Prehospital-initiated thrombolysis

OBJECTIVE: To evaluate the feasibility, safety, and efficacy of prehospital-initiated thrombolysis in decreasing the mortality rate due to acute myocardial infarction. DATA SOURCES: English-language clinical studies, abstracts, and review articles identified from MEDLINE searches and bibliographies of identified articles. Epidemiologic data were extracted from the Internet. STUDY SELECTION: Eight randomized clinical trials and two meta-analyses that compared prehospital-initiated thrombolysis with in-hospital-initiated thrombolysis. DATA EXTRACTION: Pertinent studies were selected and the data were synthesized into a review format. DATA SYNTHESIS: Early reperfusion of an infarct-related coronary artery is associated with lower mortality rates. Most of the delay in initiating treatment is caused by patient delay rather than transport delay or hospital delay. In addition, more than 30% of eligible patients do not receive thrombolytic therapy. Prehospital initiation of thrombolysis has been evaluated as a means of decreasing hospital delay and increasing the number of eligible patients receiving thrombolysis. Clinical trials document that prehospital-initiated thrombolysis is feasible and safe, and saves time. Of the eight randomized trials, three demonstrated a decrease in either cardiac or total mortality with prehospital thrombolysis. All studies were limited by relatively small sample sizes. Two published meta-analyses suggest a 16-17% reduction in mortality with prehospital thrombolysis. In the US, prehospital thrombolysis is not routinely recommended due to medical issues related to diagnostic accuracy and monitoring, legal concerns, and economic implications. Additional strategies, such as community-wide education and prehospital diagnostic electrocardiograms (ECGs), are being studied. CONCLUSIONS: In clinical trials, prehospital-initiated thrombolytic therapy was shown to be safe and probably more effective than in-hospital administration of thrombolytic therapy, but this has not proven feasible in the US at this time. Despite time-savings by decreasing treatment delay with prehospital-initiated thrombolysis, patient delay still persists and accounts for the majority of delay. Future investigations will center on increasing the number of patients treated with thrombolytic agents through patient education, in-patient and out-patient programs that rapidly identify eligible patients, as well as prehospital diagnostic ECGs.

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