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 ,
Kristin C. Schuhwerk, BS*,
Robert P. Giugliano, MD, SM*,
James A. deLemos, MD ,
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
Department of Emergency Medicine, Good Samaritan Medical Center, Brockton, Massachusetts, USA
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.
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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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