A system approach to intravenous thrombolysis in acute myocardial infarction in community hospitals: The influence of paramedics

Abstract

Summary: During a 3-year period, intravenous streptokinase (IV STK) was given to 110 consecutive patients ages 34-78 in the course of acute myocardial infarction (AMI) in three community hospitals served by the same paramedic system. 1.5 million units of IV STK was given over 30 minutes. Half of the patients were brought to the hospital by paramedics. The average time from onset of pain to administration of IV STK was 107 minutes in the paramedic group and 182 minutes for the others. Of 110 patients, 98 (89%) showed clinical evidence of reperfusion and 94 of 106 patients (89%) showed angiographic reperfusion. Angiography was performed from 1 to 10 days post-AMI. Mean time to angiography was 6 days for the first 58 patients and 2 days for the last 52 patients. In-hospital mortality was 2 of 110 patients and there was 1 late death at 8 months for an overall 3-year mortality 2.7%. Of 86 patients, 83 (96%) working before their infarct are working now. Of 107 survivors, 96 (90%) are Functional Class I. Conclusions: (1) IV STK is safely administered in a high percentage of AM1 patients. (2) IV STK is safely administered in community hospitals. (3) Paramedics act as an early waming system and allow for earlier treatment than patients presenting without paramedic involvement. (4) Successful coronary reperfusion with IV STK results in low mortality rates and minimizes functional disability. (5) A systemwide approach to reducing time to treatment in AM1 may be the most influential factor in affecting morbidity and mortality.

Patients with acute myocardial infarction using ambulance or private transport to reach definitive care: which mode is quicker?

“…In the event of AMI symptoms, contacting the EMS may improve survival in the long term because properly trained ambulance personnel can record ECGs, detect and treat life‐threatening complications, such as cardiac arrest, at the accident scene and during transport. In addition, previous research 17–19 reported that patients using ambulance had shorter ‘door‐to‐needle’ times than those using private transportation to arrive at the hospital. Prehospital thrombolysis delivered by ambulance crews may be the most feasible means of achieving timely cardiac reperfusion under some conditions.…”

“…In accordance with the results of previous studies, 7,10–12 we have noted that one of the main reasons cited by patients with AMI for not using an ambulance was quickness of private transport (PT) 13 . Several studies have attempted to substantiate this common perception 5,14–19 . Advocates of EMS consider care to begin when ambulance crews reach the accident scene.…”

“…13 Several studies have attempted to substantiate this common perception. 5,[14][15][16][17][18][19] Advocates of EMS consider care to begin when ambulance crews reach the accident scene. Using EMS arrival at the scene as a measure of initiation of care, calling ambulance would almost always result in quicker access to care compared with PT to a hospital.…”

“…Using arrival at the hospital as a measure of initial care, Hutchings et al 5 found only a 4-min delay for those using ambulance transport (AT) compared with those using private transportation. However, using administration of cardiac reperfusion as a more rigorous measure of initiation of definitive treatment, studies [3][4][5][6][17][18][19] indicate that using ambulance results in a shorter door-to-reperfusion (doorto-needle or door-to-balloon) time. So far, there are no data regarding these in China.…”

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“…However, in most centers there is a substantial delay from presentation to actual drug infusion (door-to-needle time). The average door-to-needle time has been reported as 45-90 minutes [4][5][6][7][8][9][10]. Analysis of factors leading to delays in initiating therapy have suggested that a substantial portion of the total delay occurs after patients arrive at the hospital.…”