registration 
All paramedics have access to the registration form in REDCap. The registration form can be ac-
cessed through a QR-code on the study medicine box or through an internet browser. When a pa-
tient is registered, the patient will be allocated a patient identification number by a computer-gener-
ated code. The identification number will be used to identify the patient throughout the whole study. 
The identification number consists of three digits assigned in sequential order as patients are 

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screened (001, 002, 003, etc.). All patients who are screened for eligibility will be registered in an 
electronic database, REDCap. In the registration form, the paramedic will annotate the following 
information about the patient: 1) civil registration number, 2) the number of the study medicine box, 
3) time of intervention, and 4) if the study medicine was given according to the protocol (yes/no), 
and if not, why the study medicine was not given. The paramedic in the ambulance will sign the 
registration form following inclusion.  
 
8.3 Randomization 
Randomization of the patient will take place in the pre-hospital setting. Patients who satisfy all the 
eligibility requirements will be randomized. Randomization is done by the paramedic in the ambu-
lance. Patients will be randomized in a 1:1 ratio to either infusion of 250 mg methylprednisolone or 
placebo that are placed in identical boxes. The paramedic randomizes the patient by picking a ran-
dom box stored in the ambulance delivered by the pharmacy, including methylprednisolone or pla-
cebo, and administrates (over a period of 5 minutes) the content by a bolus infusion. Following in-
fusion of the randomized treatment, the ambulance will bring the box to the hospital alongside with 
ECGs obtained in the ambulance in case of emergency unblinding. All boxes are identical and has a 
unique box serial number. Once a patient has been randomized, the patient is considered enrolled 
and included in the study. The box serial number is not necessarily the same as the patient identifi-
cation number. In case of any technical issues, the responsible Ph.D. student or other investigators 
from the steering committee will be available. 
All including RD’s at Rigshospitalet, legally designated representative, and paramedics have 
relevant knowledge of the study from the handing out of the study protocol, protocol summaries, 
and pocket cards as well as via e-mail and on-going project recaps. None of the including RDs, le-
gally designated representative, or paramedics are involved with the trial except for screening, en-
rollment, and inclusion of the patients.  
 
8.4 Study Medicine and Placebo 
Patients will be allocated to either infusion of 250 mg methylprednisolone or placebo that are 
placed in identical boxes. Each box will either contain Solu-Medrol or placebo and will be num-
bered randomly by the pharmacy. Administration of the study medicine will not prolong the trans-

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portation or any aspect of the standard treatment of the patient. The patients will be treated accord-
ing to standard procedures in the ambulance. Primary PCI and antithrombotic regimens will be per-
formed according to standard procedures at Rigshospitalet, Denmark.  
All study medicine and placebo boxes are identical and numbered in a random manner at the 
pharmacy. The numbers on the identical boxes are unique, and the pharmacy has the allocation list. 
The study medicine is 2 x 125 mg/2 mL Solu-Medrol, a total of 250 mg/4 mL, which comes as a 
sterile powder with preservative free isotonic NaCl as diluent. The medicine takes 30 to 60 seconds 
to mix and needs to be used within 48 hours when opened. The placebo will be 0.9% NaCl in 4 mL 
ampoules. The infusion of both the study medicine and placebo will be done over a period of 5 
minutes during transportation.  
 
8.5 Blinding 
The pharmacy of the Capital Region of Denmark will pack inbox and label the study medicine and 
placebo ampoules. The randomization will be allocated by the pharmacy and their independent stat-
istician using a random number generator.  The pharmacy will keep the allocation list and will not 
be involved otherwise in the trial. Sponsor and Investigators of the trial keep an allocation list 
locked at in a safety cabinet in case of emergency unblinding. Sponsor and Investigators are respon-
sible for any emergency unblinding. Moreover, Investigators can unblind the study medication 
without prior contact to the sponsor. According to the ICH-GCP guideline 4.3.1, the Investigators 
are responsible for all trial-related medical decisions and are able to unblind immediately without 
restrictions. The pharmacy is not able to make matching placebo ampoules as Solu-Medrol does not 
come in a premixed ampoule and needs to be mixed before use in the ambulance. The treating para-
medic is therefore unblinded after inclusion, however, the paramedic will not take any further part 
in the trial nor the treatment of the patient once arrived at Rigshospitalet, Denmark.  
Following preparation, the boxes will be shipped to all the critical care unit stations in the 
Capital Region and Region Zealand of Denmark. All units are manned 24 hours 7 days a week. The 
investigators will make sure that all ambulances at the different stations always have boxes in stor-
age and ready for use. Before each shift, the paramedic will make sure that a minimum of five 
boxes are stored in each ambulance.  
 

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8.6 Dosage Adjustments 
The dose of the study medicine will be fixed. In case of any clinical signs of an allergic reaction or 
severe side effects are suspected, the infusion will be terminated immediately. No dosage adjust-
ments are allowed.   
 
8.7 Discontinuation of Study Participation  
A patient can withdraw from the study at any time, or when medically necessary, as judged by the 
Investigator. The information about withdraw at any time from the trial is emphasized to the patient. 
Emergency unblinding may occur judged by the Investigators. Sponsor and Investigators are re-
sponsible for the unblinding procedure. Investigators can unblind the study medication without 
prior contact to the sponsor. According to the ICH-GCP guideline 4.3.1, the Investigators are re-
sponsible for all trial-related medical decisions and are able to unblind immediately without re-
strictions. Other reasons for ST-segment elevation (e.g. myocarditis, pericarditis, takotsubo) and pa-
tients who does not fulfill inclusion- and exclusion criteria (post-randomization exclusions) will be 
excluded from the study but followed for 3 months for safety monitoring. 
 
8.8 Research Biobank 
During the study, around 50 mL of blood in total will be drawn for a research biobank. Blood sam-
ples will be drawn at admission in the catherization laboratory, after 24 hours in the ward, and at 
follow-up after 3 months. The research biobank will be constructed in accordance with national leg-
islation. Biological material in the research biobank will be used for analyses of biomarkers for in-
flammation as well as other markers of interest as described in the section “4.2 Secondary objec-
tives and 5. Endpoints”. The analysis of biomaterial in the research biobank will occur following 
completion of the trial, i.e. during 2026, and all samples and data will be stored pseudo-anony-
mously. Following analyses, the research biobank will be terminated in 2026, before the 31th of 
December. If any biological material remains following analyses in 2026, the material will be fro-
zen in a biobank for future research and destroyed after ten years. Any further future analyses of un-
used research biobank material associated to this project will require ethics committee approval.  
 

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8.9 Concomitant Procedures 
8.9.1 Primary PCI Procedure 
The patient is admitted to the hospital because of STEMI with symptom onset less than 12 hours 
before contact, defined as a primary PCI according to guidelines10. The primary PCI will be per-
formed as usual clinical practice. The patient is pretreated with aspirin (300 mg) and 10.000 units of 
heparin in the pre-hospital setting by the paramedics as soon as the including RD at Rigshospitalet 
has set the diagnosis of STEMI and referred the patient to primary PCI at Rigshospitalet, Denmark. 
These procedures are of standard clinical practice and in accordance with guidelines. Primary PCI is 
prepared and performed as usual in the catheterization laboratory. Immediately subsequent to pri-
mary PCI, a loading dose of either 60 mg prasugrel or 180 mg ticagrelor is given per os. 
Clopidogrel 600 mg can be chosen alternatively at the discretion of the treating physician (e.g. high 
bleeding risk, ongoing anticoagulation therapy).  
 
8.9.2 Follow-Up Medical Treatment  
The follow-up medical treatment will be completely in accordance with international guidelines and 
local standard operating procedures. Dual antiplatelet therapy with aspirin 75 mg once daily and 
prasugrel 10 mg or 5 mg b.i.d., or ticagrelor 90 mg will be given for 12 months. Deviation from this 
is allowed at the discretion of the PCI operator.  
 
8.9.3 Follow-Up Investigations  
ECG’s and cardiac enzymes will be obtained as of standard practice and routine. Echocardiography 
will be performed both bedside before the primary PCI, to ensure no mechanical complications are 
present at admission, and within the first days of index event in a stable phase. Additionally, a 
standard echocardiography will be performed at 3 months following index event as part of standard 
care.  
 
CMR, as part of the study, will be performed on all study participants without contraindica-
tions towards CMR (decreased renal function (estimated glomerular filtration rate (eGFR <30 
ml/min), severe claustrophobia, ferrous metallic foreign body, pacemaker/implementable cardio-
verter-defibrillator (ICD), or allergy to contrast (Gadolinium)) within the first 48 hours of index 
event and 3 months after the index event at Rigshospitalet, Copenhagen University Hospital, Den-
mark. The CMR will be performed during admission at Rigshospitalet within 48 hours to measure 

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area at risk, MVO, edema, hemorrhage, and acute infarct size. The CMR at 3 months will be per-
formed to measure final infarct size which is the primary endpoint of the trial. Patients will be of-
fered transportation renumeration to undertake the CMR scan at 3 months. CMR is not associated 
with any complications. All scans are analyzed for in Circle Cardiovascular Imaging (CVI42). The 
CMR protocol is described in detail in Appendix A.   
 
8.9.4 10 Year Follow-Up 
The study is completed following total inclusion of 378 patients for the primary endpoint. Records 
of the patients are assessed after 10 years to access mortality and hospitalization for HF. No safety 
event recording and annual safety reports will be done in the time between completion of the trial 
and the 10-year follow-up assessment. 
 
9. Ethical Considerations 
9.1 Ethical Conduct of the Study 
The ethics committee will approve the study protocol and ICF before the initiation of the trial. The 
study protocol will be registered at the Danish Data Protection Agency. Good Clinical Practice will 
be observed throughout the whole trial and appropriate international, European, and national legis-
lations and guidelines will be respected. The Data Safety Monitoring Board (DSMB) will monitor 
the study by assessing the safety and efficacy of interventions during the trial and the overall con-
duct of the clinical trial. The responsibilities of the DSMB is described thorough in the DSMB char-
ter.. The trial will be conducted in compliance with the published trial protocol, the Helsinki Decla-
ration, the GCP guidelines (ICH-GCP), and national laws.  
 
Due to the acute nature of STEMI, vulnerability, and inability of the patient to provide in-
formed consent in the pre-hospital setting, intervention will occur in the pre-hospital setting prior to 
obtaining informed consent. Patients referred to primary PCI at Rigshospitalet are in an acute, vul-
nerable, and painful situation during transportation to the hospital, therefore, we find it acceptable 
to include and initiate the intervention in the pre-hospital setting before provision of informed con-
sent. The study medicine (methylprednisolone) is a known and well-described drug used in several 
acute settings and is therefore considered safe without any harm/risks to the patient. Additionally, 
time from medical contact to intervention and treatment is pivotal to secure the best possible prog-
nosis of patients with STEMI. Thus, intervention in the pre-hospital setting without informed con-
sent ensure no delay of the urgent treatment of the patient’s medical condition.  

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9.2 Informed Consent 
Up to 92.5% of patients with STEMI will be stable, without chest pain, and able to provide in-
formed consent as soon as possible following the acute treatment with primary PCI. Following the 
acute phase, a study nurse or one of the investigators will provide detailed and thorough infor-
mation about the study and obtain informed consent from the patient (signature of the ICF). Signa-
ture of ICF is designed and encrypted in REDCap and will be signed in REDCap following in-
formed consent. The patient will provide informed consent as soon as possible following the acute 
initial treatment (primary PCI), once the patient is stable. The right to withdraw informed consent at 
any time will be emphasized to the patient. If the patient does not wish to participate in the study, 
the data collection of the patient will be stopped immediately.  
In the remaining 7.5% patients with STEMI unable to provide informed consent following 
primary PCI, consent will be obtained by the legally designated representative who will sign the 
ICF. The legally designated representative consent will be followed by informed consent and signa-
ture of the ICF by the patient, once the patient is stable and able to provide consent. If the patient 
remains unable to provide informed consent 3 days following admission, the closest relative to the 
patient and legally designated representative will provide consent on behalf of the patient and sign 
the ICF as soon as possible. The patient will subsequently provide informed consent as soon as pos-
sible. In cases of death prior to informed consent, the legally designated representative will provide 
informed consent as soon as possible. The closest relative will be informed about participation in 
the study including the use of the patient’s data in relation to the study. Further, the closest relative 
will be informed of the patient’s right to discontinue from the study at any time. In case of any ob-
jection or unwillingness towards participation in the study, the patient will then be excluded from 
the study. However, medical records of the patient following death informed consent will be 
checked for causes of death to ensure no relation to the study medicine.  
The informing doctor/study nurse will ensure:  
1. Each patient is given full and adequate oral and written information about the nature, pur-
pose, possible risk, and benefit of the study, 
2. The patient is aware of the right to discontinue from the study at any time,  
3. The patient is given the opportunity to ask questions about the study.  
 

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9.2.1 In the Emergency Situation  
The inherent acute nature of the study necessitates circumvention of the usual requirements of a 24-
hour time for consideration, as it has previously been done in comparable acute studies e.g. AT-
LANTIC35, EUROMAX36, DANAMI-337, CONDI-2/EPIC-PPCI38, and DANEGAPTIDE39. This 
approach is reasonable because the intervention is without any known risk and because the inter-
vention has potential benefit for the individual patient.  
Up to 60% of patients with STEMI have reperfusion in the pre-hospital setting due to effec-
tive antithrombotic treatment with heparin and aspirin. To investigate the effect on glucocorticoid 
on reperfusion induced inflammation and injury, randomization and intervention is done in the pre-
hospital setting. Hence, intervention in the ambulance before reperfusion is needed to initiate the 
potentially beneficial and immediate nongenomic effects and subsequent protective genomic ac-
tions of pulse glucocorticoid therapy as soon as possible. Moreover, as demonstrated in previous 
trials, the potential effect of a treatment seems to be more pronounced if the treatment is initiated 
early after the onset of STEMI. In addition to reperfusion induced inflammation, ischemia itself, 
immediately after occlusion of the artery, induces inflammation. Hence, initiation of the interven-
tion is needed as close to the debut of symptoms as possible to inhibit the inflammation adequately 
and effectively in relation to STEMI. Thus, by performing intervention in the pre-hospital setting, 
we expect that participation in the trial will have the potential to produce a direct clinically relevant 
benefit for the patient resulting in a measurable health-related improvement alleviating the suffering 
and potentially improving the health of the patient and the prognosis of the medical condition. 
Moreover, the trial relates directly to the patient’s medical condition and it is not possible to obtain 
prior informed consent from the patient and to supply prior proper information about the trial due to 
the acute nature of STEMI. Therefore, the trial is of such nature that it may be conducted solely in 
emergency situations. This encounters that the usual requirements about a 24-hour time for consid-
eration and discussion with a lay representative cannot be met. We are aware of this relationship, 
which we found reasonable to deviate from.  
Patients with STEMI are unable to provide prior informed consent and receive prior infor-
mation on the clinical trial, as STEMI is a sudden, life-threatening, and serious medical condition 
requiring urgent treatment. Most of patients with STEMI treated with primary PCI at Rigshospita-
let, Denmark have less than 30 minutes of transportation to the hospital. Therefore, it is not possible 
within the therapeutic window to supply all prior information about the trial and obtain prior in-
formed consent. The including RD is continuously in touch with the paramedic in the ambulance by 

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telephone from the time of screening until randomization has been done. The including RD has all 
necessary information about the patient through medical records to ensure that the patient does not 
have any objections towards participating in the trial. In addition, the trial and intervention pose 
minimal risk and burden on the patient in comparison with standard treatment of the patient’s con-
dition, as Solu-Medrol (methylprednisolone) is a well-known and thorough investigated drug of 
minimal risk if administrated as a single dose administration.  
Most of patients with STEMI will be able to provide informed consent and receive adequate 
information about the trial as soon as possible following the acute treatment. Continuation of partic-
ipation in the trial will therefore be ensured with adequate information and informed consent as 
soon as possible following the acute treatment.  
The Principal Investigator(s) will ensure: 
1. Each patient will give informed consent based on the ICF as soon as possible following the 
acute treatment (primary PCI) including signature of the ICF.  
2. In patients who are unable to provide informed consent as soon as possible following the 
primary PCI procedure, informed consent will be obtained by the legally designated repre-
sentative including signature of the ICF followed by informed consent from the patient as 
soon as possible.  
3. In patients who remain unable to provide informed consent 3 days following admission, the 
legally designated representative and nearest relative will provide informed consent and sig-
nature of the ICF on behalf of the patient. Informed consent from the patient will subse-
quently be obtained as soon as possible.   
4. In patients who do not wish to participate in the study, the data collection of the patient will 
be stopped immediately. 
5.  In cases of death prior to informed consent, the legally designated representative will pro-
vide informed consent as soon as possible. The closest relative will be informed about par-
ticipation in the study including the use of the patient’s data in relation to the study. In case 
of any objection or unwillingness towards participation in the study, the patient will then be 
excluded from the study. 
6. All signed ICFs are encrypted and kept in REDCap. 
7. A copy of the signed ICF is offered to the patient.  
 
  

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9.3 Benefits and Risks 
The expectation of the trial is, that administration of 250 mg methylprednisolone in the pre-hospital 
setting will reduce the infarct size and thereby better prognosis in patients with STEMI undergoing 
primary PCI. The patients included in the study will have a closer medical control due to participa-
tion and detailed follow-up, however, there is no guarantee that the individual participants achieve 
any benefits from participating in the trial. The study will not delay or interfere with standard thera-
peutic or diagnostic procedures. Only patients who consent are included in the trial.   
 
The infusion of methylprednisolone needs to be administrated in the acute phase in the pre-
hospital setting before primary PCI in order to alleviate the inflammatory response following reper-
fusion. Intervention in the pre-hospital setting before informed consent is therefore needed. 
Methylprednisolone is easy to administrate, has an acute effect, and implementation of methylpred-
nisolone administration in the pre-hospital setting is feasible to be a part of the routine clinical care 
of patients with STEMI undergoing primary PCI. The study medicine is approved and recom-
mended in other medical conditions and is expected to be of minimal risk to patients. If successful, 
the increased knowledge on the therapeutic beneficial potential of methylprednisolone will 1) in-
crease scientific knowledge, and 2) improve clinical outcomes in patients with STEMI by reducing 
the number of cardiac deaths and reducing the number of patients with HF following STEMI. The 
information gathered from this study may therefore help future patients and change future clinical 
guidelines.  
10. Statistics  
The data management work up and statistical analyses will be performed at Rigshospitalet, Copen-
hagen University Hospital, Denmark.  
 
10.1 Power Calculations 
The primary endpoint is final infarct size (% of left ventricle mass) measured by LGE on CMR at 3 
months. Based on results of the CMR sub-studies of the DANAMI-3 trial40-45, the mean final infarct 
size measured by LGE on CMR is 13% with a standard deviation (SD) of 9% in patients with 
STEMI. To demonstrate a relative reduction in final infarct size of 20% with a two-sided alpha 
level of 0.05 and a power of 80%, recruitment of 378 patients is needed. A drop-out rate of 40% is 
expected for the primary endpoint. Therefore, we expect to randomize 530 patients in total. How-
ever, patients will be included until 378 patients have completed the CMR at 3 months. The power 
calculations have been calculated by a biostatistics professor. 

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10.2 Statistical Analysis 
For patients fulfilling all in- and exclusion criteria, the treatment groups will be compared as inten-
tion-to-treat principle. Additional as-treated analyses will be performed. Patients included that sub-
sequently are excluded due to meeting exclusion criteria will be considered screen failure. These 
patients will still be followed for safety reasons. Differences between group means/medians will be 
assessed with parametric or non-parametric statistics accordingly. Chi-square analysis or Fisher’s 
exact test will be used to test differences between categorical variables. Differences between groups 
in the time-to event secondary endpoints will be assessed using Kaplan-Meier and Cox regression 
model. In case of an event or until last patient has been followed, the patients will be censored. 
Probability of survival will be displayed using Kaplan-Meier methodology. Hazard ratios between 
groups will be calculated using a Cox proportional hazard model. A two-tailed P-value <0.05 is 
considered statistically significant.  
 
10.3 Pre-specified Subgroup Analyses 
The primary endpoint will be compared between treatment groups in pre-specified subgroup anal-
yses: age, gender, pre-PCI TIMI flow, culprit in LAD, time from first medical contact to primary 
PCI, and duration from symptom to primary PCI. These subgroups will be analyzed using interac-
tion tests. The pre-specified subgroups are factors that are known to influence the clinical course in 
patients with STEMI. 
11. Sub-study 
Prior studies have shown that reperfusion injury following primary PCI in patients with STEMI is 
equivalent to damage in the microcirculation causing microvascular dysfunction. The microvascular 
function can be investigated by thermodilution-derived parameters including CFR and IMR as well 
as absolute flow and absolute resistance. Prior studies in STEMI patients have shown that IMR has 
a prognostic value and correlates to MVO. Glucocorticoid may limit reperfusion injury by decreas-
ing the inflammatory response in direct proximity to the microcirculation. To investigate this hy-
pothesis, we will measure CFR and IMR on eligible patients included in PULSE-MI directly after 
initial primary PCI but before the catheter is removed.  
 
CFR and IMR is measured by a pressure gauge wire and a 2-minute infusion of adenosine. 
This procedure will only prolong the normal PCI by 5 minutes and does not add any additional risk 
to the procedure and does not increase the risk of complications. The patient may experience a brief 

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feeling of shortness of breath during the infusion of adenosine but is not associated with other com-
plications or side effects. Adenosine is often used in standard coronary angiography (CAG) and PCI 
procedure.  
12. Data Storing and Handling of Personal Data 
All study data will be stored pseudo-anonymously for 25 years. Data of the included patients with 
STEMI will be stored at an electronic database, RedCap, where data will be blinded, and patients 
will be identified by a study identification number only. Study participation will be annotated in the 
medical record of the patient.  
13. Assessments of Safety and Harm  
Mortality following STEMI has decreased after implementation of primary PCI and drug-eluting 
stents (DES), yet the 1-year mortality rate has unsatisfactorily plateaued at approximately 10%. Pri-
mary PCI is performed daily at Rigshospitalet, Copenhagen University Hospital, and the risks asso-
ciated with the procedure is well known. STEMI is often complicated by a myocardial dysfunction 
leading to HF and arrhythmias during the acute phase. However, mechanical complications such as 
free wall rupture, ventricular septal rupture, and papillary muscle rupture may also occur in the set-
ting of STEMI10. These complications are well known, and, as part of standard care, an echocardi-
ography is performed in all patients admitted for primary PCI to assess potential mechanical com-
plications and the function of the left and right ventricle. AEs/SAEs potentially related to the inter-
vention of the study will include: death, infection, gastroduodenal ulcer, hypertension, fluid reten-
tion resulting in peripheral edema, anaphylaxis, and skin complications such as acne, atrophy, pur-
pura, and wound healing complications. The half-life of methylprednisolone is 12 hours, and the 
drug is considered eliminated following 5 half-times. Therefore, AEs will be recorded for the first 3 
days following intervention. 
 
13.1 Adverse Events (AEs) 
AEs are considered any untoward medical occurrence in the patient to whom intervention 
(methylprednisolone) has been administrated and which does not necessarily have a causal relation-
ship with this treatment. The AEs that will be recorded is infection and any skin complications. 
 

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13.2 Serious Adverse Events (SAEs) 
The Principal Investigator and other Investigators will report all SAEs to Sponsor within 24 hours 
of awareness. All SAEs are any toward medical occurrence that at any dose requires inpatient hos-
pitalization or prolongation of existing hospitalization, results in persistent or significant disability 
or incapacity, results in a congenital anomaly or birth defect, is life-threatening, or results in death.  
All SAEs occurring from the time the study medicine has been administrated until the pa-
tient has completed the trial will be reported by filling out and sending the SAE form within 24 
hours, after the investigator becomes aware that the event meets the protocol definition of an SAE. 
Patients will therefore be followed for late-onset SAEs until completion of the trial (1 year).  
 
Hospitalization and prolongation of hospitalization is defined as presentation at hospital for 
an urgent, unscheduled emergency department visit or hospital admission (>24 hours). 
In the electronic database, REDCap, the following events will be reported: Death, hospitali-
zation for heart failure, recurrent AMI, stroke/TIA, bleeding, and cardiac arrhythmia.  
 
13.3 Suspected Unexpected Serious Adverse Reactions (SUSARs) 
A SUSAR is defined as a suspected, serious adverse reaction, the nature, severity, or outcome of 
which is not consistent with the reference safety information. ‘Unexpected’ reactions are defined 
using the summary for product characteristics (SPC) for Solu-Medrol32. Sponsor of the trial will be 
registered in the EudraVigilance system prior to initiation of the trial and is responsible of reporting 
any SUSARs to the EudraVigilance systemand the ethics committee as soon as possible, at latest 7 
days following awareness of event if life-threatening. If the SUSAR is not life-threating the event 
will be reported at latest 15 days following awareness of the event. 
14. Finance and Insurance 
This study is investigator-initiated, and the study will be funded by external foundations for medical 
research. No funding has been obtained at present time. Sponsor is responsible for funding the costs 
of the trial until funding has been achieved. When funding is achieved, the ethics committee will be 
noticed. The preliminary budget of the study is approximately 6.2 million DKK.  
 
All patients participating in the trial are insured by the Patient Compensation Association 
and the Danish patient insurance.  

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15. Publication 
All results (positive, negative, or inconclusive) will be published in international peer-reviewed 
journals. The data will also be presented at national and international congresses. No participants 
will be identified in any reports or publications. All analyses will be conducted by the investigators 
of the trial. The trial will not be unblinded until acceptance from the steering committee. The publi-
cation policy of the trial data will be uploaded to the Clinical Trials Information System (CTIS) da-
tabase within one year after end of trial in accordance with Clinical Trial Regulation 536/2014 An-
nex IV. 
 
The authorship order: Dr. Jasmine Melissa Madsen will be first author and Dr. Jacob 
Lønborg and Professor Thomas Engstrøm will be shared last author. The following authorships will 
be granted in according to ICMJE guidelines. However, all co-investigators will be offered author-
ship.  
16. Annual Safety Report 
Throughout the whole study, annual safety reports will be uploaded to the CTIS database every 
year. Annual safety reports will not be sent in the period between trial completion and the 10 years 
follow up on mortality and hospitalization of HF.  
 
 
 

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1. 
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic 
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Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, et al. ST-segment 
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Nepper-Christensen L, Lønborg J, Høfsten DE, Sadjadieh G, Schoos MM, Pedersen F, et al. 
Clinical outcome following late reperfusion with percutaneous coronary intervention in 
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Heusch G, Gersh BJ. The pathophysiology of acute myocardial infarction and strategies of 
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Appendix A (Cardiac Magnetic Resonance Protocol and Endpoints) 
 
Purpose:  
• To describe the cardiac magnetic resonance (CMR) imaging scan for the PULSE-MI trial.  
• To determine final infarct size by late gadolinium enhancement (LGE) on CMR 3 months 
after ST-Segment Elevation Myocardial Infarction (STEMI).  
 
Setting:  
All CMR scans will be performed at Rigshospitalet, Copenhagen University Hospital, Denmark.  
 
Key points 
The CMR scanner is of 1.5 Tesla field strength with a standard phased array cardiac surface coil.  
The CMR scans should be performed twice post-STEMI. The first scan will be performed within 48 
hours (Acute scan), and the second scan will be performed 3 months following STEMI (Follow-up 
scan).  
Acute scan: The acute scan will be performed preferably within 48 hours of STEMI due to logistics 
at Rigshospitalet, Denmark. However, there is no set upper limit to the time from index event to 
scan, as long as it is performed within 5 days of index event (acute phase).   
Follow-up: The follow-up scan should be performed as close to 3 months following the index event 
as possible.  
The primary endpoint of the study is final infarct size (% of the left ventricle (LV) mass) measured 
by LGE on CMR 10-15 minutes after gadolinium contrast (0.15 mmol/kg) is given. 
 
CMR set-up: 
CMR will only be performed in patients who have given written and oral informed consent and if 
no contraindications exist. The patient will undergo a CMR safety check including renal function 
prior to scan.  
Contraindications to CMR in the study: Ferrous metal foreign body, severe claustrophobia, 
decreased renal function (eGFR <30 ml/min).  
Patients will be profoundly prepared and informed about the CMR scan. Following the scan, 
patients will be briefed shortly of the findings.  
 

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CMR protocol (Acute and Follow-Up Scan): 
1 
Patient preparation 
2 
Localizers and planning  
3 
Cine long axis (2ch, 3ch, 4ch) 
Short axis (SA) localizer of ventricles and subsets (basal, mid, apical) 
4 
Cine para-coronal 
5 
T1-mapping pre-contrast (SA subsets)  
6 
T2* pre-contrast (full LV-coverage) 
7 
Contrast: 0.15 mmol/kg 
8 
Dynamic rest 
9 
Function, SSFP (SAX-stack, full LV-coverage) 
10 
Late gadolinium enhancement (SAX-stack, 2ch, 3ch, 4ch).  
11 
Aortic flow rate 
12 
Patient Briefing 
 
Contrast administration: 
The Intravenous contrast agent is gadobutrol (Gadovist®, Bayer; 1.5 mmol/ml solution for injection) 
which will be administrated in one single-dose. The dose will be given as 0.15 mmol/kg. An auto-
mated pump injector will be used for intravenous injection of Gadovist. The amount of isotonic sa-
line (0.9%) given with Gadovist is double the amount of contrast given (0.30 mmol/kg).  
 
Poor breath-holding: 
In patients with poor breath-holding, compressed sense sequences will be used to conduct CINE im-
ages. These sequences are free breathing.   
 
CMR endpoints 
The primary efficacy parameter for the clinical trial is the amount of infarct size (% of LV mass) re-
vealed by LGE 10-15 minutes after contrast administration on CMR performed 3 months following 
STEMI.  
 

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Acute CMR  
• Microvascular obstruction on LGE (presence/absence)  
• Extent of MVO on LGE  
• Infarct size on LGE  
• Area at risk  
• Extent of edema  
• Initial myocardial salvage index (acute infarct size/area-at-risk) 
• LV ejection fraction (LVEF)  
• Hemorrhage 
Follow-up CMR 
• Final infarct size (Primary endpoint) 
• Myocardial salvage index (final infarct size/area at risk) 
• Change in infarct size 3 months after procedure 
• LVEF  
• Change from baseline LVEF to follow-up LVEF 
 
Analyses of CMR 
All analyses will be performed in Circle Cardiovascular Imaging (CVI42).  
 
 

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Appendix B (End-point Definitions) 
The clinical event committee (CEC) will review and adjudicate all occurrences of the clinical end-
points according to the 2014 ACC/AHA Key Data Elements and Definitions for Cardiovascular 
Endpoint Events in Clinical Trials46.  
1. All-Cause Mortality  
2. Recurrent Myocardial Infarction  
3. Hospitalization for Heart Failure 
4. Stroke/TIA 
 
Mortality will to the extent possible be classified according to underlying disease. The CEC will 
classify the mortality as cardiovascular or non-cardiovascular death.  
 
Cardiovascular mortality 
Mortality considered as cardiovascular unless it is clearly attributable to another cause and thus in-
cludes: 
• Death due to proximate cardiac cause (e.g. myocardial infarction, cardiac tamponade, 
worsening heart failure).  
• Death caused by non-coronary vascular conditions such as neurological events, pulmo-
nary embolism, ruptured aortic aneurysm, dissecting aneurysm, or other vascular dis-
ease.  
• All procedure-related deaths, including those related to a complication of the procedure 
or treatment for a complication of the procedure.  
• All valve-related deaths including structural or non-structural valve dysfunction or other 
valve-related adverse events.  
• Sudden or unwitnessed death.  
• Death of unknown cause. 
 
Non-cardiovascular mortality 
Any death in which the primary cause of death is clearly related to another condition (e.g. infection, 
cancer, suicide, accident, pulmonary, hepatobiliary, gastrointestinal, renal, overdose, neurological 
(excluding stroke and or cardiovascular hemorrhage of central nervous system). 
 

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Hospitalization for heart failure is prolongation of hospitalization because of worsening of heart 
failure or presentation of the patient for an urgent, unscheduled clinic/office/emergency department 
visit or hospital admission (>24 hours), with a primary diagnosis of heart failure (HF), AND 
where the patient exhibits new or worsening symptoms of HF on presentation, AND 
has objective evidence of new or worsening HF*, AND 
receives initiation or intensification of treatment specifically for HF.  
 
*Objective evidence consists of at least 2 physical examination findings OR at least 1 physical ex-
amination finding and at least 1 laboratory criterion (chest x-ray or BNP) of new or worsening HF 
on presentation. 
 
Table 3. Value definition heart failure 
Values 
Value definition 
     New or worsening symptoms of HF 
 
Dyspnea 
Decreased exercise tolerance 
Fatigue 
Volume overload 
     Objective evidence of new or worsening HF 
Either at least one on physical exanimation: 
Peripheral edema 
Increasing abdominal distention or ascites 
Pulmonary rales/ crackles/crepitations 
Increased jugular venous pressure and/ or hepa-
tojugular reflux 
S3 gallop 
Clinically significant or rapid weight gain 
Or at least on laboratory criterion: 
Biomarker increases BNP/ NT-pro BNP (> up-
per reference limit). In patients with chroni-
cally elevated natriuretic peptides, a significant 
increase above baseline is required. 

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Radiological evidence of pulmonary conges-
tion: imaging findings consistent with in-
creased intravascular blood volume in the 
lungs. 
     Receives initiation or intensification of 
treatment specifically for HF 
Augmentation of oral diuretic therapy 
Intravenous diuretic, inotrope, or vasodilator 
therapy 
Mechanical or surgical intervention including 
any LV assist device and mechanical fluid re-
moval 
 
 
 
 

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Appendix C (the PULSE-MI committee members and investigators) 
Steering committee: 
Dr. Jacob Lønborg, MD, PhD, DMSc (Principal Investigator)  
Dr. Jasmine Melissa Madsen, MD (Co-Principal Investigator)  
Prof. Thomas Engstrøm, MD, PhD, DMSc (Co-Principal Investigator) 
 
Sub-Investigators:  
Dr. Laust Obling, MD 
Dr. Charlotte Barfod, MD, PhD 
Dr. Lars Bredevang Andersen, MD 
Dr. Niels Vejlstrup, MD, PhD 
Dr. Lia Evi Bang, MD, PhD 
 
Data management committee:  
Dr. Jasmine Melissa Madsen, MD  
 
Writing committee:  
According to publication charter (TBD) 
 
Clinical event committee (CEC):  
TBD 
 
Data Safety Monitoring Board (DSMB): 
Lars Køber (suggested) 
Nico Pijls (suggested) 
Won Yong Kim (suggested)