Prehospital fibrinolysis

Welsh RC, Travers A, Senaratne M, Williams R, Armstrong PW. Feasibility and applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006 152(6) 1007-14. 

Steg PG, Bonnefoy E, Chabaud S, Lapostolle F, Dubien PY, Cristoflni P, Leizorovicz A, Touboul P. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty. Data from the CAPTM randomized clinical trial. Circulation 2003 108 2851-2856. 

Bonnefoy E, LapostoUe F, Leizorovicz A, et al. Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction a ran-donfised study. Lancet 2002 360 825-829. 

Meta-analysis of six trials of prehospital fibrinolysis including 6434 patients suggests that its use is associated with a substantial reduction in time to treat (58 min) and a 17% relative risk reduction of mortality (45). However, these studies were largely performed in European centers with mobile care units staffed by physicians and nurses experienced in the administration of fibrinolytic therapy, a scenario uncommon in American care systems. Therefore, the applicability of such findings is limited in the United States. 

The recently described international ASSENT-3 plus trial evaluated the safety and efficacy of prehospital fibrinolysis with TNK -i-enoxaparin and TNK -i- UFH versus historical controls from ASSENT-3. In the former study, the primary efficacy endpoint of the 30-day incidence of death, myocardial infarction, or in-hospital refractory ischemia tended to favor the enoxaparin group, although the results did not achieve statistical significance (14.2% vs. 17.4% p = 0.08) (46). The efficacy and safety endpoint was the composite of the efficacy endpoint with in-hospital major bleeding or intracranial hemorrhage... 

ST-Elevation Myocardial Infarction (STEMI) is a life-threatening event, thus prehospital treatment is expected to be available by establishing a sophisticated system for this purpose. In this condition a fibrinolysis protocol is advised. 

The basic concept of prehospital care and patient transfer is carrying the patient to a facility capable of rapid revascularization, if fibrinolysis therapy is contraindicated. If the patient cannot be transferred to the facility capable of prompt intervention, fibrinolytic therapy is strongly recommended to start within 90 minutes of first medical contact. After such treatment, medical therapy will become important in managing the patient. 

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