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Acute myocardial infarction: the case for pre-hospital thrombolysis with or without percutaneous coronary intervention
  1. P M Schofield
  1. Correspondence to:
    Dr Peter M Schofield
    Papworth Hospital NHS Trust, Papworth Everard, Cambridge CB3 8RE, UK; peter.schofieldpapworth.nhs.uk

https://doi.org/10.1136/hrt.2004.058529

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    The open artery hypothesis suggests that establishing reperfusion as soon as possible after the onset of symptoms of acute myocardial infarction should be a priority; this has been highlighted as an important objective in the National Service Framework document in the UK.1 Currently, patients with acute myocardial infarction are treated with thrombolytic therapy or by percutaneous coronary intervention (PCI). The vast majority at the present time receive in-hospital thrombolysis. With thrombolytic treatment, the earlier that patients are treated, the better their outcome. As a result, there has been a move towards the administration of thrombolytic treatment before hospital admission.

    THROMBOLYTIC TREATMENT

    There are many large randomised clinical trials which have shown benefit for thrombolytic treatment in acute myocardial infarction. These are summarised in the fibrinolytic therapy trialists collaborative group publication2 which demonstrated an overall risk reduction in 35 day mortality of 18% with thrombolytic treatment.2 The beneficial effect of thrombolysis includes patients presenting within 12 hours of the onset of symptoms, but it is clear that the earlier patients are treated the better their outcome. Thrombolytic treatment saves about 30 lives in 1000 patients presenting within six hours of symptom onset, but only 20 lives per 1000 when treatment is given between 6–12 hours. Beyond 12 hours, benefit is uncertain.

    Fibrin specific lytics such as tissue plasminogen activator (t-PA) and reteplase should, in theory, be more effective at opening coronary arteries than streptokinase. Angiographic studies have shown a higher percentage of patients with patent arteries after t-PA treatment than with streptokinase (around 70% v around 35%).3 In the GUSTO (global utilization of streptokinase and t-PA for occluded coronary arteries) trial, where a more aggressive regimen was compared to standard streptokinase, there was a small but significant mortality benefit favouring t-PA (6.3% v 7.3%).4 Although there was an …

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