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J Am Coll Cardiol, 2002; 40:71-77
© 2002 by the American College of Cardiology Foundation
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CLINICAL STUDY

Evaluation of the time saved byprehospital initiation of reteplase forST-elevation myocardial infarction

Results of the early retavase-thrombolysisin myocardial infarction (ER-TIMI) 19 trial

David A. Morrow, MD, MPH*,*, Elliott M. Antman, MD, FACC*, Assaad Sayah, MD{dagger}, Kristin C. Schuhwerk, BS*, Robert P. Giugliano, MD, SM*, James A. deLemos, MD{ddagger}, Michael Waller, MD§, Sidney A. Cohen, MD§, Donald G. Rosenberg, MD||, Sally S. Cutler, MBA*, Carolyn H. McCabe, BS*, Ron M. Walls, MD, Eugene Braunwald, MD, FACC* Early Retavase-Thrombolysis In Myocardial Infarction (ER-TIMI) 19 Investigators

* Cardiovascular Division and TIMI Study Group, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
{dagger} Department of Emergency Medicine, Good Samaritan Medical Center, Brockton, Massachusetts, USA
{ddagger} Department of Medicine, University of Texas Southwestern, Dallas, Texas, USA
§ Centocor, Inc., Malvern, Pennsylvania, USA
|| Division of Cardiology, University of Florida, Miami, Florida, USA
Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA

Manuscript received January 30, 2002; revised manuscript received March 7, 2002, accepted March 23, 2002.

* Reprint requests and correspondence: Dr. David A. Morrow, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis Street,Boston, Massachusetts 02115, USA.
damorrow{at}bics.bwh.harvard.edu

OBJECTIVES: The Early Retavase-Thrombolysis In Myocardial Infarction (ER-TIMI) 19 trial tested the feasibility of prehospital initiation of the bolus fibrinolytic reteplase (rPA) and determined the time saved by prehospital rPA in the setting of contemporary emergency cardiac care.

BACKGROUND: Newer bolus fibrinolytics have undergone only limited evaluation for prehospital administration. In addition, as door-to-drug times have decreased, the relevance of findings from prior trials of prehospital fibrinolysis has become less certain.

METHODS: Patients (n = 315) with ST-elevation myocardial infarction (STEMI) were enrolled in 20 emergency medical systems in North America. The time from emergency medical service (EMS) arrival to administration of a fibrinolytic was compared between study patients receiving prehospital rPA and sequential control patients from 6 to 12 months before the study who received a fibrinolytic in the hospital.

RESULTS: Acute myocardial infarction was confirmed in 98%. The median time from EMS arrival to initiation of rPA was 31 min (25th to 75th percentile, 24 min to 37 min). The time from EMS arrival to in-hospital fibrinolytic for 630 control patients was 63 min (25th to 75th percentile, 48 min to 89 min), resulting in a time saved of 32 min (p < 0.0001). By 30 min after first medical contact, 49% of study patients had received the first bolus of fibrinolytic compared with only 5% of controls (p < 0.0001). In-hospital mortality was 4.7%. Intracranial hemorrhage occurred in 1.0%.

CONCLUSIONS: Prehospital administration of rPA is a feasible approach to accelerating reperfusion in patients with STEMI. Valuable time savings can be achieved in the setting of contemporary transport and door-to-drug times and may translate into an improvement in clinical outcomes.

Abbreviations and Acronyms
  CI
  confidence interval
  ECG
  electrocardiogram
  EMS
  emergency medical service
  ER-TIMI
  Early Retavase-Thrombolysis In Myocardial Infarction trial
  MI
  myocardial infarction
  MITI
  Myocardial Infarction Triage and Intervention trial
  rPA
  reteplase
  STEMI
  ST-segment elevation myocardial infarction
  STRES
  ST-segment resolution




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