Prehospital Pulse-dose Glucocorticoid in Patients With ST-segment Elevation Myocardial Infarction 2 - The PULSE-MI 2 Trial
Phase: PHASE3
Conditions: STEMI - ST Elevation Myocardial Infarction
Sponsor: Thomas Engstrom

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Dept. of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark 
Dept. of Cardiology, Aarhus University Hospital, Aarhus, Denmark 
Dept. of Cardiology, Odense University Hospital, Odense, Denmark 
Dept. of Cardiology, Aalborg University Hospital, Aalborg, Denmark 
 
Version: 2 
Date: 24-02-2026 
EU-CT number: 2025-524320-21-00 
 
 
 
PREHOSPITAL PULSE-DOSE GLUCOCORTICOID IN PATIENTS WITH ST-SEG-
MENT ELEVATION MYOCARDIAL INFARCTION 2 – THE PULSE-MI 2 TRIAL 

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Table of Contents 
1. ABBREVIATIONS ........................................................................................................................ 5 
2. BACKGROUND ............................................................................................................................ 8 
3. HYPOTHESIS AND AIM ........................................................................................................... 10 
4. CLINICAL RELEVANCE.......................................................................................................... 10 
5. TRIAL SETUP ............................................................................................................................. 10 
5.1 TRIAL DESIGN ................................................................................................................................ 10 
5.2 TARGET PATIENT POPULATION AND NUMBER OF PATIENTS ........................................................... 11 
5.3 TRIAL SETTING .............................................................................................................................. 11 
5.4 ESTIMATED STUDY DURATION ....................................................................................................... 11 
5.5 INCLUSION AND EXCLUSION CRITERIA ........................................................................................... 12 
6. TRIAL PROGRESS AND CONDUCT...................................................................................... 13 
6.1 SCREENING AND INCLUSION ........................................................................................................... 13 
6.2 RANDOMIZATION ........................................................................................................................... 14 
6.3 STUDY MEDICINE AND PLACEBO .................................................................................................... 14 
6.4 BLINDING ....................................................................................................................................... 15 
6.4.1 EMERGENCY UNBLINDING ........................................................................................................................ 16 
6.5 REGISTRATION .............................................................................................................................. 16 
6.6 DOSAGE ADJUSTMENTS .................................................................................................................. 17 
6.7 DISCONTINUATION OF STUDY PARTICIPATION ............................................................................... 17 
6.8 CONCOMITANT PROCEDURES......................................................................................................... 17 
6.8.1 ACUTE CAG AND PRIMARY PCI PROCEDURE ........................................................................................... 17 
6.8.2 ACUTE CORONARY ARTERY BYPASS GRAFT (CAGB) ................................................................................. 17 
6.8.3 FOLLOW-UP MEDICAL TREATMENT ......................................................................................................... 17 
6.8.4 FOLLOW-UP............................................................................................................................................. 18 
7. ENDPOINTS ................................................................................................................................ 18 

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7.1 ENDPOINT DEFINITION ................................................................................................................... 19 
7.2 ENDPOINT RECORDING .................................................................................................................. 19 
7.3 MONITORING ................................................................................................................................. 19 
8. ETHICAL ASSESSMENT .......................................................................................................... 20 
9. ETHICAL CONSIDERATIONS ................................................................................................ 20 
9.1 ETHICAL CONDUCT OF THE STUDY ................................................................................................ 20 
9.2 INFORMED CONSENT ...................................................................................................................... 21 
9.2.1 LEGALLY DESIGNATED REPRESENTATIVE ................................................................................................. 22 
9.2.2 IN THE EMERGENCY SITUATION ................................................................................................................ 23 
9.3 BENEFITS AND RISKS...................................................................................................................... 24 
10. STATISTICS .............................................................................................................................. 25 
10.1 DATA MANAGEMENT ................................................................................................................... 25 
10.2 POWER CALCULATIONS AND SAMPLE SIZE .................................................................................. 25 
10.3 ANALYSIS POPULATIONS .............................................................................................................. 26 
10.3.1 INTENTION-TO-TREAT (ITT) .................................................................................................................... 26 
10.3.2 ADDITIONAL KEY ANALYSIS ..................................................................................................................... 26 
10.4 STATISTICAL ANALYSIS................................................................................................................ 26 
10.4.1 MISSING DATA ....................................................................................................................................... 27 
10.3 PRE-SPECIFIED SUBGROUP ANALYSES .......................................................................................... 27 
11. DATA STORING AND HANDLING OF PERSONAL DATA ............................................ 27 
11.1 SERIOUS BREACHES ..................................................................................................................... 27 
12. ASSESSMENTS OF SAFETY AND HARM .......................................................................... 27 
12.1 ADVERSE EVENTS (AES)............................................................................................................... 28 
12.2 SERIOUS ADVERSE EVENTS (SAES) .............................................................................................. 28 
12.3 SUSPECTED UNEXPECTED SERIOUS ADVERSE REACTIONS (SUSARS) ........................................... 29 
13. FINANCE AND INSURANCE ................................................................................................. 29 

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14. PUBLICATION ......................................................................................................................... 29 
15. ANNUAL SAFETY REPORT .................................................................................................. 30 
APPENDIX B (THE PULSE-MI 2 COMMITTEE MEMBERS AND INVESTIGATORS) ... 35 
APPENDIX B (STATISTICAL ANALYSIS PLAN) .................................................................... 36 
 
 
 
 

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1. Abbreviations  
AEs 
 
 
Adverse Events 
CAG  
 
Coronary Angiography 
CABG  
            Coronary Artery Bypass Graft 
CEC 
 
 
Clinical Event Committee 
ECG  
 
Electrocardiogram 
GCP  
 
Good Clinical Practice 
ICF 
 
 
Informed Consent Form 
ICU 
 
 
Intensive Care Unit 
LVEF   
 
Left Ventricular Ejection Fraction 
PCI 
 
 
Percutaneous Coronary Intervention 
PPJ 
 
 
Prehospital Patient Journal 
PULSE-MI 
Prehospital Pulse Glucocorticoid Therapy in Patients with ST-Segment Eleva-
tion Myocardial Infarction Trial 
RD 
 
 
Referring Cardiology Fellow Doctor 
SAEs  
 
Serious Adverse Events 
STEMI 
 
ST-segment elevation myocardial infarction  
SUSARs 
 
Suspected Unexpected Serious Adverse Reactions 
TIMI  
 
Thrombolysis In Myocardial Infarction  
 
 

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Designation of investigational treatments 
Prehospital pulse-dose glucocorticoid in patients with ST-segment elevation myocardial infarction (STEMI) trans-
ferred for acute coronary angiography  
Title of the trial  
Prehospital pulse-dose glucocorticoid in patients with STEMI – the PULSE-MI 2 trial 
Principal Investigators  
Jacob Thomsen Lønborg, Associate Professor, MD, PhD, DMSc (Dept. Of Cardiology, Rigshospitalet, Copenhagen 
University Hospital, Denmark) 
Christian Juhl Terkelsen, Professor, MD, PhD, DMSc (Dept. Of Cardiology, Aarhus University Hospital, Denmark) 
Lisette Okkels Jensen, Professor, MD, PhD, DMSc (Dept. Of Cardiology, Odense University Hospital, Denmark) 
Ashkan Eftekhari, MD, PhD (Dept. Of Cardiology, Aalborg University Hospital, Denmark) 
Study Centers 
Rigshospitalet, Copenhagen University Hospital; Aarhus University Hospital; Odense University Hospital; Aalborg 
University Hospital 
Planned Study Period 
2026-2036 
Objectives 
The aim of this nationwide trial is to evaluate the effect of prehospital pulse-dose glucocorticoid on all-cause mortality 
compared to placebo in patients with STEMI 
Methodology  
Prior to informed consent, patients will be randomized in the prehospital setting in a 1:1 fashion to either pulse-dose 
glucocorticoid (250 mg methylprednisolone) or placebo. A nationwide, randomized, blinded, placebo-controlled, mul-
ticenter trial.  
Number of patients 
A total of 5204 patients with 2602 in the glucocorticoid group and 2602 in the placebo group.  
Inclusion Criteria 
1. Age ≥18 years including fertile women* 
2. Acute onset of chest pain with < 24 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 elevation 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 indicating posterior acute myocardial infarction, 
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 

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*It is not possible to perform a pregnancy test (HCG urine test) in the prehospital setting. However, methylprednisolone is not 
contraindicated in pregnant women. 
Exclusion Criteria 
1. Suspected other than type I acute myocardial infarction at time of potential randomization 
2. Initial presentation with cardiac arrest (out-of-hospital cardiac arrest) 
3. Known allergy to glucocorticoid 
Primary Outcome 
All-cause mortality until the last included patient has been followed for 1 year 

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2. Background 
ST-segment elevation myocardial infarction (STEMI) remains a leading cause of global all-cause 
mortality despite significant advances in reperfusion therapies with timely primary percutaneous cor-
onary intervention (PCI)1. One-year mortality after STEMI has decreased to around 8%, yet a sub-
stantial number of patients still develop heart failure, which entails high morbidity and an increased 
risk of cardiovascular mortality2. Moreover, high-risk patients with STEMI, such as patients present-
ing with cardiogenic shock, continues to have a 50% risk of death within the first year3.  Therefore, 
while overall mortality after STEMI have decreased, the most critically ill patients continue to have 
a very poor survival probability, primarily driven by cardiovascular causes such as arrythmia and 
cardiogenic shock4.  
Inflammation is induced immediately after the onset of acute myocardial ischemia and is sub-
sequently exacerbated following reperfusion5. Hence, inflammation in the setting of STEMI is a piv-
otal factor in both acute myocardial ischemia and the subsequent healing of the infarcted myocar-
dium, which is why inflammation per se is a feasible and desirable target for improving prognosis in 
these patients. Nevertheless, inflammation may constitute both favorable and deleterious effects in 
patients with STEMI6. On one hand, the inflammatory response induced after STEMI may serve a 
protective and healing role favorable for the infarcted myocardium6. On the other hand, residual in-
flammation and in particular the acute burst of inflammation in the early phase of STEMI may con-
tribute to excessive cardiomyocyte death, adverse remodeling, and recurrent major adverse cardiac 
events6,7. When targeting inflammation in STEMI as a therapeutic strategy, it therefore remains cru-
cial to inhibit the deleterious inflammatory response without compromising the protective inflamma-
tory effects.  
Glucocorticoids are crucial in regulation of the systemic inflammatory response and may 
therefore be beneficial in limiting myocardial injury after STEMI8. If given in high doses, glucocor-
ticoids mediate two different mechanisms: the genomic effect mediated by glucocorticoid receptor 
occupation, gene transcription, 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 mem-
brane bound receptors and independent of cytosolic receptor occupation and genomic regulation9. 
Some of the proposed nongenomic effects of glucocorticoids on the cardiovascular system include 
decreased vascular inflammation and reduced infarct size by activating the endothelial nitric oxide 
synthase, cardioprotection through membrane stabilization through nitric oxide production, and in-
creasing the contractility of the vascular smooth muscle cells9. Taken altogether, the non-genomic 

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actions secure that the anti-inflammatory effect is initiated quickly to protect the myocardium imme-
diately whereas, in addition, the genomic actions protect 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, gluco-
corticoids showed beneficial effects on hemodynamics and infarct size following ischemia, however 
most studies were performed in non-reperfused animals10–12. Albeit this, clinical studies in patients 
with STEMI have shown conflicting results10–12. However, these studies performed in patients with 
STEMI were before the era of primary PCI10, and since the implementation of PCI, the prognosis in 
these patients has improved significantly1. Therefore, we conducted a phase-II randomized, placebo-
controlled, clinical trial (PULSE-MI) investigating the effect of prehospital pulse-dose glucocorticoid 
on final infarct size in patients with STEMI transferred for acute coronary angiogram (CAG)13. The 
trial was conducted between November 2022 and October 2023, and in 742 patients with STEMI 
randomized in the prehospital setting, pulse-dose glucocorticoid deemed safe and showed acute ben-
eficial effects on left ventricular ejection fraction (LVEF), infarct size, and microvascular obstruc-
tion14. Moreover, there was a trend towards a lower incidence of both all-cause mortality (7 (3%) vs 
13 (5%)) at three months in patients treated with glucocorticoid compared to placebo (Figure 1)14.  
 
Figure 1. All-cause mortality in patients included in PULSE-MI 
 

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As this was a phase II trial, the trial was not powered to detect differences in clinical outcomes. 
Therefore, it remains to be proven whether prehospital pulse-dose glucocorticoid in patients with 
STEMI transferred for acute CAG will translate into reduced mortality after STEMI.  
 
3. Hypothesis and Aim 
In patients with STEMI, single-pulse-dose glucocorticoid (250 mg methylprednisolone) adminis-
trated in the prehospital setting reduces mortality after STEMI. Thus, the aim of this prospective, 
randomized trial is to evaluate the effect of prehospital pulse-dose glucocorticoid in patients with 
STEMI.  
 
4. Clinical Relevance 
A Continued aim to improve the prognosis after STEMI is pivotal as it remains one of the leading 
causes of death worldwide. The main cause of death in patients with STEMI is cardiovascular due to 
myocardial damage leading to either arrythmia or fatal heart failure. Thus, inflammation serves as a 
key factor, and inhibiting the acute, deleterious inflammatory response without compromising the 
subsequent protective inflammatory response may be crucial to improve the prognosis in patients 
with STEMI. The proof-of-concept trial (PULSE-MI) showed acute beneficial effects of prehospital 
glucocorticoid in patients with STEMI, and patients treated with glucocorticoid had numerically 
lower incidence of all-cause mortality at three months14. As this was a phase-II trial and not powered 
to detect differences in clinical outcomes, this present and adequately powered trial addresses whether 
prehospital pulse-dose glucocorticoid improves survival in patients with STEMI.  
 
5. Trial Setup 
5.1 Trial Design 
This multicenter trial is an investigator-initiated, 1:1 randomized, blinded, placebo-controlled clinical 
trial to investigate whether pulse-dose glucocorticoid (250 mg methylprednisolone) in the prehospital 
setting reduces all-cause mortality in patients with STEMI. The trial will be chaired at the Department 
of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark. Other sites include 
Odense University Hospital, Aarhus University Hospital, and Aalborg University Hospital.  
 

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5.2 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 with symptom onset within 24 hours. As done 
in the previous PULSE-MI trial13, randomization will be managed by an ambulance staff in the pre-
hospital setting and patients are included by the referring doctor (on-call cardiology fellow doctor 
(RD)). 
A total of 5204 patients with STEMI (2602 patients treated with intravenous infusion of glu-
cocorticoid (250 mg methylprednisolone) and 2602 patients with intravenous placebo infusion) will 
be included for the primary endpoint of all-cause mortality.  
 
5.3 Trial Setting 
Patients with STEMI will be included in the prehospital setting throughout all regions of Denmark 
prior to acute CAG at Rigshospitalet, Aarhus University Hospital, Odense University Hospital, or 
Aalborg University Hospital if eligible to participate in the study. Eligibility will be carefully 
screened by the RD at Rigshospitalet, Aarhus University Hospital, Odense University Hospital, or 
Aalborg University Hospital.  
 
5.4 Estimated Study Duration  
We expect the trial to begin once the trial has been approved by the ethical and legal authorities 
(estimated start/medio 2026). The trial will run in all four regions covering 6.0 million Danish citizens 
as of Q3 202515 and perform approximately 4000 acute CAG procedures per year. Inclusion is ex-
pected to be completed in 4 years. All patients will be followed for a minimum of 1 year.  
All primary and secondary outcomes will be assessed after the initial follow-up period defined 
as when the last patient has been followed for 1 year (planned 2031).  
After 10 years (planned 2036), patient charts will be assessed for vital status and hospitaliza-
tions.  
Expected study period: 
Start of trial: start/medio 2026  
End of initial follow-up: start/medio 2031 
Completion of overall follow-up: start/medio 2036 
Table 1. Schedule of activities 
 
2026 
2027 
2028 
2029 
2030 
2031 
2032-2036 
Assessed using 
Start of trial  
                   
 
 
 
 
 
 

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Inclusion period 
 
 
 
 
 
 
 
 
Initial follow-up 
 
 
 
 
 
 
 
Patient chart 
Primary analysis 
 
 
 
 
 
 
 
Patient chart 
Overall follow-up 
 
 
 
 
 
 
 
Patient chart 
 
 
Inclusion  Day 
1 
Day 
2 
Day 
3 
Day 
4 
Day 
5 
Day 
6 
Day 7 
 
AEs 
 
 
 
 
 
 
 
 
Patient chart 
SAEs 
 
 
 
 
 
 
 
 
Patient chart 
 
5.5 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 < 24 hours duration  
3. STEMI as characterized on electrocardiogram (ECG) by one of the following16:  
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 indicating posterior acute myocar-
dial infarction (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 
patient to be eligible: 
1. Suspected other type I acute myocardial infarction at time of potential randomization17 
2. Initial presentation with cardiac arrest (out of hospital cardiac arrest) 
3. Known allergy to glucocorticoid 
 
* It is not possible to perform a pregnancy test (HCG urine test) in the prehospital setting. However, methylprednisolone 
is not contraindicated in pregnant women. 

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6. Trial Progress and Conduct  
6.1 Screening and Inclusion 
As in the PULSE-MI trial13, screening, inclusion, and registration will be done in the ambulance in 
the prehospital setting. The including RD will carefully check the eligibility of the patient to partici-
pate in the trial. The including RD is continuously in touch with the ambulance staff in the ambulance 
by telephone from the time of screening until randomization has been done. The including RD has 
all the necessary information about the patient including previous medical history, actual medications, 
and clinical status. Clinical status includes patients’ general condition, blood pressure, heart rate, and 
ECG changes. Due to the acute nature of STEMI and the trial design, the qualifying ECG will be 
performed in the prehospital settings as normal procedure. These data will be used for eligibility 
evaluation by the including doctor (RD). The RD that is responsible for inclusion of the patient via 
telephone must ensure that there are no contraindications for administration of glucocorticoids as part 
of the eligibility check. The RD is responsible to ensure that the patient has not expressed any previ-
ous objection to participate in the trial. This information is available via the patient charts that will be 
assessed by the RD. If the including RD finds the patient eligible to participate in the study, the 
including RD will ask the ambulance staff to give the study medicine to the patient in the prehospital 
setting.  
In the prehospital setting, the ambulance staff will do the following:  
1. Include the patient in the study following eligibility check by the RD  
2. Randomize the patient by picking a random box from a storage in the ambulance containing 
the study medicine (glucocorticoid or placebo). All boxes are identical, and the ambulance 
staff is therefore blinded when randomizing 
3. Register the patient in an electronic database, REDCap (described in section 6.5) 
All patients, or the legally designated representatives (trial guardian and next of kin) must personally 
sign and date the informed consent form (ICF) as soon as possible following the acute treatment of 
the patient (primary PCI/acute coronary artery bypass graft (CABG)) (described in detail in section 
9.2). If patients remain unable to provide informed consent five 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 and ethical considerations are described thoroughly in section 9.2 and 9.2.1, respectively.  
 

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6.2 Randomization 
Randomization of the patient will take place in the prehospital setting. Patients who satisfy all the 
eligibility requirements will be randomized. Randomization is done by the staff in the ambulance. 
Patients will be randomized in a 1:1 ratio to either infusion of glucocorticoid (250 mg methylpredni-
solone) or placebo that are placed in identical boxes. The ambulance staff randomizes the patient by 
picking a random box stored in the ambulance delivered by the pharmacy, including glucocorticoid 
or placebo, and administrates (over a period of 5 minutes) the content as a bolus infusion. After infu-
sion of the study intervention, the ambulance will bring the box to the hospital alongside with ECGs 
obtained in the ambulance in case of need for emergency unblinding (described in detail in section 
6.4). All boxes are identical and has a unique box serial number. Once a patient has been randomized 
(i.e. a box is opened), the patient is considered included in the trial. The ambulance staff will ensure 
the following:  
1. Annotate the number of the study medicine box in the prehospital journal (PPJ) 
2. Take a picture of the study medicine box in the PPJ 
3. Bring the study medicine box to the hospital  
4. Register the patient by scanning QR-code on study medicine box  
The hospital staff and investigators will always have access to the PPJ of the patients. All RD’s and 
ambulance staff 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. In case of 
any technical issues (i.e. register the patient with QR-code), one of the investigators will be available 
by telephone. 
 
6.3 Study Medicine and Placebo 
Patients will be allocated to either infusion of glucocorticoid (250 mg methylprednisolone) or placebo 
that are placed in identical boxes. Each box will contain either methylprednisolone or placebo and 
each box will be numbered by the pharmacy. Administration of the study medicine will not prolong 
the transportation or any aspect of the standard treatment of the patient. The patients will be treated 
according to standard procedures in the ambulance. Primary PCI and antithrombotic regimens will 
be performed according to standard procedures. 
The numbers on the identical boxes are unique, and the pharmacy has the allocation list. The 
active 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 

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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 study medicine and placebo will be done over a period of 5 minutes 
during transportation.  
Following preparation of the study medicine boxes and before initiation of the trial, the boxes 
will be shipped to all the critical care unit stations in the respective regions. All units are manned 24 
hours 7 days a week. To ensure that all ambulances always have study medicine boxes in all ambu-
lance, the ambulance staff will pick up a new study medicine box from the receiving hospital personal 
following transfer of a randomized patient. 
 
6.4 Blinding 
The pharmacy of the Capital Region of Denmark will pack the boxes and label the study medicine 
and placebo ampoules. The randomization will be allocated by the pharmacy and their independent 
statistician 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 double-
locked in a safety cabinet in case of emergency unblinding. Sponsor and investigators are responsible 
for any emergency unblinding. Moreover, investigators can unblind the study medication without 
prior contact to the sponsor. See section 6.4.1 for the emergency unblinding procedure. According to 
the ICH-GCP guideline 4.3.1, the investigators are responsible for all trial-related medical decisions 
and may 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 ambulance 
staff is therefore unblinded after randomization, however, the ambulance staff will not take any fur-
ther part in the trial nor the treatment of the patient once arrived at the hospital.  
Ambulance personnel involved in the trial will receive thorough training prior to study initi-
ation. This will include structured presentations, teaching sessions, video and written instructions, 
including pocket cards, detailing the correct administration procedures and the importance of main-
taining allocation concealment. The training will specifically emphasize that information regarding 
treatment allocation must not be disclosed to the patient or to hospital staff. In addition, the study 
medication will be administered immediately after standard prehospital medication given as part of 
routine care. As the study procedures are integrated into the existing clinical workflow and do not 
significantly alter standard clinical practice. 
 

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6.4.1 Emergency Unblinding  
Information regarding treatment allocation is stored in sealed individual envelopes kept in a binder 
located in a double-locked safety cabinet within the department. If emergency unblinding is required, 
one of the investigators will be contacted by the hospital staff. The investigators have 24-hour access 
to the cabinet with the envelopes. Envelopes are numbered according to the study medicine box num-
ber. The emergency unblinding can be performed at any time, including outside regular working 
hours.  
The investigator is responsible for the medical care of the individual trial subject (Declaration 
of Helsinki 3§ and ICH GCP 4.3). If the blinding is prematurely broken, it is the responsibility of the 
investigator to promptly document and explain any unblinding to the sponsor. 
The investigators have unrestricted access to the safety cabinet. Envelopes are clearly labeled 
for emergency use only. The responsibility to break the treatment code in emergency situations re-
sides solely with the investigator.  
Any unblinding will be documented in the patient’s medical record and in the trial master file 
(and eCRF), including the date, time, reason for unblinding, and the identity of the physician per-
forming the unblinding. Patients who undergo emergency unblinding will not be withdrawn from the 
study due to unblinding. The trial follows the intention-to-treat principle and will be analyzed as such. 
 
6.5 Registration 
All ambulance staff have access to the registration form in REDCap. The registration form can be 
accessed 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 screened 
(001, 002, 003, etc.). All patients considered for acute CAG due to suspected STEMI are screened 
for eligibility will be registered in an electronic database, REDCap. In the registration form, the am-
bulance staff will annotate the following information about the patient: 1) civil registration number 
of the patient, 2) the number of the study medicine box, 3) time of study medicine intervention, and 
4) if the study medicine was given according to the protocol (yes/no), and if not, why the study med-
icine was not given. The staff in the ambulance will sign the registration form following inclusion.  
 
All data collected in the ambulance and from the medical records as part of the trial are ob-
tained as part of standard clinical care at the participating sites.  

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6.6 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 adjustments 
are allowed.   
 
6.7 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.  
 
6.8 Concomitant Procedures 
6.8.1 Acute CAG and Primary PCI Procedure 
The patient is admitted to the hospital because of STEMI with symptom onset less than 24 hours 
before contact. The acute CAG and primary PCI will be performed as usual clinical practice. The 
patient is pretreated with aspirin (300 mg) and 10.000 units of heparin in the prehospital setting by 
the ambulance staff as soon as the including RD has set the diagnosis of STEMI and referred the 
patient to acute CAG. These procedures are of standard clinical practice and in accordance with 
guidelines. Primary PCI is prepared and performed as per guidelines the catheterization laboratory. 
Immediately after primary 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). 
 
6.8.2 Acute Coronary Artery Bypass Graft (CAGB) 
Approximately 4% of patients transferred for acute CAG with STEMI will undergo acute CABG as 
judged by the treating PCI operator and thoracic surgeons14. This is part of the standard procedure. 
 
6.8.3 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 pra-
sugrel 10 mg or 5 mg (age above 75 or body weight under 60 kg) 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.  
 

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6.8.4 Follow-Up 
All randomized patients will be followed for events for a maximum of 10 years. All patients will be 
followed for at least 1 year. The initial follow-up period ends after the last included patient has been 
followed for 1 year. The completion of the overall follow-up period will be 10 years after the first 
included patient. See section 5.4 for expected study duration. Follow-up will be done using patient 
charts. Schedule of activities is shown in Table 1 (Section 5.4). 
7. Endpoints 
Primary and secondary endpoints are listed in Table 2.  
Table 2. PULSE-MI 2 endpoints 
Timeframe 
 
Intervention with glucocorticoid vs. 
placebo 
 
Primary endpoint All-cause mortality 
>1 year 
Secondary 
end-
points 
Cardiovascular mortality 
>1 year 
 
Spontaneous myocardial infarction 
>1 year 
 
Admission for heart failure  
>1 year 
 
All-cause mortality or admission for 
heart failure 
>1 year 
 
Cardiovascular mortality or admis-
sion for heart failure 
>1 year 
 
Recurrent non-fatal cardiovascular 
events (spontaneous myocardial in-
farction and admission for heart fail-
ure) with death treated as a terminal 
event 
>1 year 
 
Exploratory endpoints: 
1. Urgent revascularization  
2. Target vessel revascularization 

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3. Target lesion revascularization 
4. Any repeat revascularization 
5. Definitive stent thrombosis 
6. Peak troponin-T within 24 hours of STEMI  
7. Malignant ventricular arrhythmia during admission 
8. Admission to intensive unit during admission 
9. Implantation of implantable cardioverter defibrillator (ICD) 
 
7.1 Endpoint Definition 
All endpoints are defined according to previous definitions (please see Appendix A for endpoint def-
initions)17–19.  
 
7.2 Endpoint Recording  
All endpoints will be identified using patient charts, in which all deaths and hospital referrals are 
reported. All clinical endpoints are defined in Appendix A. Violations of the protocol will be moni-
tored continuously. All clinical endpoints will be adjudicated by an independent clinical events com-
mittee (CEC) who will review all relevant medical records. The CEC will consist of at least two 
cardiologists, and the members will be selected before initiation of the trial. No members of the CEC 
participate in recruitment or data collection or have access to any information regarding treatment 
allocation. A list of the proposed CEC members is given in Appendix B.   
 
7.3 Monitoring  
Monitoring of the study will be done by a local Good Clinical Practice (GCP) units. The trial will be 
conducted in compliance with the trial protocol, the Helsinki Declaration, the GCP guidelines (ICH-
GCP), and European 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 100 patients. The following meet-
ings will be held as needed. A full monitoring plan will be elaborated and composed before initiation 
of the trial by the local GCP unit. 
 

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8. 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 personal 
data (data protection law) and the Danish Health Act. As to the need for fast transportation and acute 
treatment, 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 trial. 
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 vulnerable patients. 
Moreover, the ability of the patient to provide informed consent in the prehospital setting is question-
able due to vulnerability, chest pain, and acute setting. This implies the following:  
• Recruitment and randomization in the prehospital setting will be performed by the ambu-
lance staff 
• The including doctor is the RD. The including RD is continuously in touch with the am-
bulance staff in the ambulance by telephone from the time of screening until randomiza-
tion has been done  
• The patient will provide informed consent as soon as possible following the acute man-
agement of the patient (primary PCI/acute CABG), once the patient is stable 
• The process of informed consent is described thorough in section 9.2. The process follows 
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 
 
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 legisla-
tions 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 conduct of 
the clinical trial. The responsibilities of the DSMB will be described thorough in the DSMB charter. 

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The trial will be conducted in compliance with the published trial protocol, the Helsinki Declaration, 
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 prehospital setting, intervention will occur in the prehospital setting prior to 
obtaining informed consent. Patients referred to primary PCI are in an acute, vulnerable, and painful 
situation during transportation to the hospital, therefore, we find it acceptable to include and initiate 
the intervention in the prehospital setting before provision of informed consent. The study medicine 
(glucocorticoid (250 mg methylprednisolone)) is a well-known and described drug used in several 
acute settings and is therefore considered safe without any harm/risks to the patient. This was tested 
in the PULSE-MI trial and there were no differences in terms of adverse and serious adverse events 
in patients treated with glucocorticoid compared with placebo14. Additionally, time from medical 
contact to intervention and treatment is pivotal to secure the best possible prognosis of patients with 
STEMI. Thus, intervention in the prehospital setting without informed consent ensure no delay of the 
urgent treatment of the patient’s medical condition.  
 
9.2 Informed Consent 
Patients will be transported by ambulance directly to the PCI centre, where acute diagnostic evalua-
tion and primary PCI are performed without delay as part of standard emergency care. After the acute 
treatment, patients are admitted to the cardiac ward or intensive care unit where informed consent 
from the patient will be obtained. Up to 90-95% of patients with STEMI will be stable, without chest 
pain, and able to provide informed consent as soon as possible after the acute treatment with primary 
PCI. After the acute treatment, one of the investigators will provide detailed and thorough information 
about the study and obtain informed consent from the patient without undue delay (signature of the 
ICF). Signature of ICF is designed and encrypted in REDCap and will be signed in REDCap after 
informed consent. 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. Data will be kept and used; if the patient or next of kin does not give consent, 
they will be informed of their right to object to the use of data obtained from the clinical trial.  
Approximately 5% of patients with STEMI are unable to provide informed consent directly 
after primary PCI. In this case, consent will be obtained by the legally designated representative (trial 
guardian and closest relative (next of kin)) as soon as possible. The legally designated representative 

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consent will be followed by informed consent and signature of the ICF by the patient, once the patient 
is stable and able to provide informed consent without undue delay.  
In cases of death prior to informed consent, the trial guardian will provide informed consent 
as soon as possible. Closest relative (next of kin) will be informed about participation in the trial 
including the use of the patient’s data in relation to the study and informed consent will be obtained. 
All attempts to obtain informed such consent will be thoroughly documented in REDCap and the 
patient chart. If it is not possible to identify or contact next of kin, the procedures set out in § 21 of 
the Danish “lovbekendtgørelse om kliniske forsøg med lægemidler” will be followed. In such cases, 
after approval from the Danish Medical Research Ethics Committee, further collection of relevant 
information from the patient’s medical records and assessment of already collected data may be car-
ried out, provided that such processing is necessary for the completion, control, or monitoring of the 
clinical trial.  Further, the closest relative will be informed of the patient’s right to discontinue from 
the study at any time. In case of any objection or unwillingness towards participation in the trial, the 
patient will then be excluded from the study. However, medical records of the patient after death will 
be checked for causes of death to ensure no relation to the study medicine.  
The investigator will ensure:  
1. Each patient is given full and adequate oral and written information about the nature, purpose, 
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.  
 
9.2.1 Legally Designated Representative  
The legally designated representative includes both the trial guardian and the closest relative (next of 
kin).  
Information regarding relatives is routinely registered in the electronic patient chart as part of 
standard clinical practice. In situations where the patient is unable to provide informed consent, the 
closest relative will be identified based on the information documented in the electronic patient chart. 
The patient chart includes both the identity of the contact person, their relationship to the patient, and 
relevant contact information.  
The trial guardian is pre-specified prior to trial initiation. The trial guardian is an independent 
physician who is not involved in the conduct of the trial and has no conflict of interest. In situations 

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where the patient is temporarily unable to provide informed consent directly after acute treatment, 
the trial guardian will provide informed consent.   
 
9.2.2 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. PULSE-
MI14, ATLANTIC20, EUROMAX21, and CONDI-2/EPIC-PPCI22. This approach is reasonable be-
cause the intervention is without any known risk and because the intervention has potential benefit 
for the individual patient.  
Up to 60% of patients with STEMI have reperfusion in the prehospital setting due to effective 
antithrombotic treatment with heparin and aspirin. Thus, myocardial damage and inflammation oc-
curs immediately after myocardial ischemia and is further exacerbated following reperfusion. To ef-
fectively alleviate the acute inflammation and myocardial injury, randomization and intervention is 
to be done in the prehospital setting. Hence, intervention in the ambulance before reperfusion is 
needed to initiate the potentially beneficial and immediate nongenomic effects and subsequent pro-
tective genomic actions of pulse-dose glucocorticoid 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 inter-
vention 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 prehospital 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. More-
over, 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 emer-
gency situations.  
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 have less than 30 
minutes of transportation to the hospital. Therefore, it is not possible within the therapeutic window 

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to supply all prior information about the trial and obtain prior informed consent. The including RD is 
continuously in touch with the ambulance staff in the ambulance by 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 condition, as glucocorticoid is a well-
known and thoroughly investigated drug of minimal risk if administrated as a single dose administra-
tion. Moreover, the PULSE-MI trial showed no harm of glucocorticoid compared with placebo14. 
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/acute CABG) including signature of the ICF.  
2. In patients who are unable to provide informed consent as soon as possible after the primary 
PCI procedure, informed consent will be obtained from the trial guardian and next of kin 
including signature of the ICF followed by informed consent from the patient as soon as pos-
sible. Informed consent from the patient will subsequently be obtained as soon as possible.   
3. In patients who do not wish to participate in the study, the data collection of the patient will 
be stopped immediately. 
4.  In cases of death prior to informed consent, the trial guardian will provide informed consent 
as soon as possible. The closest relative (next of kin) will be informed about participation in 
the study including the use of the patient’s data in relation to the study and provide informed 
consent. In case of any objection or unwillingness towards participation in the study, the pa-
tient will then be excluded from the study. 
5. All signed ICFs are encrypted and kept in REDCap. 
 
  
9.3 Benefits and Risks 
The expectation of the trial is that administration of pulse-dose glucocorticoid (250 mg methylpred-
nisolone) in the prehospital setting will reduce death in patients with STEMI. The patients included 
in the study will have a closer medical control due to participation, however, there is no guarantee 

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that the individual participants achieve any benefits from participating in the trial. The study will not 
delay or interfere with standard therapeutic or diagnostic procedures.  
 
Based on the experience from the PULSE-MI trial and the findings hereof, glucocorticoid is 
easy to administrate, has an acute effect, and implementation of glucocorticoid administration in the 
prehospital setting is highly feasible to be a part of the routine clinical care of patients with 
STEMI13,14,23. The feasibility of the trial is underlined by all patients in the PULSE-MI trial (742 
patients) being included within 11 months and only 4% of eligible patients transferred to Rigshospi-
talet with STEMI were not included in the trial14. The study medicine (glucocorticoid) is approved 
and recommended in other medical conditions and is expected to be of minimal risk to patients as a 
single dose. If successful, the increased knowledge on the therapeutic beneficial potential of gluco-
corticoid will 1) increase scientific knowledge, and 2) improve clinical outcomes in patients with 
STEMI by reducing the number of deaths after STEMI. The information gathered from this trial may 
therefore help future patients and change future clinical guidelines.  
10. Statistics  
A detailed statistical analysis plan is given in Appendix C done by a statistician and the principal 
investigators.  
 
10.1 Data Management 
The data management work up and statistical analyses will be performed at Rigshospitalet, Copen-
hagen University Hospital, Denmark.  
 
10.2 Power Calculations and Sample Size 
All patients will be followed until the last included patient has been followed for 1 year. With an 
expected inclusion period of 4 years, the median follow-up is expected to be 3 years. The primary 
outcome will be all-cause mortality until the last included patient has been followed for 1 year.  
As an estimate based on findings from the PULSE-MI trial14 and the DANAMI-3 trial24, the 
estimated event rate of in the placebo arm is 9%. Glucocorticoid is expected to reduce all-cause mor-
tality corresponding to a hazard ratio of 0.77. To demonstrate the reduction in the primary outcome 
with an 80% power at a 5% significance level, 2602 patients in each treatment arm is needed. The 
primary analyses will be intention to treat principle.  

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After inclusion of 50% of the planned sample size, a blinded evaluation of the total number 
of events will be conducted annually to assess the need for potential sample size adjustment. No 
interim analysis will be done.   
 
10.3 Analysis populations 
10.3.1 Intention-to-treat (ITT) 
The intention-to-treat (ITT) analysis population will include all randomized patients who provided 
consent for use. 
 
10.3.2 Additional key analysis 
A differentiation between a classic type I myocardial infarction with plaque rupture and thrombosis 
formation and a type II myocardial infarction with other reasons for ST-segment elevation (e.g. tako-
tsubo, myocarditis, pericarditis, spontaneous coronary artery dissection, coronary embolism, coro-
nary spasm, anemia, etc.17) can only be made after inclusion and acute CAG. Any patient with type 
II myocardial infarction or a patient who does not fulfill all inclusion and no exclusion criteria will 
be excluded from the additional analysis. Hence, the additional analysis will only include patients 
with STEMI and type I myocardial infarction17. 
 
10.4 Statistical Analysis 
All analysis will be performed in the ITT population. The primary outcome is defined as the occur-
rence of all-cause mortality until the last included patient has been followed for 1 year. The primary 
analysis will be a comparison of the rate of mortality between the glucocorticoid group and placebo 
group. Hazard ratios and 95% confidence intervals will be calculated using Cox proportional hazard 
model and probability of survival will be displayed using the Kaplan-Meier methodology. The as-
sumptions for the Cox proportional hazard model will be assessed and if there is clear non-propor-
tionality, hazard ratios will be presented separately for the relevant time periods. A two-tailed P-value 
<0.05 will be considered statistically significant.  
 
Secondary outcomes will be handled as time-to-event outcomes. The composite endpoints 1. 
all-cause mortality and admission for heart failure and 2. cardiovascular mortality and admission for 
heart failure will also be handled as binary outcomes. Kaplan-Meier curves for each treatment group 
will be calculated, graphically displayed, and compared using either the log-rank test or competing 

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risk models. Competing risk models may be used to account for the competing risk of all-cause mor-
tality. Further, Cox proportional hazard models will be calculated to assess differences in the time to 
event between groups. Analysis of cumulative number of events is described in Appendix C. 
All endpoints will also be assessed in an additional key analysis in patients with type I myocardial 
infarction (please see section 10.3.2 for the description of the population).  
 
  
 
10.4.1 Missing Data 
Missing values for the primary endpoint will be minimal to none, as survival status is noted in all 
patient charts. 
 
10.3 Pre-specified Subgroup Analyses 
The primary endpoint will be compared between treatment groups in pre-specified subgroup analyses: 
Age, sex, left ventricular ejection fraction <45% at arrival, anterior infarction, multivessel disease 
(>50% angiographic stenosis in non-culprit artery), symptom to intervention <6 hours, and thrombo-
lysis in myocardial infarction grade 0-1 before percutaneous coronary intervention. 
11. Data Storing and Handling of Personal Data 
All trial 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.  
 
11.1 Serious Breaches 
A serious breach is one that is likely to significantly impact the safety and rights of a subject or the 
reliability and robustness of the clinical data. The sponsor will notify any serious breaches via the 
CTIS system within 7 calendar days of awareness in accordance with article 52 of CTR.  
12. Assessments of Safety and Harm  
Mortality after STEMI has decreased after implementation of primary PCI and drug-eluting stents 
(DES). Primary PCI is performed daily at all participating hospitals, and the risks associated with the 
procedure is well known. STEMI is often complicated by a myocardial dysfunction leading to heart 
failure and arrhythmias during the acute phase. However, mechanical complications such as free wall 

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rupture, ventricular septal rupture, and papillary muscle rupture may also occur in the setting of 
STEMI10. These complications are well known, and, as part of standard care, an echocardiography is 
performed in all patients admitted with STEMI to assess potential mechanical complications and the 
function of the left and right ventricle. AEs/SAEs potentially related to the intervention of the study 
will include: death, infection, gastroduodenal ulcer, hypertension, fluid retention resulting in periph-
eral edema, anaphylaxis, and skin complications such as acne, atrophy, purpura, and wound healing 
complications. In the first PULSE-MI trial, we observed no difference in occurrence of events poten-
tially related to the intervention between the placebo and glucocorticoid group. 
Schedule for reporting of AE/SAE are shown in Table 1 (Section 5.4). 
 
12.1 Adverse Events (AEs) 
AEs are considered any untoward medical occurrence in the patient to whom intervention (glucocor-
ticoid) has been administrated and which does not necessarily have a causal relationship with this 
treatment. The PULSE-MI trial showed no risk of glucocorticoid administration regarding adverse 
events. Therefore, the AE that will be recorded is infection. C-reactive protein, a known acute-phase 
reactant, increases as a direct result of STEMI. Therefore, this cannot be considered sign of infection 
per se and infection as an AE will be defined as as evident signs of infection such as fever, fatigue 
and/or delirium accompanied by positive blood or urine screening.  
The half-life of methylprednisolone is 12 hours, and the drug is considered eliminated after 5 
half-times. AEs will be recorded for the first seven days after intervention. Information regarding 
AEs will be assessed using patient charts.   
 
12.2 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 hospital-
ization or prolongation of existing hospitalization, results in persistent or significant disability or in-
capacity, results in a congenital anomaly or birth defect, is life-threatening, or results in death.  
SAEs will be recorded for the first seven days after intervention. SAEs are reported by com-
pleting the SAE form within 24 hours after the investigator becomes aware that the event meets the 
protocol definition of an SAE. Templates from the GCP unit will be used to report SAEs, and all 
reports will be submitted to the CTIS-system. Additionally, all SAEs will be reported in the encrypted 
electronic database, REDCap. All SAEs will be assessed using patient charts. 

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Hospitalization is defined as presentation at hospital for an urgent, unscheduled emergency 
department visit, or an inpatient hospitalization.  
 
12.3 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-Medrol25. 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 system and the ethics committee as soon as possible, at latest 7 
days after awareness of event if life-threatening. If the SUSAR is not life-threating the event will be 
reported at latest 15 days after awareness of the event. 
13. Finance and Insurance 
This study is investigator-initiated, and the study will be funded by external foundations for medical 
research. The study has received funding from Hjerteforeningen (8.8 mio.) and Sundhedsdonationer 
(6.0 mio). The preliminary budget for the study is estimated at approximately 18 million DKK, and 
funding applications are being submitted on an ongoing basis. 
 
All patients participating in the trial are insured by the Patient Compensation Association and 
the Danish patient insurance.  
14. Publication 
All results (positive, negative, or inconclusive) will be published in international peer-reviewed jour-
nals. 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 and a statistician. The trial will not be unblinded until acceptance from the steering committee. 
The publication policy of the trial data will be uploaded to the Clinical Trials Information System 
(CTIS) database within 1 year after end of trial in accordance with Clinical Trial Regulation 536/2014 
Annex IV. 
 
The authorship order: Dr. Jasmine Melissa Madsen will be first author, Dr. Ben Elezi will be 
second author and Professor Thomas Engstrøm will be last author. The following authorships will be 
granted in according to ICMJE guidelines. However, all co-investigators will be offered authorship.  

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15. Annual Safety Report 
Throughout the whole study period, annual safety reports will be uploaded to the CTIS database. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix A (End-Point Definitions) 
The clinical event committee (CEC) will review and adjudicate all occurrences of the clinical end-
points according to the 2017 Cardiovascular and Stroke Endpoint Definitions for Clinical Trials19 and 
Standardized End Point Definitions for Coronary Intervention Trials: The Academic Research Con-
sortium-2 Consensus Document18: 
1. Mortality: Cardiovascular and non-cardiovascular  
2. Admission for heart failure 
3. Spontaneous myocardial infarction 
4. Revascularization  
5. Malignant ventricular arrhythmia 
 
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 disease.  
• All procedure-related deaths, including those related to a complication of the procedure 
or treatment for a complication of the procedure.  
• 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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Admission for heart failure is presentation of the patient for an urgent, unscheduled clinic/of-
fice/emergency department visit or hospital admission (>24 hours), with a primary diagnosis of heart 
failure (HF) after discharge of STEMI hospitalization,  
OR  
Initial STEMI admission is prolonged due to heart failure as characterized below 
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 exam-
ination finding and at least 1 laboratory criterion (chest x-ray or BNP) of new or worsening HF on 
presentation. 
 
Table 1. 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 chronically 

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elevated natriuretic peptides, a significant in-
crease above baseline is required. 
Radiological evidence of pulmonary conges-
tion: imaging findings consistent with increased 
intravascular blood volume in the lungs. 
     Receives initiation or intensification of treat-
ment 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 
 
Spontaneous myocardial infarction is defined according to current guidelines16,17. The definition 
of spontaneous myocardial infarction is:  
1. Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least 1 value above 
the 99th percentile URL, together with the evidence of myocardial ischemia with at least 1 of the 
following:  
(i) Symptoms of ischemia,  
(ii) ECG changes indicative of new ischemia (new ST-T changes or new left bundle branch 
block),  
(iii) new pathological Q-waves in at least 2 contiguous leads,  
(iv) imaging evidence of a new loss of viable myocardium or new wall motion abnormality,  
(v) Identification of an intracoronary thrombus by angiography or autopsy.  
2. Sudden, unexpected cardiac death or aborted cardiac death, involving cardiac arrest, often with 
symptoms suggestive of myocardial ischemia, but death occurring before blood samples could be 
obtained, or at a time before the appearance of cardiac biomarkers in the blood and accompanied by 
at least 1 of the following:  
i) Presumably new ST-segment elevation,  
ii) New left bundle branch block,  
iii) Evidence of fresh thrombus by coronary angiography and/or at autopsy 
 
3. Pathological findings of a myocardial infarction 

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Revascularization will be grouped and defined accordingly:  
- 
Urgent revascularization: Revascularization during admission for acute coronary syndrome 
which covers patients with STEMI, non-ST-segment elevation myocardial infarction, and un-
stable angina16. 
- 
Target vessel revascularization: Revascularization will be classified according to the culprit 
lesion of index STEMI. Definitions are:  
o Target vessel: the entire culprit vessel including side branches.  
o Target vessel revascularization: any repeat PCI or surgical bypass of any segment of 
the target vessel including the target lesion. 
- 
Target lesion revascularization: Revascularization will be classified according to the culprit 
lesion of index STEMI as target/non-target lesion/vessel. Definitions are as allow:  
o Target lesion: treated culprit segment including the 5-mm margin proximal and distal 
to the stent.  
o Target lesion revascularization: repeat PCI on the target lesion or bypass surgery of 
the target vessel performed for restenosis or the complication of the target lesion. 
- 
Any repeat revascularization: Any PCI or surgical coronary intervention. 
 
Malignant ventricular arrhythmia is any ventricular arrhythmia with sustained ventricular tachy-
cardia or ventricular fibrillation leading to acute medical treatment or acute cardioversion.  
 
 

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Appendix B (the PULSE-MI 2 committee members and investigators) 
Steering committee: 
Jacob Lønborg, MD, PhD, DMSc (Principal Investigator)  
Jasmine Melissa Marquard, MD (Co-Principal Investigator) 
Thomas Engstrøm, MD, PhD, DMSc (Sponsor, Co-Principal Investigator))  
Ben Elezi, MD (Sub-investigator) 
Sub-Investigators: 
Ben Elezi, MD 
Laust Obling, MD, PhD 
Helle Collatz Christensen, MD, PhD 
Fredrik Folke, MD, PhD  
Christian Juhl Terkelsen, MD, PhD, DMSc (Principal Investigator, Aarhus) 
Lars Wiuff Andersen, MD, MPH, PhD, DMSc  
Ashkan Eftekhari, MD, PhD (Principal Investigator, Aalborg) 
Martin Rostgaard-Knudsen, MD 
Lisette Okkels Jensen, MD, PhD (Principal Investigator, Odense) 
Søren Mikkelsen, MD, PhD 
Statistician: 
Thomas Scheike 
Writing committee: 
According to publication charter (TBD) 
Clinical event committee (CEC): 
Kasper Iversen (Suggested) 
David Erlinge (Suggested)  
Felix Böhm (Suggested)  
Data Safety Monitoring Board (DSMB): 
Lars Køber, chair (suggested) 
Nico Pijls (suggested) 
Steen Dalby Kristensen (suggested) 
Christian Torp (suggested) 
Data manager: 
Emil Fosbøl (Unblinded data (independent)) 
Rasmus Paulin Beske (Data handling of blinded data only) 
 
 
 

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Appendix B (Statistical Analysis Plan) 
Statistical Analysis Plan 
Prehospital Pulse-Dose Glucocorticoid in Patients 
with ST-Segment Elevation Myocardial Infarction – 
PULSE-MI 2 
 
 
 
 

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Table of contents 
Preamble  
Aim of PULSE-MI 2  
Methodology 
Inclusion criteria  
Exclusion criteria 
Randomization 
Endpoints  
Sample size justification  
General statistical considerations 
Data and safety monitoring 
Analysis of primary endpoint 
Analyses of secondary endpoints  
Missing data 
References  
 
 
 

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Preamble 
This statistical analysis plan represents an overview of the statistical methods, which will be used for 
the main analyses in the PULSE-MI 2 trial. The main analyses of the primary and secondary outcomes 
of the PULSE-MI 2 trial will be performed according to this statistical analysis plan. Additional sta-
tistical analyses for predefined exploratory endpoints will be specified in separate protocols and are 
not intended to be included in main publication. 
 
 

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Aim 
The aim of this prospective, randomized PULSE-MI 2 trial is to evaluate the effect of pre-hospital 
pulse-dose glucocorticoid in patients with STEMI.  
 
Methodology 
This trial is an investigator-initiated, 1:1 randomized, blinded, multicenter, placebo-controlled clini-
cal trial to investigate whether pulse-dose glucocorticoid (250 mg methylprednisolone) in the pre-
hospital setting reduces mortality in patients with STEMI.  
 
Inclusion criteria 
1. Age ≥18 years including fertile women* 
2. Acute onset of chest pain with < 24 hours duration  
3. STEMI as characterized on electrocardiogram (ECG) by one of the following26:  
a. 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, 
b. presumed new left bundle branch block with ≥1 mm concordant ST-segment elevation 
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 
c. 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 infarction 
(AMI) 
d. ST-segment depression ≥1 mm in eight or more surface leads, coupled with ST-seg-
ment elevation in aVR and/or V1 suggesting left main-, or left main equivalent- coro-
nary obstruction 
* It is not possible to perform a pregnancy test (HCG urine test) in the pre-hospital setting. However, 
methylprednisolone is not contraindicated in pregnant women. 
 
Exclusion criteria 
1. Suspected other than type I acute myocardial infarction at the time of potential randomiza-
tion27 

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2. Initial presentation with cardiac arrest (out of hospital cardiac arrest) 
3. Known allergy to glucocorticoid 
 
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 staff in the ambulance. 
Patients will be randomized in a 1:1 ratio to either infusion of glucocorticoid (250 mg methylpredni-
solone) or placebo that are placed in identical boxes. The ambulance staff randomizes the patient by 
picking a random box stored in the ambulance delivered by the pharmacy, including glucocorticoid 
or placebo, and administrates (over a period of 5 minutes) the content as a bolus infusion. Following 
infusion of the study intervention, 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 included in 
the trial. The pharmacy of the Capital Region of Denmark will pack inbox and label the study medi-
cine and placebo ampoules. The randomization will be allocated by the pharmacy and their independ-
ent statistician using a random number generator.   
Endpoints 
Table 1. PULSE-MI-2 endpoints 
 
Intervention with glucocorticoid vs. placebo 
Primary endpoint 
All-Cause mortality 
Secondary endpoints 
Cardiovascular mortality 
 
Spontaneous myocardial infarction 
 
Admission for heart failure  
 
All-cause mortality and admission for heart failure 
 
Cardiovascular mortality and admission for heart failure 
 
Recurrent non-fatal cardiovascular events (spontaneous myocar-
dial infarction and admission for heart failure) with death as a 
terminal event 
 
Sample size 

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All patients will be followed until the last included patient has been followed for 1 year. With an 
expected inclusion period of 4 years, the median follow-up is expected to be 3 years. The primary 
outcome will be all-cause mortality until the last included patient has been followed for 1 year.  
As an estimate based on findings from the PULSE-MI trial28 and the DANAMI-3 trial24, the 
estimated event rate in the placebo arm is 9% during follow-up. Glucocorticoid is expected to reduce 
all-cause mortality corresponding to a hazard ratio of 0.77. To demonstrate this reduction in the pri-
mary outcome with an 80% power at a 5% significance level, 2602 patients in each treatment arm is 
needed. The primary analyses will be intention to treat principle. 
After inclusion of 50% of the planned sample size, a blinded evaluation of the total number 
of events will be conducted annually to assess the need for potential sample size adjustment. No 
interim analysis will be done.   
 
General statistical considerations 
The endpoints will be analyzed as intention-to-treat principle. A prespecified additional key analysis 
will also be done due to the following:  
A differentiation between a classic type I myocardial infarction with plaque rupture and 
thrombosis formation and a type II myocardial infarction with other reasons for ST-segment elevation 
(e.g. takotsubo, myocarditis, pericarditis, spontaneous coronary artery dissection, coronary embo-
lism, coronary spasm, anemia, etc.27) can only be made after inclusion and acute coronary angiogram. 
Any patient with type II myocardial infarction or who does not fulfill any other inclusion or exclusion 
criteria will be excluded from the additional analysis but included in the intention-to-treat analysis.  
Approximately 15% of the included patients are expected to have other reasons for ST-segment ele-
vation28. 
Thus, endpoints will be assessed in the following populations:  
The intention-to-treat (ITT) analysis population will include all randomized patients. 
 
The additional analysis will include patients with STEMI and type I myocardial infarc-
tion27.  
In general, differences between groups in time-to-event endpoints will be assessed with the log-rank 
test. Survival probabilities will be displayed using Kaplan-Meier methodology. Hazard ratios be-
tween groups will be calculated using a Cox proportional hazard model. Differences between group 
means/medians will be assessed with parametric or non-parametric statistics. The Chi-square analysis 

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or Fisher's exact test will be used to test differences between proportions. All statistical tests and/or 
confidence intervals, as appropriate, will be performed at α=0.05 (2-sided), except for those specified 
otherwise. A two-tailed P-value <0.05 is considered statistically significant. All endpoints will also 
be assessed in the additional key analysis only including patients with type I myocardial infarction. 
 
Data safety monitoring 
The data safety monitoring board (DSMB) should meet at least once when the first 25% of the patients 
have been included. Also, the primary endpoint for these patients much be adjudicated by the event 
committee. All additional patients included at the time point of full event adjudication will also be 
included in the safety analysis. The DSMB will receive data on the primary endpoint from the data 
manger. The DSMB may ask for additional data and events at the discretion of the DSMB. The DSMB 
will 1) evaluating the quality of ongoing study conduct including accrual rate, adherence to protocol, 
accuracy and completeness of data capture and 2) assessing safety and efficacy data. The DSMB 
develops consensus on its list of recommendations including that relating to whether the trial should 
continue While no formal statistical stopping boundaries are mandated, the DSMB will consider early 
termination for safety, efficacy, or futility based on magnitude, consistency, and clinical plausibility 
of observed effects. A recommendation of stopping the study is at the discretion of the DSMB. The 
DSMB may ask the study team to provide additional data (baseline and endpoints ect.) before the 
report is finalized. The DSMB Chair will formalize the recommendations in secure email or formal 
with the DSMB’s final recommendations to the principal investigator within 2 weeks of the meeting. 
Details on the DSMB is described in the DSMB Charter.  
 
Analysis of primary endpoint 
The primary endpoint all-cause mortality will be analyzed using Cox proportional hazards analysis 
after testing that the assumption of proportional hazards is met. The primary analysis will be an un-
adjusted analysis of treatment effect. Predefined subgroup analyses will be performed for: Age, sex, 
left ventricular ejection fraction <45% at arrival, anterior infarction, multivessel disease (>50% angi-
ographic stenosis in non-culprit artery), symptom to intervention <6 hours, and thrombolysis in my-
ocardial infarction grade 0-1 before percutaneous coronary intervention. A Forest plot of hazard ratios 
for the primary endpoint and 95%-confidence intervals resulting from univariate comparisons be-
tween the treatment groups will be shown for these subgroups.  
 

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Analyses of secondary endpoints  
The secondary composite endpoints will be analyzed using Cox proportional hazards analysis after 
testing that the assumption of proportional hazards is met. This will be done as unadjusted analyses 
of treatment effect and presented as hazard ratio and corresponding confidence intervals. Data will 
be presented in Kaplan Meier plot when appropriate. For secondary endpoints not involving all-cause 
mortality, the endpoints may also be analyzed considering all-cause death as a competing risk.  
Recurrent non-fatal cardiovascular events (spontaneous myocardial infarction and hospitali-
zation for heart failure) with death as a terminal event will be analyzed using a cox-type model for 
the mean cumulative function according to Gosh and Lin.  
 
 
Missing data 
All centers will be encouraged to obtain as complete data as possible and optimized with 100% mon-
itoring. Missing values for the primary endpoint will be minimal to none, as survival status is noted 
in patient charts. Imputations of missing data for the primary endpoint will not be performed. In the 
event of loss to follow-up patients will be censored at the last date at which respective patient data 
was recorded.  
 

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