Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics

Pedley, D K; Bissett, Kim; Connolly, Elizabeth; Goodman, Carol G; Golding, Ian; Pringle, T. H.; Mcneill, G. P.; Pringle, Stuart D.; Jones, Matthew C.

doi:10.1136/bmj.327.7405.22

Cited by 77 publications

(43 citation statements)

References 10 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Multiple randomized controlled trials (RCTs) have demonstrated the safety and feasibility of prehospital fibrinolytic therapy, with decreased treatment times ranging from 30 to 140 minutes. 42,143,[145][146][147][149][150][151]153 A meta-analysis of 6 higherquality RCTs revealed an approximately 60-minute reduction in time from symptom onset to delivery of fibrinolytic therapy with prehospital versus hospital-based administration, with a corresponding 17% reduction in risk of all-cause hospital mortality. 154 Analysis of a subgroup of patients enrolled in the CAPTIM (Comparaison de l'Angioplastie Primaire et de la Thrombolyse) trial within 2 hours of symptom onset showed a significantly lower 5-year mortality rate for patients treated with prehospital fibrinolysis than for patients managed with primary PCI (P=0.04).…”

Section: Prehospital Fibrinolytic Therapymentioning

confidence: 99%

“…The time delay from symptom onset to treatment can be shortened by administration of prehospital fibrinolytic therapy by a trained EMS unit either with a physician on board [142][143][144][145][146][147] or with a hospital-based physician [148][149][150][151][152] in direct contact, especially in rural areas. Multiple randomized controlled trials (RCTs) have demonstrated the safety and feasibility of prehospital fibrinolytic therapy, with decreased treatment times ranging from 30 to 140 minutes.…”

Section: Prehospital Fibrinolytic Therapymentioning

confidence: 99%

See 1 more Smart Citation

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

O’Gara¹,

Kushner²,

Ascheim³

et al. 2013

Circulation

2,540

930

View full text Add to dashboard Cite

Section: Prehospital Fibrinolytic Therapymentioning

confidence: 99%

Section: Prehospital Fibrinolytic Therapymentioning

confidence: 99%

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

O’Gara¹,

Kushner²,

Ascheim³

et al. 2013

Circulation

2,540

930

View full text Add to dashboard Cite

“…21 The potential benefit from widespread increases in the use of prehospital treatment, while of proven value for longer journey times, remains to be determined for a more urban and semirural population where journey times are short. 22 Performance within hospital In contrast to care before admission, there was a striking improvement in the process of care of patients admitted to hospital with ST elevation myocardial infarction. The median delay from arrival in hospital to thrombolytic treatment fell from 38 to 20 minutes, with 77.6% of eligible patients receiving thrombolytic treatment within 30 minutes of arrival compared with 42.6% in the first six months of the study.…”

Section: Use Of Secondary Prevention Medicationmentioning

confidence: 99%

Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP)

Birkhead

2004

Heart

View full text Add to dashboard Cite

Objective: To describe the improvements in care that have followed the introduction of an electronic data entry and analysis system providing contemporary feedback on the management of acute coronary syndromes in 230 hospitals in England and Wales. Design: Observational study Methods: A secure electronic system was used to transfer encrypted data on patients with acute coronary syndromes from collaborating hospitals to central servers for analysis. Immediate online data entry to the central servers by hospitals allowed contemporary analyses of performance and immediate comparison with the national aggregate performance. Results: The records of 156 902 patients receiving a final diagnosis of acute coronary syndrome during three years between October 2000 and September 2003 were analysed. Of 69 113 patients with ST segment elevation infarction, 75.4% received thrombolytic treatment. Between the first and last years of the study the median interval from hospital arrival to treatment fell for eligible patients from 38 (interquartile range 22-58) to 20 (interquartile range 14-28) minutes. By mid 2003 77.6% were receiving thrombolytic treatment within 30 minutes of arrival. The proportion treated within two hours of onset of symptoms increased from 32.5% to 40.3% (a difference of 7.8 percentage points, p , 0.0001). The use of secondary prevention medication for acute coronary syndromes increased over this period: angiotensin converting enzyme inhibitors, 62.4% to 72.4%; b blockers, 76.3% to 82.6%; statins, 69.6% to 83.8%; and aspirin, 89.3% to 90.2%. Conclusion: The provision of contemporary online performance analyses has underpinned substantial improvement in the care of patients with acute coronary syndromes.

show abstract

“…[12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] The direction and magnitude of the time savings are clinically relevant, resulting in an approximately 10-minute decrease in door-to-drug time and 15-to 20-minute decrease in door-to-balloon time. 12,13 However, these time savings may not reflect the full potential of prehospital ECGs to decrease delays in reperfusion therapy.…”

Section: What Are the Benefits Of Using Prehospital Ecgs In Patients mentioning

confidence: 99%

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Ting¹,

Krumholz²,

Bradley³

et al. 2008

Circulation

221

View full text Add to dashboard Cite

Clinical case: A 58-year-old woman called 9-1-1 with acute onset of chest pain that had persisted for 30 minutes. She had a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus but no previous history of myocardial infarction or heart failure. Her medications included aspirin, atorvastatin, lisinopril, and metoprolol. Paramedics were dispatched, and a prehospital ECG demonstrated 3-to 4-mm ST-segment elevation in leads I, aVL, and V 2 through V 6 (Figure 1). Her examination revealed a regular pulse of 90 bpm, a blood pressure of 100/60 mm Hg, clear lungs, and normal heart sounds with no murmurs. Paramedics interpreted the prehospital ECG and activated the catheterization laboratory en route to the hospital. On hospital arrival, the patient was transported directly to the catheterization laboratory. Coronary angiography demonstrated an occluded proximal left anterior descending artery, which was successfully treated with balloon angioplasty and a stent. The pertinent time intervals were as follows: paramedic dispatch to balloon time, 56 minutes; paramedic arrival at the scene to balloon time, 46 minutes; hospital door to balloon time, 23 minutes. Her biomarkers revealed a peak troponin T of 2.42 ng/mL and a peak creatine kinase muscle-brain isoenzyme of 26.8 ng/mL. An echocardiogram demonstrated normal left ventricular ejection fraction of 55%, with mild anterior hypokinesis, and the patient was discharged on hospital day 3. Current Guidelines for Prehospital ECGs Among Patients With ST-Segment-Elevation Myocardial InfarctionAmerican Heart Association national guidelines, 1-3 as well as other consensus and scientific statements, 4 -11 recommend that emergency medical services (EMS) acquire and use prehospital ECGs to evaluate patients with suspected acute coronary syndrome. Despite these recommendations, prehospital ECGs are used in fewer than 10% of patients with ST-segment-elevation myocardial infarction (STEMI), 12,13 and this rate has not substantially changed since the mid1990s. Furthermore, even when a prehospital ECG is acquired, the information is often not effectively translated into action and coordinated with hospital systems of care to decrease delays in reperfusion therapy. 13 The purpose of this article is to summarize evidence concerning the benefits of using prehospital ECGs, review barriers and challenges to routine use, and recommend approaches to enhance their effectiveness for improving quality of care for patients with acute coronary syndromes.The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

show abstract

Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics

Cited by 77 publications

References 10 publications

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction

Improving care for patients with acute coronary syndromes: initial results from the National Audit of Myocardial Infarction Project (MINAP)

Implementation and Integration of Prehospital ECGs Into Systems of Care for Acute Coronary Syndrome

Contact Info

Product

Resources

About