Prehospital Fibrinolysis Research Articles

ВЫРАЖЕННОСТЬ ДЕПРЕССИИ И АНДРОГЕННОГО ДЕФИЦИТА У МУЖЧИН МОЛОДОГО ВОЗРАСТА С ИМПST НА ЭКГ С УЧЕТОМ АНГИОГРАФИЧЕСКОЙ КАРТИНЫ

Abstract. Introduction. In young age, due to low evidence and gender inequality, non-obstructive acute coronary syndrome including slow blood flow is in priority. Aim. The aim was to evaluate severity of depression and androgen deficiency in young men with ST segment elevation myocardial infarction due to atherothrombosis and slow flow phenomenon.Material and methods. 99 men aged 25 to 44 years, were observed: 60 patients with ST segment elevation myocardial infarction and slow flow phenomenon, 39 patients with infarction due to coronary artery occlusion. The study did not include patients with body mass index more than 35 kg/m2, diabetes, valve diseases, arrhythmias, conductive disorders, previous history of acute coronary syndrome and pre-hospital fibrinolysis, surgery on pelvic organs and scrotum, prostate cancer, congenital hypogonadism, taking steroids, chronic kidney and liver diseases with impaired function, refusal to participate. Subjective signs of androgen deficiency and erectile dysfunction were analyzed, as well as presence and severity of depression according to Beck's Depression Inventory. Serum levels of prolactin, testosterone, luteinizing hormone, cortisol, sex steroid-binding globulin and free testosterone were measured.Results and discussion. Slow flow phenomenon patients had higher free testosterone and lower serum cortisol concentrations (p=0.04 and p=0.02). In the first group, mild erectile disfunction prevailed (35%), it was absent in 23.3% of respondents, severe disorders were noted in 13.3% of cases. In the second group, erectile disfunction was absent in 23.3%, and 36.7% of respondents had mild symptoms. 23.3% had moderate erectile disfunction. Males with severe and moderate symptoms of androgen deficiency prevailed in the second group. The absence of depression was found in 18.3% and 23.3% in both groups. Conclusion. High prevalence of depression in young men with type 1 myocardial infarction and with slow coronary blood flow has been established. Differences were found in levels of cortisol and free testosterone in groups, which did not correlate with subjective severity of erectile dysfunction symptoms. The results suggest that there is a relationship between estimated parameters, angiogram, and severity of myocardial damage in case of myocardial infarction in young men. To confirm this hypothesis, a prospective follow-up with assessment of one-year survival is required.

Survival in Patients with Paramedic-Identified ST-Segment Elevation Myocardial Infarction

Background Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of care for these patients. There is a paucity of studies in the setting of paramedic-identified STEMI. This study investigated mortality and factors associated with mortality in a large state-wide prehospital STEMI sample. Methods: Included were adult STEMI patients identified and treated with reperfusion therapy by paramedics in the field between January 2016 and December 2018 in Queensland, Australia. 30-day and one-year all-cause mortality was compared between two prehospital reperfusion pathways: prehospital fibrinolysis versus direct referral to a hospital for primary percutaneous coronary intervention (direct percutaneous coronary intervention [PCI] referral). For prehospital fibrinolysis patients, factors associated with failed fibrinolysis were investigated. For direct PCI referral patients, factors associated with mortality were examined. Results: The 30-day mortality was 2.2% for prehospital fibrinolysis group and 1.8% for direct PCI referral group (p = 0.661). One-year mortality for the two groups was 2.7% and 3.2%, respectively (p = 0.732). Failed prehospital fibrinolysis was observed in 20.1% of patients receiving this therapy, with male gender and history of heart failure being predictors. For direct PCI referral group, low left ventricular ejection fraction (LVEF) on admission and cardiogenic shock prior to PCI were predictors of both 30-day and one-year mortality. Aboriginal and Torres Strait Islander status, and impaired kidney function on admission, were associated with one-year but not 30-day mortality. Being overweight was associated with lower 30-day mortality. Conclusions: Mortality in STEMI patients identified and treated by paramedics was low, and the prehospital fibrinolysis treatment pathway was effective with a mortality rate comparable to that of patients undergoing primary PCI. Key words: prehospital; Queensland; cardiac reperfusion; STEMI

Outcomes of a Provincial Myocardial Infarction Reperfusion Strategy: A Population-Based, Retrospective Cohort Study.

Fibrinolysis is an acceptable treatment for acute ST-segment elevation myocardial infarction (STEMI) when primary percutaneous coronary intervention (PCI) cannot be performed within 120 minutes. The American Heart Association has recommended Emergency Medical Services (EMS) interventions such as prehospital fibrinolysis (PHF), prehospital electrocardiogram (ECG), and hospital bypass direct to PCI center. Nova Scotia, Canada has incorporated these interventions into a unique province-wide approach to STEMI care. A retrospective cohort analysis comparing the primary outcome of 30-day mortality for patients receiving either prehospital or emergency department (ED) fibrinolysis (EDF) to patients transported directly by EMS from community or regional ED for primary PCI was conducted. This retrospective, population-based cohort study included all STEMI patients in Nova Scotia who survived to hospital admission from July 2011 through July 2013. Three provincial databases were used to collect demographic, 30-day mortality, hospital readmission, and rescue PCI data. The results were grouped and compared according to reperfusion strategy received: PHF, EDF, patients brought by ambulance via EMS direct to PCI (EMS to PCI), and ED to PCI (ED to PCI). There were 1,071 STEMI patients included with 145 PHF, 606 EDF, 98 EMS to PCI, and 222 ED to PCI. There were no significant differences in 30-day mortality across groups (n, %): PHF 5(3); EDF 36(6); EHS to PCI <5(2); and ED to PCI 10(4); P = .28. There was no significant difference in patients receiving fibrinolysis who underwent rescue PCI. Prehospital fibrinolysis incorporated into a province-wide approach to STEMI treatment is feasible with no observed difference in patient 30-day mortality outcomes observed.

Residual platelet reactivity, thrombus burden and myocardial reperfusion in patients treated by PCI after successful pre-hospital fibrinolysis compared to primary PCI.

We compared residual platelet reactivity and post PCI atherothrombotic burden using OFDI in patients successfully treated by primary PCI versus pharmacoinvasive approach (PI) defined as PCI after successful pre-hospital fibrinolysis. Despite pre-hospital P2Y12-inhibitor loading dose, high rates of high on-treatment platelet reactivity were found at the time of PCI in both groups. Primary PCI patients had higher post stenting thrombus burden and lower rates of final normal myocardial blush grade compared to PI. These findings support the use of a pharmacoinvasive reperfusion strategy especially when primary PCI cannot be timely performed.

Paramedic-Delivered Fibrinolysis in the Treatment of ST-Elevation Myocardial Infarction: Comparison of a Physician-Authorized versus Autonomous Paramedic Approach

Background: For those patients who receive fibrinolysis in the treatment of ST-elevation myocardial infarction (STEMI), early treatment, i.e., within 2 hours of symptom onset, confers the greatest clinical benefit. This rationale underpins paramedic-delivered fibrinolysis in the prehospital setting. However, the current New Zealand approach requiring paramedics to first gain physician authorization, has proved inefficient and time consuming, particularly due to technological failings. Therefore, this study aimed to trial a new autonomous paramedic-delivered fibrinolysis model, examining the impact on time-to-treatment, paramedic diagnostic accuracy and patient outcomes. Methods: Utilizing a prospective observational approach, over a 24-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI, and initiated fibrinolysis. These patients were compared to a historic cohort who received fibrinolysis by paramedics within the same regions but following physician authorization. The main outcome measures were pain-to-needle (PTN) time and accuracy of paramedic diagnosis. A secondary end-point was 30-day and 6-month mortality and hospital length of stay (LOS). Results: A total of 174 patients received fibrinolysis (mean age, 64 years, SD ± 11.2). Median PTN time was 87 minutes (IQR = 58) for the historic cohort (n = 96), versus 65 minutes (IQR = 31) for the experimental cohort (n = 78), (p = 0.007). Autonomous paramedic diagnosis showed a sensitivity of 96% (95% CI 89–99) and specificity of 91% (95% CI 76–98). A significant reduction in both 30-day mortality and hospital LOS was observed among the experimental cohort (p = 0.04 and <0.001, respectively). No significant difference was observed between groups in terms of 6-month mortality. Conclusions: Prehospital fibrinolysis provided autonomously by paramedics without direct physician oversight is safe and feasible. Moreover, this independent approach can significantly improve time-to-treatment, resulting in short term mortality benefit and reduced hospital LOS.

Prehospital ST-Segment Elevation Myocardial Infarction (STEMI) in Queensland, Australia: Findings from 11 Years of the Statewide Prehospital Reperfusion Strategy

Background: Field identification and treatment of ST-segment elevation myocardial infarction (STEMI) by paramedics is an important component of the continuum of care for these patients. This study described real-world clinical practice in prehospital management of STEMI patients in Queensland, Australia. Methods: Retrospective analysis of data sourced from the STEMI database of the Queensland Ambulance Service, Australia. Adult STEMI patients identified by paramedics between February 2008 and December 2018 in Queensland were included. Key aspects of prehospital STEMI care were described. Clinically-important time intervals from symptom onset to reperfusion were reported. Results: A total of 8,388 patients were included. The proportion of patients receiving prehospital reperfusion treatment has improved markedly, increasing from 34% in 2008 to 65% in 2018 (p < 0.001). Direct referral of patients to a hospital for primary percutaneous coronary intervention (pPCI), and administration of preparatory antiplatelet and anticoagulant medications, was the main reperfusion treatment pathway, accounting for 75% of patients receiving reperfusion treatment. Time from paramedic arrival at scene to first 12-lead electrocardiogram has significantly reduced, from 11 minutes in 2008 to 6 minutes from 2012 onwards (p < 0.001). Median (interquartile range, IQR) time from prehospital STEMI identification to reperfusion was 88 (74–103) minutes for patients referred by paramedics to a hospital for pPCI. Fifty-five percent of patients who underwent pPCI achieved time from STEMI identification to reperfusion within 90 minutes. For patients receiving prehospital fibrinolysis, median (IQR) time from STEMI identification to administration of a fibrinolytic agent was 21 (12–33) minutes. Conclusion: The implementation of a statewide prehospital reperfusion strategy has markedly improved the rate of prehospital reperfusion treatment and key time metrics. Ongoing quality improvement efforts are required to further reduce delays in reperfusion.

A Beating Left Main Coronary Artery

A 37-year-old man with a history of active smoking and heroin addiction was admitted after successful pre-hospital intravenous fibrinolysis for ST-segment elevation myocardial infarction. Coronary angiography ([Figure 1][1]) performed systematically after fibrinolysis showed a dynamic severe

Abstract 162: Evolution of Acute Coronary Syndrome Treatment During Last Years in Russian Hospitals (Based on Results of RECORDs Registries)

Background and Purpose: The prospective registries are the most powerful evaluation tool to characterize patients and features of acute coronary syndrome (ACS) treatment. There have been a lot of changes in ACS treatment in Russian hospitals in recent 5-7 years. The aim of our study was to evaluate changes in the ACS treatment occurred in Russia during the last few years. Methods: We conducted the series of independent registries of ACS which were organized by the initiative of their participants - RECORD registries. The first regi stry was held in 2007 (18 centers in 13 cities, n=796). The RECORD-2 registry was conducted in 2009-2011 (7 centers in 7 cities, n=1656). In this analysis pooled data of the RECORD and RECORD-2 (“old” registries; n=2452) were compared with data of the RECORD-3 (“new” registry), conducted in March-April 2015 (47 centers in 37 cities, n=2370). Results: In comparison with “old” registries significantly more patients from “new” registry were hospitalized in PCI-capability hospitals (72.5% vs 56.7%; p&lt;0.0001). The rate of troponin detection was also higher in “new” registry (75.7% vs 41.5%; p&lt;0.0001). The rate of primary PCI (pPCI) in ST-elevation myocardial infarction (STEMI ) was 39.0% in “new” and 36.3% in “old” registry (p=0.24). The rate of pPCI in PCI-capability centers wasn’t also significantly higher in “new” registry (47.2% vs 45.8%). The rate of fibrinolysis in STEMI was nearly similar (32.1% vs 32.2%; p=0.98), but the rate of prehospital fibrinolysis and the rate of PCI after fibrinolysis became more frequent in “new” registry (50.9% vs 23.5%; p&lt;0.0001 and 52.4% vs 25.0%; p&lt;0.0001 respectively). In patients with non-ST elevation ACS (NSTEACS) the rate of diagnostic coronarography (CAG) and the rate of PCI within 72 hours after admission weren’t significantly different in “new” and “old” registries (68.2% vs 71.8%; p=0.15 and 26.6% vs 23.6%; p=0.19 respectively). Among discharge medication from “old” to “new” registries decreasing of aspirin and beta-blockers prescription (89.7% and 91.3%; p=0.009 and 86.0% vs 90.2%; p&lt;0.0001 respectively) and increasing of dual antiplatelet therapy and statin prescription (82.6% vs 43.7%; p&lt;0.0001 and 90.9% vs 78.1%; p&lt;0.0001 respectively) were obtained.The duration of in-hospital stay in “new” registry was shorter than in “old” registries (10,2 vs 13.4 days; p&lt;0.0001), the proportion of patients transferred in non-PCI-capability centers to CAG was higher (16.3% vs 2.2%; p&lt;0.0001) and the rate of in-hospital death was lower (5.1% vs 6.6%; p=0.041). Conclusion: A series of prospective independent registries RECORDs showed that in recent years some progress towards better adherence to the guidelines has been made in the treatment of ACS in Russian hospitals participating in those registries. However, there wasn’t a clear increase in the rate of pPCI and fibrinolysis in STEMI and the rate of invasive strategy in NSTEACS.

Outcome of out-of-hospital cardiac arrest after fibrinolysis with reteplase in comparison to the return of spontaneous circulation after cardiac arrest score in a geographic region without emergency coronary intervention.

Coronary occlusion and pulmonary embolism are responsible for the majority of cases of out-of-hospital cardiac arrest (OHCA). Despite previous favourable results of pre-hospital fibrinolysis in cases of OHCA, the benefit could not be confirmed in a large controlled study using the fibrinolytic tenecteplase. For reteplase (r-PA), there are hardly any data regarding pre-hospital fibrinolysis during ongoing resuscitation. The present study reported results using r-PA therapy in a German physician-supported Emergency Medical Services system. The data of OHCA patients who received pre-hospital fibrinolytic treatment with r-PA after an individual risk/benefit assessment were retrospectively analysed. To assess the effectiveness of this approach, the rate of patients with a return of spontaneous circulation (ROSC) was compared with the corresponding figure that was calculated with the help of the RACA (ROSC after cardiac arrest) score. The RACA algorithm predicts the probability of ROSC based on data from the German Resuscitation Registry. Further outcome data comprised hospital discharge rate and neurologic status at discharge. From 2001 to 2009, 43 patients (mean age, 58.5 years; 65.1% male; 58.1% ventricular fibrillation) received r-PA. Of these, 20 patients (46.5%) achieved ROSC, compared to a probability of 49.8% according to the RACA score (P=0.58). A total of 8 patients (18.6%) were discharged alive, including 5 (11.2%) with a good neurological outcome. For the analysed small patient collective, pre-hospital r-PA did not offer any benefits with regard to the ROSC rate. Further analyses of larger patient numbers on a nationwide registry basis are recommended.

Rural Inequity in STEMI Treatment Can Be Addressed by Implementation of the New Zealand National STEMI Pathway

Background: Although timely reperfusion therapy is instrumental in determining treatment outcomes for ST-elevation myocardial infarction (STEMI) patients, the lack of a coordinated approach in regional Australasia leads to substantial delays in the delivery of time critical treatment. Methods: A collaborative treatment algorithm involving Emergency Medical Services (EMS) and secondary care aimed to deliver either primary percutaneous coronary intervention (PPCI) or pre-hospital thrombolysis with routine immediate transfer of eligible patients to a PCI centre was developed, trialled and evaluated in the predominantly rural Nelson and Marlborough region of New Zealand. Using data from ANZACS-QI and EMS; parameters including pre-hospital ECG transmission, fibrinolysis administration, device and transfer times were evaluated. Results: Sixty-seven of the 100 consecutive STEMI/presumed STEMI patients from February 2016 onwards met the eligibility criteria; the initial reperfusion strategy included PPCI (n = 36), fibrinolysis (n = 28), and medical treatment (n = 1). First medical contact (FMC) to device time for PPCI patients was 89 minutes (43-194, n = 36, 72.2% < 120 minutes), FMC to pre-hospital needle time was 44 minutes (16-78, n = 28, 23.8% < 30 minutes). FMC to arrival at a PCI centre was 75 minutes (27-278, n = 54, 66% < 90 minutes), however door-in-door-out time (DIDO) time for patients presenting to a non-PCI centre was 99 minutes (25-248, n = 9, 11.10% < 30 minutes). Conclusion: A coordinated STEMI pathway can lead to timely arrival at PCI centres and reperfusion therapy for patients that receive PPCI and reasonable FMC to pre-hospital fibrinolysis. However, poor DIDO from non-PCI centres times require further improvement to achieve equity.

12-Lead ECG Transmission for STEMI Management for Regional Patients.

Introduction: Fibrinolysis remains a vital reperfusion therapy for STEMI patients in regional and rural areas due to lack of timely access to primary PCI. Formal 24/7 support for 12-lead ECG confirmation and advice for managing STEMI patients have facilitated the wider use of fibrinolysis including prehospital fibrinolysis. Method: We studied consecutively transmitted 12-lead ECGs for suspected STEMI patients via LifeNet (PhysioControl) from paramedic point of contact and/or regional hospitals to our CCU staff for 12 months commencing February 2016. Result: 76 ECGs were studied. 62 patients met criteria for STEMI reperfusion therapy. 42 patients received tenecteplase (median age 64.5 yrs, male 78%, point of contact at home 26%, diabetes 9.5%, smokers 19%, prior MI 12%, prior PCI 12%, anterior MI 38%, inferior MI 50%, successful reperfusion 75%, subsequent angio 42 pts with PCI in 38 pts). 12 patients received primary PCI (median age 59.5 yrs, male 81%, diabetes 25%, smokers 37.5%, prior MI 25%, prior PCI 25%, prior CVA 14.2%, anterior MI 36%, inferior MI 47%, median transfer time and door-to-balloon time 105 mins and 19.5 mins respectively). 13 ECGs did not meet STEMI criteria (5 NSTEMI, 3 pericarditis, 2 tako-tsubo cardiomyopathy). 7 patients with transmitted STEMI were not transferred to us. There was one in-hospital mortality (82-yr-old male who had rescue PCI following unsuccessful fibrinolysis and died from cerebral infarction). Conclusion: Fibrinolysis was successful in a high proportion of eligible patients for regional and rural patients. Pts not eligible for fibrinolysis have significantly longer transfer time.

Prehospital fibrinolysis versus primary percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials.

BackgroundPrimary percutaneous coronary intervention (PPCI) is the preferred reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI), but its benefit over prehospital fibrinolysis (FL) is not clear.MethodsWe performed a systematic review and meta-analysis of randomized controlled trials in which outcomes of patients with STEMI managed with FL early in the prehospital setting versus PPCI were compared.ResultsCompared with PPCI, FL was consistently associated with similar rates of short-term (30–90 days) death (relative risk [RR] 0.94, 95 % CI 0.67–1.31) and cardiovascular death (RR 0.95, 95 % CI 0.64–1.4), a decreased risk of cardiogenic shock (RR 0.67, 95 % CI 0.48–0.95), and an increased risk of any stroke (RR 3.57, 95 % CI 1.39–9.17) and hemorrhagic stroke (RR 4.37, 95 % CI 1.25–15.26). FL was also associated with similar rates of 1-year mortality (RR 1.01, 95 % CI 0.75–1.34) and major bleeding (RR 1.31, 95 % CI 0.96–1.78) in comparison with PPCI, but with a notable level (I 2 index 30.5 % and 59.8 %) of heterogeneity among studies.ConclusionsOur study suggests that, compared with PPCI, FL performed in the early prehospital setting is associated with similar mortality rates, lower rates of cardiogenic shock, and higher rates of stroke in patients with STEMI. Although the number of studies comparing the two strategies is relatively low, our results support prehospital FL and transfer to hub percutaneous coronary intervention (PCI) centers as a valid alternative to PPCI, allowing potential limitation of resources allocated to developing proximity 24/7 PCI facilities.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1530-z) contains supplementary material, which is available to authorized users.

Disseminated intravascular coagulation with the fibrinolytic phenotype predicts the outcome of patients with out-of-hospital cardiac arrest.

BackgroundWe tested the hypothesis that disseminated intravascular coagulation (DIC) during the early phase of post-cardiopulmonary resuscitation (CPR) is associated with systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS) and affects the outcome of out-of-hospital cardiac arrest (OHCA) patients.MethodsA review of the computer-based medical records of OHCA patients was retrospectively conducted and included 388 patients who were divided into DIC and non-DIC patients based on the Japanese Association for Acute Medicine DIC diagnostic criteria. DIC patients were subdivided into two groups: those with and without hyperfibrinolysis. Pre-hospital factors, platelet count, coagulation and fibrinolysis markers and lactate levels within 24 h after resuscitation were evaluated. The outcome measure was all-cause hospital mortality.ResultsDIC patients exhibited lower platelet counts, prolonged prothrombin time, decreased levels of fibrinogen and antithrombin associated with increased fibrinolysis than those without DIC. DIC patients more frequently developed SIRS and MODS, followed by worse outcomes than non-DIC patients. The same changes were observed in DIC patients with hyperfibrinolysis who showed a higher prevalence of MODS, leading to worse outcome than those without hyperfibrinolysis. Logistic regression analyses showed that lactate levels predicted hyperfibrinolysis and DIC is an independent predictor of patient death. Survival probabilities of DIC patients during hospital stay were significantly lower than non-DIC patients. The area under the receiver operating characteristic curve of DIC for the prediction of death was 0.704.ConclusionsThe fibrinolytic phenotype of DIC during the early phase of post-CPR more frequently results in SIRS and MODS, especially in patients with hyperfibrinolysis, and affects the outcome of OHCA patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12959-016-0116-y) contains supplementary material, which is available to authorized users.

Coordinated regional care of myocardial infarction in a rural area in Brazil: Minas Telecardio Project 2.

In Brazil, there are considerable disparities in access to healthcare. The aim of this study was to assess how implementation of a coordinated regional management protocol for patients with ST-elevation myocardial infarction (STEMI) affected quality of care and outcomes in a rural and deprived Brazilian region with considerable social inequalities. The quality of care and outcomes of STEMI was evaluated in two cohorts before (n = 214) and after (n = 143) implementation of the coordinated regional management protocol. Central to this protocol was a tablet-based digital electrocardiogram (ECG) recording in the emergency ambulance that was transmitted for analysis by trained professionals. If the pre-hospital ECG was diagnostic, it triggered a management cascade involving a direct transfer to the regional intervention centre with reperfusion by primary percutaneous coronary intervention (PPCI) or pre-hospital fibrinolysis for anticipated journey times of less than or greater than 2 h, respectively. Following implementation of the protocol, the adjusted medical delay (system delay - transport time) decreased by 40% (95% confidence intervals: -66%, -13%). The proportion of patients who received reperfusion therapy increased from 70.6 to 80.8% (P = 0.045), with increases in treatment with aspirin [94.2-100% (P = 0.003)] and P2Y12 inhibitors [87.5-100% (P < 0.001)]. The odds of in-hospital death showed a non-significant decrease [odds ratio 0.73 (95% confidence intervals: 0.34-1.60)]. The implementation of a coordinated regional management protocol for patients with STEMI led to marked improvements in the quality of care in a remote Brazilian region with limited resources.

LO026: Outcomes of a provincial cardiac reperfusion strategy: a population-based, retrospective cohort study

Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.

Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction.

We investigated whether prehospital, reduced dose fibrinolysis coupled with urgent percutaneous coronary intervention (FAST-PCI) reduces mortality and cardiac magnetic resonance (CMR) measures of infarct size, compared with primary percutaneous coronary intervention (PPCI), in patients with ST-elevation myocardial infarction (STEMI). Current standard therapy for STEMI is PPCI. However, FAST-PCI may shorten ischemic time (IT) and improve outcomes. Eligible STEMI patients received prehospital, reduced dose fibrinolysis along with standard therapy, and were transported for urgent percutaneous coronary intervention, or else they received usual treatment without prehospital fibrinolysis. Patients were divided retrospectively into four groups based on IT (<120, 120-179, 180-239 min, ≥240) for a mortality analysis cohort, and into three groups (<120, 120-179, ≥180 min) for a CMR analysis cohort. Within each IT group, patients were compared by FAST-PCI vs. PPCI strategy. Between 1/2007 and 2/2014, 1,112 STEMI patients were treated. FAST-PCI was employed in 551 and PPCI in 561. Of these, 357 (32.1%) underwent CMR. The treatment groups were well matched. In STEMI patients with short IT (<120 and 120-179 min groups), those treated by FAST-PCI had lower 30-day mortality and myocardial scar sizes compared with PPCI treatment. For IT ≥180 min, the mortalities and myocardial scar sizes were equivalent for both groups. In STEMI patients with IT <180 min, FAST-PCI may reduce 30-day mortality and myocardial scar size compared with PPCI. This suggests that infarct interventions must be instituted within 3 hr of symptom onset in order to detect an optimal beneficial effect both clinically and by CMR measurement. © 2016 Wiley Periodicals, Inc.

Transport and treatment of patients with STEMI in rural Iceland--Only a few patients receive PPCI within 120 minutes

ST-segment Elevation Myocardial Infarction (STEMI) is a life-threatening disease and good outcome depends on early restoration of coronary blood flow. Primary percutaneous coronary intervention (PPCI) is the treatment of choice if performed within 120 minutes of first medical contact (FMC) but in case of anticipated long transport or delays, pre-hospital fibrinolysis is indicated. The aim was to study transport times and adherence to clinical guidelines in patients with STEMI transported from outside of the Reykjavik area to Landspitali University Hospital in Iceland. Retrospective chart review was conducted of all patients diagnosed with STEMI outside of the Reykjavik area and transported to Landspitali University Hospital in Reykjavik in 2011-2012. Descriptive statistical analysis and hypothesis testing was applied. Eighty-six patients had signs of STEMI on electrocardiogram (ECG) at FMC. In southern Iceland nine patients (21%) underwent PPCI within 120 minutes (median 157 minutes) and no patient received fibrinolysis. In northern Iceland and The Vestman Islands, where long transport times are expected, 96% of patients eligible for fibrinolysis (n=31) received appropriate therapy in a median time of 57 minutes. Significantly fewer patients received appropriate anticoagulation treatment with clopidogrel and enoxaparin in southern Iceland compared to the northern part. Mortality rate was 7% and median length of stay in hospital was 6 days. Time from FMC to PPCI is longer than 120 minutes in the majority of cases. Pre-hospital fibrinolysis should be considered as first line treatment in all parts of Iceland outside of the Reykjavik area. Directly electronically transmitted ECGs and contact with cardiologist could hasten diagnosis and decrease risk of unnecessary interhospital transfer. A STEMI database should be established in Iceland to facilitate quality control.

Five-Year Survival in Patients With ST-Segment–Elevation Myocardial Infarction According to Modalities of Reperfusion Therapy

Background— Although primary percutaneous coronary intervention (pPCI) is the preferred reperfusion method for ST-segment–elevation myocardial infarction, it remains difficult to implement in many areas, and fibrinolytic therapy is still widely used. Methods and Results— We assessed 5-year mortality in patients with ST-segment–elevation myocardial infarction from the French Registry of Acute ST-Elevation or Non-ST Elevation Myocardial Infarction (FAST-MI) 2005 according to use and type of reperfusion therapy. Of 1492 patients with ST-segment–elevation myocardial infarction with a first call ≤12 hours from onset, 447 (30%) received fibrinolysis (66% prehospital; 97% with subsequent angiography, 84% with subsequent PCI), 583 (39%) had pPCI, and 462 (31%) received no reperfusion. Crude 5-year survival was 88% for the fibrinolytic-based strategy, 83% for pPCI, and 59% for no reperfusion. Adjusted hazard ratios for 5-year death were 0.73 (95% confidence interval, 0.50–1.06) for fibrinolysis versus pPCI, 0.57 (95% confidence interval, 0.36–0.88) for prehospital fibrinolysis versus pPCI, and 0.63 (95% confidence interval, 0.34–0.91) for fibrinolysis versus pPCI beyond 90 minutes of call in patients having called ≤180 minutes from onset. In propensity score–matched populations, however, survival rates were not significantly different for fibrinolysis and pPCI, both in the whole population (88% lysis, 85% pPCI) and in the population seen early (87% fibrinolysis, 85% pPCI beyond 90 minutes from call). Conclusions— In a real-world setting, on a nationwide scale, a pharmaco-invasive strategy constitutes a valid alternative to pPCI, with 5-year survival at least equivalent to that of the reference reperfusion method. Clinical Trial Registration— URL: www.clinicaltrials.gov . Unique identifier: NCT00673036.

Primary Percutaneous Coronary Intervention Not Always the Best Reperfusion Strategy?

For patients with an ST-elevation–myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) is the preferred reperfusion modality.1 Primary PCI, however, requires a catheterization laboratory and 24/7 availability of an experienced team. Worldwide, only a minority of STEMI patients present directly to a PCI-capable hospital. Most patients are first seen by an ambulance crew or at the emergency room of a non-PCI–capable hospital. Although in some regions almost all STEMI patients can be transferred to a primary PCI center within a guideline-recommended timeframe, in many other regions across the world timely transport remains a major issue because of distance, weather conditions, traffic, and, very often, a poor organization of the emergency medical system (EMS). The organization of regional transfer can indeed be complex and costly. It requires close collaboration among ambulance systems, emergency departments, and catheterization laboratories.2 Article see p 1629 Fibrinolytic therapy given before an already planned PCI to mitigate the delay associated with primary PCI does not improve outcome.3 In most of these studies, no clopidogrel was given upfront, and anticoagulant therapy was often suboptimal. Several more recent studies, however, suggest that coronary angiography and PCI performed between 3 and 24 hours after administration of the lytic, in case of successful reperfusion, reduces the risk of new ischemic events.4–6 As now mentioned in the guidelines, if fibrinolysis is indicated, it needs to be followed by an early coronary angiography. This strategy is often referred to as pharmaco-invasive therapy. Because of the absence of cross-linking of fibrin in the fresh occlusive clot, such a strategy is especially effective in patients presenting early after symptom onset. In a post hoc analysis of the Comparison of Primary Angioplasty and Pre-hospital Fibrinolysis in Acute Myocardial Infarction (CAPTIM) study, prehospital fibrinolysis in the subset of STEMI patients presenting …

Pre-hospital Fibrinolysis in the Management of Patients with ST Elevation Acute Coronary Syndrome: Review of the Evidence, Implementation and Future Directions

Time to reperfusion is among the strongest predictors of clinical outcome in patients who present with ST elevation acute myocardial infarction. When time to access is equivalent, primary percutaneous coronary intervention has demonstrated superior outcomes to fibrinolysis. However, where significant delays exist in accessing percutaneous intervention, fibrinolysis has an important role. The potential for fibrinolysis delivery in the pre-hospital setting means that delays to primary percutaneous intervention need to be considered from the time that the patient becomes eligible for fibrinolysis in the field. This can be particularly challenging in patients with symptom duration ofless than two hours, as some evidence suggests fibrinolysis may be particularly beneficial in this early phase. Additionally, access to primary percutaneous intervention provided by an experienced operator, in a timely manner at any time of the day or night, is not an available option in many healthcare settings. This review focuses on the current evidence and practice of pre-hospital fibrinolysis and assesses potential roles for this therapy in the future.