Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian Region Early Anistreplase Trial (GREAT)

Medicines Assessment Research Unit, University of Aberdeen, Scotland, United Kingdom.

OBJECTIVES. Our aim was to determine the time saved by administration of thrombolytic therapy at home rather than in the hospital and to assess whether earlier thrombolysis resulted in decreased mortality from acute myocardial infarction. BACKGROUND. There is much theoretic, experimental and trial evidence to indicate that in acute myocardial infarction the earlier that thrombolytic therapy is given, the greater its efficacy. However, the clinical importance of this time effect is uncertain. METHODS. In a randomized double-blind parallel-group clinical trial, 311 patients with suspected acute myocardial infarction seen by their general practitioners within 4 h of symptom onset were given intravenous anistreplase (30 U) either at home or later, after arrival in the hospital. RESULTS. Anistreplase was given at home or in the hospital at median times of 101 and 240 min, respectively, after symptom onset. The median time saved by domiciliary thrombolysis was 130 min. By the end of 1 year after trial entry, 17 (10.4%) of 163 patients given anistreplase at home died compared with 32 (21.6%) of 148 in those allotted anistreplase in the hospital (relative reduction 52%, 95% confidence interval 14% to 89%, p = 0.007). CONCLUSIONS. In this trial the time saved by domiciliary thrombolysis by primary care physicians was > 2 h. It is likely that a similar time saving would be achieved if prehospital thrombolysis were to become established practice. Prehospital thrombolysis resulted in a halving of the mortality rate from acute myocardial infarction.

This article has been cited by other articles:

				S McLean, G Egan, P Connor, and A D Flapan Collaborative decision-making between paramedics and CCU nurses based on 12-lead ECG telemetry expedites the delivery of thrombolysis in ST elevation myocardial infarction Emerg. Med. J., June 1, 2008; 25(6): 370 - 374. [Abstract] [Full Text] [PDF]

				S. G. Goodman, V. Menon, C. P. Cannon, G. Steg, E. M. Ohman, and R. A. Harrington Acute ST-Segment Elevation Myocardial Infarction: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 708S - 775S. [Abstract] [Full Text] [PDF]

				W. E. Boden, K. Eagle, and C. B. Granger Reperfusion Strategies in Acute ST-Segment Elevation Myocardial Infarction: A Comprehensive Review of Contemporary Management Options J. Am. Coll. Cardiol., September 4, 2007; 50(10): 917 - 929. [Abstract] [Full Text] [PDF]

				P G Steg, J-P Cambou, P Goldstein, E Durand, P Sauval, Z Kadri, D Blanchard, J-M Lablanche, P Gueret, Y Cottin, et al. Bypassing the emergency room reduces delays and mortality in ST elevation myocardial infarction: the USIC 2000 registry Heart, October 1, 2006; 92(10): 1378 - 1383. [Abstract] [Full Text] [PDF]

				E. Bjorklund, U. Stenestrand, J. Lindback, L. Svensson, L. Wallentin, B. Lindahl, and on behalf of the RIKS-HIA Investigators Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction Eur. Heart J., May 2, 2006; 27(10): 1146 - 1152. [Abstract] [Full Text] [PDF]

				S Johnston, R Brightwell, and M Ziman Paramedics and pre-hospital management of acute myocardial infarction: diagnosis and reperfusion Emerg. Med. J., May 1, 2006; 23(5): 331 - 334. [Abstract] [Full Text] [PDF]

				F. W.A. Verheugt, B. J. Gersh, and P. W. Armstrong Aborted myocardial infarction: a new target for reperfusion therapy Eur. Heart J., April 2, 2006; 27(8): 901 - 904. [Abstract] [Full Text] [PDF]

				Part 8: Stabilization of the Patient With Acute Coronary Syndromes Circulation, December 13, 2005; 112(24_suppl): IV-89 - IV-110. [Full Text] [PDF]

				Part 5: Acute Coronary Syndromes Circulation, November 29, 2005; 112(22_suppl): III-55 - III-72. [Full Text] [PDF]

				K. Huber, R. D. Caterina, S. D. Kristensen, F. W.A. Verheugt, G. Montalescot, L. B. Maestro, F. V. d. Werf, and for the Task Force on Pre-hospital Reperfusion The Pre-hospital reperfusion therapy: a strategy to improve therapeutic outcome in patients with ST-elevation myocardial infarction Eur. Heart J., October 1, 2005; 26(19): 2063 - 2074. [Full Text] [PDF]

				H Dargie Heart failure post-myocardial infarction: a review of the issues Heart, May 1, 2005; 91(suppl_2): ii3 - ii6. [Abstract] [Full Text] [PDF]

				J.A.L. Smith, K.P. Jennings, E.A. Anderson, P. Green, and G.S. Hillis Reducing call-to-needle times: the critical role of pre-hospital thrombolysis QJM, October 1, 2004; 97(10): 655 - 661. [Abstract] [Full Text] [PDF]

				V. Menon, R. A. Harrington, J. S. Hochman, C. P. Cannon, S. D. Goodman, R. G. Wilcox, H. J. Schunemann, and E. M. Ohman Thrombolysis and Adjunctive Therapy in Acute Myocardial Infarction: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 549S - 575S. [Abstract] [Full Text] [PDF]

				H.A. Alhadi and K.A.A. Fox Do we need additional markers of myocyte necrosis: the potential value of heart fatty-acid-binding protein QJM, April 1, 2004; 97(4): 187 - 198. [Abstract] [Full Text] [PDF]

				E J P Lamfers, T E H Hooghoudt, D P Hertzberger, A Schut, P W J Stolwijk, and F W A Verheugt Abortion of acute ST segment elevation myocardial infarction after reperfusion: incidence, patients' characteristics, and prognosis Heart, May 1, 2003; 89(5): 496 - 501. [Abstract] [Full Text] [PDF]

				J Rawles GREAT: 10 year survival of patients with suspected acute myocardial infarction in a randomised comparison of prehospital and hospital thrombolysis Heart, May 1, 2003; 89(5): 563 - 564. [Full Text] [PDF]

				M. J. Schull, L. J. Morrison, M. Vermeulen, and D. A. Redelmeier Emergency department overcrowding and ambulance transport delays for patients with chest pain Can. Med. Assoc. J., February 4, 2003; 168(3): 277 - 283. [Abstract] [Full Text] [PDF]

				T.P. Mathew, I.B.A. Menown, D. McCarty, H. Gracey, L. Hill, and A.A.J. Adgey Impact of pre-hospital care in patients with acute myocardial infarction compared with those first managed in-hospital Eur. Heart J., January 2, 2003; 24(2): 161 - 171. [Abstract] [Full Text] [PDF]

				H. P. Selker, J. R. Beshansky, J. L. Griffith, and for the TPI Trial Investigators* Use of the Electrocardiograph-Based Thrombolytic Predictive Instrument To Assist Thrombolytic and Reperfusion Therapy for Acute Myocardial Infarction: A Multicenter, Randomized, Controlled, Clinical Effectiveness Trial Ann Intern Med, July 16, 2002; 137(2): 87 - 95. [Abstract] [Full Text] [PDF]

				J. Llevadot, R. P. Giugliano, and E. M. Antman Bolus Fibrinolytic Therapy in Acute Myocardial Infarction JAMA, July 25, 2001; 286(4): 442 - 449. [Abstract] [Full Text] [PDF]

				E. M. Ohman, R. A. Harrington, C. P. Cannon, G. Agnelli, J. A. Cairns, and J.W. Kennedy Intravenous Thrombolysis in Acute Myocardial Infarction Chest, January 1, 2001; 119(1_suppl): 253S - 277S. [Full Text] [PDF]

				L. J. Morrison, P. R. Verbeek, A. C. McDonald, B. V. Sawadsky, and D. J. Cook Mortality and Prehospital Thrombolysis for Acute Myocardial Infarction: A Meta-analysis JAMA, May 24, 2000; 283(20): 2686 - 2692. [Abstract] [Full Text] [PDF]

				G. A. Ewy and J. P. Ornato Emergency cardiac care: introduction J. Am. Coll. Cardiol., March 15, 2000; 35(4): 825 - 880. [Full Text] [PDF]

				M A DE BELDER and J A HALL Infarct angioplasty Heart, October 1, 1999; 82(4): 399 - 401. [Full Text] [PDF]

				K. Sheikh, D. R. Thiemann, J. Coresh, N. R. Powe, and E. L. Hannan The Relation between Volume and Outcome in Health Care N. Engl. J. Med., September 30, 1999; 341(14): 1085 - 1086. [Full Text]

				D. R. Thiemann, J. Coresh, W. J. Oetgen, and N. R. Powe The Association between Hospital Volume and Survival after Acute Myocardial Infarction in Elderly Patients N. Engl. J. Med., May 27, 1999; 340(21): 1640 - 1648. [Abstract] [Full Text] [PDF]

				A. V. MAKSIMENKO New Strategy of Thrombolysis: Conjunctive Effect of Plasminogen Activators with Different Pharmacokinetic Profile Ann. N.Y. Acad. Sci., December 13, 1998; 864(1): 96 - 105. [Abstract] [Full Text] [PDF]

				J Rawles, C Sinclair, K Jennings, L Ritchie, and N Waugh Audit of prehospital thrombolysis by general practitioners in peripheral practices in Grampian Heart, September 1, 1998; 80(3): 231 - 234. [Abstract] [Full Text]

				X.-C. Wu, R. Ye, Y. Duan, and S.-L. Wong Engineering of Plasmin-Resistant Forms of Streptokinase and Their Production in Bacillus subtilis: Streptokinase with Longer Functional Half-Life Appl. Envir. Microbiol., March 1, 1998; 64(3): 824 - 829. [Abstract] [Full Text]

				M W Millar-Craig, A V Joy, M Adamowicz, R Furber, and B Thomas Reduction in treatment delay by paramedic ECG diagnosis of myocardial infarction with direct CCU admission Heart, November 1, 1997; 78(5): 456 - 461. [Abstract] [Full Text] [PDF]

				C. P. Cannon, C. H. McCabe, C. M. Gibson, M. Ghali, R. F. Sequeira, G. R. McKendall, J. Breed, N. B. Modi, N. L. Fox, R. P. Tracy, et al. TNK-Tissue Plasminogen Activator in Acute Myocardial Infarction: Results of the Thrombolysis in Myocardial Infarction (TIMI) 10A Dose-Ranging Trial Circulation, January 21, 1997; 95(2): 351 - 356. [Abstract] [Full Text]

				M. R. Di Tullio, R. L. Sacco, D. Gersony, H. Nayak, R. G. Weslow, D. E. Kargman, and S. Homma Aortic atheromas and acute ischemic stroke: A transesophageal echocardiographic study in an ethnically mixed population Neurology, June 1, 1996; 46(6): 1560 - 1566. [Abstract] [Full Text] [PDF]

				S.-A. Chen, C.-E. Chiang, C.-T. Tai, S.-H. Lee, C.-W. Chiou, K.-C. Ueng, Z.-C. Wen, C.-C. Cheng, and M.-S. Chang Longitudinal Clinical and Electrophysiological Assessment of Patients With Symptomatic Wolff-Parkinson-White Syndrome and Atrioventricular Node Reentrant Tachycardia Circulation, June 1, 1996; 93(11): 2023 - 2032. [Abstract] [Full Text]

				J. Bogousslavsky, S. Garazi, X. Jeanrenaud, N. Aebischer, G. Van Melle, and For the Lausanne Stroke with Paradoxal Embolism St Stroke recurrence in patients with patent foramen ovale: The Lausanne Study Neurology, May 1, 1996; 46(5): 1301 - 1301. [Abstract] [Full Text] [PDF]

				J. Rawles Magnitude of benefit from earlier thrombolytic treatment in acute myocardial infarction: new evidence from Grampian region early anistreplase trial (GREAT) BMJ, January 27, 1996; 312(7025): 212 - 215. [Abstract] [Full Text]

				J McMurray and A Rankin Recent Advances: Cardiology - I: Treatment of myocardial infarction, unstable angina, and angina pectoris BMJ, November 19, 1994; 309(6965): 1343 - 1350. [Full Text]

				J Rawles Attitudes of general practitioners to prehospital thrombolysis BMJ, August 6, 1994; 309(6951): 379 - 379. [Abstract] [Full Text]

				STARTING THROMBOLYTIC THERAPY AT HOME SAVES LIVES Journal Watch (General), January 28, 1994; 1994(128): 2 - 2. [Full Text]