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Pre-hospital thrombolysis in rural Victoria: successes and missed opportunities
Abstract
proceed to angiography (p=0.04) as were patients with peak troponin >1g/L (OR 15.5, 95% CI 4.3–55.8). Conclusion: In patients with rapid atrial fibrillation and a troponin elevation, presence of chest pain and troponin levels above 1g/L was predictive of the likelihood to proceed to angiography. This may not influence outcome in these patients as the troponin likely represents Type 2 ischaemia. http://dx.doi.org/10.1016/j.hlc.2015.06.115 115 Pre-hospital thrombolysis for ST-segment elevation myocardial infarction (STEMI) A. Khan 1,∗ , A. Boyle 1 , P. Fletcher 1 , L. Savage 1 , P. Stewart 2 , T. Williams 1 1 Cardiovascular
Department, John Hunter Hospital, Newcastle, NSW, Australia 2 NSW Ambulance Service, NSW, Australia Background: Delivery of timely reperfusion is the goal for all patients with STEMI. However, delivering reperfusion therapy throughout the Hunter New England Local Health District (HNELHD), which covers 130,000 square kilometres or an area comparable in size to England, remains challenging. Current guidelines recommend implementation of systems of care to provide rapid reperfusion for all. Accordingly, a system of pre-hospital thrombolysis (PHT) was introduced in 2008 for the patients more than 60 minutes from primary PCI. Tenecteplase is delivered by ambulance officers after ECG transmission to confirm STEMI. Methods and Results: We assessed all-cause mortality of STEMI patients undergoing PHT in the HNELHD-150 patients (mean age: 61.7±12.6 years, Males: 76%, n=114) were administered PHT by the ambulance staff in HNELHD from August 2008 to August 2013. The median time to PHT from symptom onset was 93.5min (Range: 31-445 min). 82% (n=123) patients underwent cardiac catheterisation during the same admission, 24.7% (n=37) were for rescue PCI (median time: 4hours, Range: 2-10hours) and 41.3% (n=62) had TIMI flow grade ≥2. The 12-month survival was 93.3%. Over a median follow-up of 2.6 years, survival was 88.7%. This compares favourably with the STREAM and the FASTMI trials. Age was the only independent predictor of death. The incidence of TIMI major bleeding was 1.3% (n=2) with 1 bleeding related death. Conclusion: Our real-world experience shows that PHT followed by early transfer to a PCI-capable centre is a safe and effective reperfusion strategy for patients remote from primary PCI centres.
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http://dx.doi.org/10.1016/j.hlc.2015.06.116 116 Pre-hospital thrombolysis in rural Victoria: successes and missed opportunities E. Sinclair ∗ , K. Murdoch, P. Meddings Ambulance Victoria, Australia Background: The pre-hospital thrombolysis (PHT) project is a Victorian State Government funded Ambulance Victoria (AV) initiative being delivered in collaboration with the Victorian Clinical Cardiac Network. During 2014, Mobile Intensive Care Ambulance (MICA) paramedics in rural Victoria were trained and equipped to deliver PHT. PHT administration is delivered in accordance with the AV ST-elevation myocardial infarction (STEMI) clinical practice guideline (CPG). The CPG outlines inclusion and exclusion criteria. For a patient to receive PHT they must be located in excess of 30 minutes from the nearest thrombolysing hospital. Aims: The aim of the project is to deliver early intervention to patients suffering acute STEMI in locations where transport times delay hospital-based thrombolysis or percutaneous coronary intervention (PCI) beyond recommended timeframes. Method: Case review of all rural STEMI cases, both those receiving PHT and those who did not, with a view to understanding remaining gaps in timely reperfusion and opportunities for closure. Results: As at March 2015, 27 patients have received PHT and approximately 20 per week are ineligible for PHT. Analysis of these cases demonstrates the majority are either attended by Advanced Life Support (ALS) paramedics who are currently not equipped to deliver PHT, are within 30 minutes of in-hospital care or self-present to hospital. Discussion/Conclusion: These results raise questions about the urgent requirement for project expansion to ALS paramedics and the potential need to re-visit the 30-minute guideline. http://dx.doi.org/10.1016/j.hlc.2015.06.117
proceed to angiography (p=0.04) as were patients with peak troponin >1g/L (OR 15.5, 95% CI 4.3–55.8). Conclusion: In patients with rapid atrial fibrillation and a troponin elevation, presence of chest pain and troponin levels above 1g/L was predictive of the likelihood to proceed to angiography. This may not influence outcome in these patients as the troponin likely represents Type 2 ischaemia. http://dx.doi.org/10.1016/j.hlc.2015.06.115 115 Pre-hospital thrombolysis for ST-segment elevation myocardial infarction (STEMI) A. Khan 1,∗ , A. Boyle 1 , P. Fletcher 1 , L. Savage 1 , P. Stewart 2 , T. Williams 1 1 Cardiovascular
Department, John Hunter Hospital, Newcastle, NSW, Australia 2 NSW Ambulance Service, NSW, Australia Background: Delivery of timely reperfusion is the goal for all patients with STEMI. However, delivering reperfusion therapy throughout the Hunter New England Local Health District (HNELHD), which covers 130,000 square kilometres or an area comparable in size to England, remains challenging. Current guidelines recommend implementation of systems of care to provide rapid reperfusion for all. Accordingly, a system of pre-hospital thrombolysis (PHT) was introduced in 2008 for the patients more than 60 minutes from primary PCI. Tenecteplase is delivered by ambulance officers after ECG transmission to confirm STEMI. Methods and Results: We assessed all-cause mortality of STEMI patients undergoing PHT in the HNELHD-150 patients (mean age: 61.7±12.6 years, Males: 76%, n=114) were administered PHT by the ambulance staff in HNELHD from August 2008 to August 2013. The median time to PHT from symptom onset was 93.5min (Range: 31-445 min). 82% (n=123) patients underwent cardiac catheterisation during the same admission, 24.7% (n=37) were for rescue PCI (median time: 4hours, Range: 2-10hours) and 41.3% (n=62) had TIMI flow grade ≥2. The 12-month survival was 93.3%. Over a median follow-up of 2.6 years, survival was 88.7%. This compares favourably with the STREAM and the FASTMI trials. Age was the only independent predictor of death. The incidence of TIMI major bleeding was 1.3% (n=2) with 1 bleeding related death. Conclusion: Our real-world experience shows that PHT followed by early transfer to a PCI-capable centre is a safe and effective reperfusion strategy for patients remote from primary PCI centres.
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http://dx.doi.org/10.1016/j.hlc.2015.06.116 116 Pre-hospital thrombolysis in rural Victoria: successes and missed opportunities E. Sinclair ∗ , K. Murdoch, P. Meddings Ambulance Victoria, Australia Background: The pre-hospital thrombolysis (PHT) project is a Victorian State Government funded Ambulance Victoria (AV) initiative being delivered in collaboration with the Victorian Clinical Cardiac Network. During 2014, Mobile Intensive Care Ambulance (MICA) paramedics in rural Victoria were trained and equipped to deliver PHT. PHT administration is delivered in accordance with the AV ST-elevation myocardial infarction (STEMI) clinical practice guideline (CPG). The CPG outlines inclusion and exclusion criteria. For a patient to receive PHT they must be located in excess of 30 minutes from the nearest thrombolysing hospital. Aims: The aim of the project is to deliver early intervention to patients suffering acute STEMI in locations where transport times delay hospital-based thrombolysis or percutaneous coronary intervention (PCI) beyond recommended timeframes. Method: Case review of all rural STEMI cases, both those receiving PHT and those who did not, with a view to understanding remaining gaps in timely reperfusion and opportunities for closure. Results: As at March 2015, 27 patients have received PHT and approximately 20 per week are ineligible for PHT. Analysis of these cases demonstrates the majority are either attended by Advanced Life Support (ALS) paramedics who are currently not equipped to deliver PHT, are within 30 minutes of in-hospital care or self-present to hospital. Discussion/Conclusion: These results raise questions about the urgent requirement for project expansion to ALS paramedics and the potential need to re-visit the 30-minute guideline. http://dx.doi.org/10.1016/j.hlc.2015.06.117