Performance of prehospital fibrinolysis
- Henderson McGinnis, MD
Henderson McGinnis, MD
- Associate Professor of Emergency Medicine
- Wake Forest University Health Sciences
- Section Editors
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis, Netherlands
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Fibrinolytics are an effective reperfusion therapy for many patients with ST elevation myocardial infarction (STEMI), but they must be administered within a tight time frame [1,2]. For each 30 minute delay to reperfusion, there is approximately a 10 percent relative increase in mortality in patients with STEMI.
Many factors may contribute to delays in therapy, including patient education and systems issues. Patients who present with STEMI in rural locations may live far from emergency departments or catheterization laboratory facilities. In these settings, prehospital fibrinolytic therapy, administered by paramedics or other prehospital personnel prior to arrival in the emergency department, may decrease the time to reperfusion [2-17].
This topic describes the training, treatment protocols, and quality assurance programs needed to ensure a safe and effective prehospital fibrinolysis program. Detailed information about the medications, including fibrinolytics, used to treat STEMI, data supporting the effectiveness of prehospital fibrinolysis, and general information about the diagnosis and management of acute coronary syndrome and STEMI are presented separately. (See "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy" and "Overview of the acute management of ST elevation myocardial infarction" and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Prehospital fibrinolysis'.)
APPLICABILITY OF PREHOSPITAL FIBRINOLYSIS TO COMMUNITY EMS PRACTICE
Achieving myocardial reperfusion as rapidly as possible is the key to improving survival and decreasing morbidity in patients with acute myocardial infarction. There are several treatment options for these patients who are found to have ST segment elevation myocardial infarction (STEMI). Multiple studies have demonstrated the effectiveness of prehospital fibrinolysis in reducing the time to treatment for patients with STEMI and improving outcomes. These studies are described separately. (See "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Prehospital fibrinolysis'.)
The practicability of using general community emergency medical services (EMS) to perform fibrinolysis has been demonstrated in several studies [14,18-22]. The ER-TIMI 19 trial included 20 EMS systems in urban, semi-urban, and rural areas in the United States and Canada [18,23]. A straightforward training program permitted paramedical personnel working with a remote medical control physician to screen patients with suspected MI by history, physical examination, and electrocardiogram (ECG). Patients with an STEMI received fibrinolytic therapy within a median of 31 minutes after arrival of paramedical personnel in comparison to 63 minutes for in-hospital fibrinolysis in a control group.
- Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators. A clinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997; 336:1621.
- Boden WE, Eagle K, Granger CB. Reperfusion strategies in acute ST-segment elevation myocardial infarction: a comprehensive review of contemporary management options. J Am Coll Cardiol 2007; 50:917.
- Welsh RC, Goldstein P, Adgey J, et al. Variations in pre-hospital fibrinolysis process of care: insights from the Assessment of the Safety and Efficacy of a New Thrombolytic 3 Plus international acute myocardial infarction pre-hospital care survey. Eur J Emerg Med 2004; 11:134.
- Wallentin L, Goldstein P, Armstrong PW, et al. Efficacy and safety of tenecteplase in combination with the low-molecular-weight heparin enoxaparin or unfractionated heparin in the prehospital setting: the Assessment of the Safety and Efficacy of a New Thrombolytic Regimen (ASSENT)-3 PLUS randomized trial in acute myocardial infarction. Circulation 2003; 108:135.
- Chamberlain D. Pre-hospital thrombolysis. Curr Opin Anaesthesiol 1999; 12:179.
- Boersma E, Maas AC, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348:771.
- Schofer J, Büttner J, Geng G, et al. Prehospital thrombolysis in acute myocardial infarction. Am J Cardiol 1990; 66:1429.
- Linderer T, Schröder R, Arntz R, et al. Prehospital thrombolysis: beneficial effects of very early treatment on infarct size and left ventricular function. J Am Coll Cardiol 1993; 22:1304.
- Rawles JM. Quantification of the benefit of earlier thrombolytic therapy: five-year results of the Grampian Region Early Anistreplase Trial (GREAT). J Am Coll Cardiol 1997; 30:1181.
- Coccolini S, Berti G, Maresta A. The magnitude of the benefit from preCCU thrombolysis in acute myocardial infarction: a long term follow up. Int J Cardiol 1998; 65 Suppl 1:S49.
- Brouwer MA, Martin JS, Maynard C, et al. Influence of early prehospital thrombolysis on mortality and event-free survival (the Myocardial Infarction Triage and Intervention [MITI] Randomized Trial). MITI Project Investigators. Am J Cardiol 1996; 78:497.
- Grijseels EW, Bouten MJ, Lenderink T, et al. Pre-hospital thrombolytic therapy with either alteplase or streptokinase. Practical applications, complications and long-term results in 529 patients. Eur Heart J 1995; 16:1833.
- Kennedy JW. 50th anniversary historical article. Thrombolytic therapy in acute myocardial infarction. J Am Coll Cardiol 1999; 33:1829.
- Bergmeijer TO, Postma S, Van't Hof AW, et al. Prehospital treatment of ST-segment elevated myocardial infarction patients. Future Cardiol 2013; 9:229.
- Sayah AJ, Roe MT. The role of fibrinolytics in the prehospital treatment of ST-elevation myocardial infarction (STEMI). J Emerg Med 2008; 34:405.
- Yeter E, Denktas AE. Prehospital fibrinolytic therapy followed by urgent percutaneous coronary intervention in patients with ST-elevation myocardial infarction. Future Cardiol 2009; 5:403.
- McCaul M, Lourens A, Kredo T. Pre-hospital versus in-hospital thrombolysis for ST-elevation myocardial infarction. Cochrane Database Syst Rev 2014; :CD010191.
- Morrow DA, Antman EM, Sayah A, et al. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial. J Am Coll Cardiol 2002; 40:71.
- Danchin N, Blanchard D, Steg PG, et al. Impact of prehospital thrombolysis for acute myocardial infarction on 1-year outcome: results from the French Nationwide USIC 2000 Registry. Circulation 2004; 110:1909.
- Pedley DK, Bissett K, Connolly EM, et al. Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ 2003; 327:22.
- Björklund E, Stenestrand U, Lindbäck J, et al. Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction. Eur Heart J 2006; 27:1146.
- Welsh RC, Travers A, Senaratne M, et al. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006; 152:1007.
- Solhpour A, Chang KW, Balan P, et al. Comparison of outcomes for patients ≥75 years of age treated with pre-hospital reduced-dose fibrinolysis followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction. Am J Cardiol 2014; 113:60.
- El Khoury C, Bochaton T, Flocard E, et al. Five-year evolution of reperfusion strategies and early mortality in patients with ST-segment elevation myocardial infarction in France. Eur Heart J Acute Cardiovasc Care 2015.
- Gibler WB, Kereiakes DJ, Dean EN, et al. Prehospital diagnosis and treatment of acute myocardial infarction: a north-south perspective. The Cincinnati Heart Project and the Nashville Prehospital TPA Trial. Am Heart J 1991; 121:1.
- Schull MJ, Vaillancourt S, Donovan L, et al. Underuse of prehospital strategies to reduce time to reperfusion for ST-elevation myocardial infarction patients in 5 Canadian provinces. CJEM 2009; 11:473.
- Myers RB. Prehospital management of acute myocardial infarction: Electrocardiogram acquisition and interpretation, and thrombolysis by prehospital care providers. Can J Cardiol 1998; 14:1231.
- Clemmensen P, Sejersten M, Sillesen M, et al. Diversion of ST-elevation myocardial infarction patients for primary angioplasty based on wireless prehospital 12-lead electrocardiographic transmission directly to the cardiologist's handheld computer: a progress report. J Electrocardiol 2005; 38:194.
- Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994; 343:311.
- Antman EM, Morrow DA, McCabe CH, et al. Enoxaparin versus unfractionated heparin as antithrombin therapy in patients receiving fibrinolysis for ST-elevation myocardial infarction. Design and rationale for the Enoxaparin and Thrombolysis Reperfusion for Acute Myocardial Infarction Treatment-Thrombolysis In Myocardial Infarction study 25 (ExTRACT-TIMI 25). Am Heart J 2005; 149:217.
- Gibson CM, Murphy SA, Montalescot G, et al. Percutaneous coronary intervention in patients receiving enoxaparin or unfractionated heparin after fibrinolytic therapy for ST-segment elevation myocardial infarction in the ExTRACT-TIMI 25 trial. J Am Coll Cardiol 2007; 49:2238.
- Gabriel RS, White HD. ExTRACT-TIMI 25 trial: clarifying the role of enoxaparin in patients with ST-elevation myocardial infarction receiving fibrinolysis. Expert Rev Cardiovasc Ther 2007; 5:851.
- Sinnaeve PR, Huang Y, Bogaerts K, et al. Age, outcomes, and treatment effects of fibrinolytic and antithrombotic combinations: findings from Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-3 and ASSENT-3 PLUS. Am Heart J 2006; 152:684.e1.
- Mehta RH, Alexander JH, Van de Werf F, et al. Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes. JAMA 2005; 293:1746.
- Sabatine MS, McCabe CH, Gibson CM, Cannon CP. Design and rationale of Clopidogrel as Adjunctive Reperfusion Therapy-Thrombolysis in Myocardial Infarction (CLARITY-TIMI) 28 trial. Am Heart J 2005; 149:227.
- Sabatine MS, Cannon CP, Gibson CM, et al. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA 2005; 294:1224.
- Verheugt FW, Montalescot G, Sabatine MS, et al. Prehospital fibrinolysis with dual antiplatelet therapy in ST-elevation acute myocardial infarction: a substudy of the randomized double blind CLARITY-TIMI 28 trial. J Thromb Thrombolysis 2007; 23:173.
- Smalling RW, Giesler GM, Julapalli VR, et al. Pre-hospital reduced-dose fibrinolysis coupled with urgent percutaneous coronary intervention reduces time to reperfusion and improves angiographic perfusion score compared with prehospital fibrinolysis alone or primary percutaneous coronary intervention: results of the PATCAR Pilot Trial. J Am Coll Cardiol 2007; 50:1612.