Impact of Prehospital Thrombolysis for Acute Myocardial Infarction on 1-Year Outcome

Abstract

for the USIC 2000 InvestigatorsBackground-Limited data are available on the impact of prehospital thrombolysis (PHT) in the "real-world" setting. Methods and Results-Of 443 intensive care units in France, 369 (83%) prospectively collected all cases of infarction (Յ48 hours of symptom onset) in November 2000; 1922 patients (median age, 67 years; 73% men) with ST-segment-elevation infarction were included, of whom 180 (9%) received intravenous thrombolysis before hospital admission (PHT). Patients with PHT were younger than those with in-hospital thrombolysis, primary percutaneous interventions, or no reperfusion therapy. Median time from symptom onset to hospital admission was 3.6 hours for PHT, 3.5 hours for in-hospital lysis, 3.2 hours for primary percutaneous interventions, and 12 hours for no reperfusion therapy. In-hospital death was 3.3% for PHT, 8.0% for in-hospital lysis, 6.7% for primary percutaneous interventions, and 12.2% for no reperfusion therapy. One-year survival was 94%, 89%, 89%, and 79%, respectively. In a multivariate analysis of predictors of 1-year survival, PHT was associated with a 0.49 relative risk of death (95% CI, 0.24 to 1.00; Pϭ0.05).When the analysis was limited to patients receiving reperfusion therapy, the relative risk of death for PHT was 0.52 (95% CI, 0.25 to 1.08; Pϭ0.08). In patients with PHT admitted in Յ3.5 hours, in-hospital mortality was 0% and 1-year survival was 99%. Conclusions-The 1-year outcome of patients treated with PHT compares favorably with that of patients treated with other modes of reperfusion therapy; this favorable trend persists after multivariate adjustment. Patients with PHT admitted very early have a very high 1-year survival rate.

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

“…The mean age of patients enrolled ranged from 57 to 80 years in the RCTs and from 57 to 91 years in the observational studies. Two RCTs 2,4 and 7 observational studies 23,35,39,49,61,62 reported prehospital administration of fibrinolytic therapy. Fibrin-specific agents were used primarily in 16 RCTs 1-4,6 -12,14,15,19,20,22 and 11 observational studies 24,33,35,37,41,43,44,48,53,57,61 (Tables I and II of Primary PCI was associated with an Ϸ34% short-term reduction in mortality (OR, 0.66; 95% CrI, 0.51 to 0.82) in RCTs ( Figure 2) and an Ϸ23% lower mortality in observational studies (OR, 0.77; 95% CrI, 0.62 to 0.95; Figure 3).…”

“…There was no conclusive difference in mortality in the meta-analysis of observational studies that used prehospital fibrinolytic therapy. 23,35,39,49,61,62 An estimate of the difference in mortality between primary PCI and prehospital fibrinolytic therapy could not be done with certainty because only 2 RCTs used prehospital fibrinolysis. 2,4 In RCTs, primary PCI was associated with a 24% reduction in long-term mortality (OR, 0.76; 95% CrI, 0.58 to 0.95; Figure 4).…”

“…The mean age of patients enrolled ranged from 57 to 80 years in the RCTs and from 57 to 91 years in the observational studies. Two RCTs 2,4 and 7 observational studies 23,35,39,49,61,62 reported prehospital administration of fibrinolytic therapy. Fibrin-specific agents were used primarily in 16 RCTs 1-4,6 -12,14, 15,19,20,22 and 11 observational studies 24 (Tables I and II of the online-only Data Supplement).…”

The Place for Systemic Thrombolysis in Modern Reperfusion Methods for Myocardial Infarction

“…В рандомизированном исследовании CAPTIM, посвященном сравнению первичного ЧКВ и догоспи-тального тромболизиса (c проведением при необходимо-сти спасительной ЧКВ) [28,29] показана сходная частота неблагоприятных исходов. Регистровые исследования подтверждали эти данные [30]. Более того у больных, получивших тромболитик в пределах двух часов от начала ОИМ, отмечена тенденция к меньшей, чем при исполь-зовании ЧКВ, смертности [29,31].…”

Current Reperfusion Therapy Possibilities in Myocardial Infarction and Ischemic Stroke

“…Для того чтобы максимально «приблизить» реперфузионную терапию к пациенту, а значит, умень-шить время до реперфузии и спасти максимально больший объем миокарда, необходимо провести ТЛТ на догоспитальном этапе. В одном из первых исследо-ваний, посвященном изучению эффективности до-госпитального тромболизиса, было показано, что при проведении его больным ИМпST госпиталь-ная смертность составила 3,3 %, тогда как при прове-дении ТЛТ в стационаре -8 %, а при отсутствии ре-перфузионной терапии -12,2 %, однолетняя выживаемость больных составила 94, 89 и 79 % соот-ветственно [14].…”