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European Heart Journal Advance Access originally published online on August 1, 2005
European Heart Journal 2005 26(19):1956-1963; doi:10.1093/eurheartj/ehi432
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© The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org

Comparison of pre-hospital combination-fibrinolysis plus conventional care with pre-hospital combination-fibrinolysis plus facilitated percutaneous coronary intervention in acute myocardial infarction

Holger Thiele1,*, Lothar Engelmann2, Kathleen Elsner1, Mathias J. Kappl1, Wulf-Hinrich Storch4, Kazem Rahimi1, Andreas Hartmann3, Dietrich Pfeiffer2, Georg D. Kneissl5, Dieter Schneider6, Thomas Möller7, Hans J. Heberling8, Ina Weise9, Gerhard Schuler1 for the Leipzig Prehospital Fibrinolysis Group

1Department of Internal Medicine/Cardiology, University of Leipzig—Heart Center, Strümpellstr. 39, 04289 Leipzig, Germany
2University of Leipzig, Leipzig, Germany
3Städtisches Klinikum St Georg, Leipzig, Germany
4Rettungsamt Leipzig, Leipzig, Germany
5Ambulantes Herzzentrum Elsterstr., Leipzig, Germany
6Kath. Krankenhaus St Elisabeth, Leipzig, Germany
7Ev. Luth. Diakonissen-Krankenhaus, Leipzig, Germany
8Städtische Klinik St Georg—Stadtkrankenhaus, Leipzig, Germany
9Park-Krankenhaus Leipzig Südost GmbH, Leipzig Germany

Received 3 January 2005; revised 16 June 2005; accepted 30 June 2005; online publish-ahead-of-print 1 August 2005.

* Corresponding author. Tel: +49 341 865 1428; fax: +49 341 865 1177. E-mail address: thielh{at}medizin.uni-leipzig.de

See page 1937 for the editorial comment on this article (doi:10.1093/eurheartj/ehi462)

Aims Early and complete reperfusion is the main treatment goal in ST-elevation myocardial infarction (STEMI). The timely optimal reperfusion strategy might be a pre-hospital initiated pharmacological reperfusion with subsequent facilitated percutaneous coronary intervention (PCI). This approach has been compared with pre-hospital combination-fibrinolysis only to determine whether either one of these methods offer advantages with respect to final infarct size.

Methods and results Patients with STEMI were randomized to either pre-hospital combination-fibrinolysis (half-dose reteplase+abciximab) with standard care (n=82) or pre-hospital combination-fibrinolysis with facilitated PCI (n=82). Primary endpoint was the infarct size assessed by delayed enhancement magnetic resonance. Secondary endpoints were ST-segment resolution at 90 min and a composite of death, re-myocardial infarction, major bleeding, and stroke at 6 months. The infarct size was lower after facilitated PCI with 5.2% [interquartile range (IQR) 1.3–11.2] as opposed to 10.4% (IQR 3.4–16.3) after pre-hospital combination-fibrinolysis (P=0.001). Complete ST-segment resolution was 80.0% after facilitated PCI vs. 51.9% after pre-hospital combination-fibrinolysis (P<0.001). After facilitated PCI, there was a trend towards a lower event rate in the combined clinical endpoint (15 vs. 25%, P=0.10, relative risk 0.57, 95% CI 0.28–1.13).

Conclusion In patients with STEMI, additional facilitated PCI after pre-hospital combination-fibrinolysis results in an improved tissue perfusion with subsequent smaller infarct size as opposed to pre-hospital combination-fibrinolysis alone. This translates into a trend towards a better clinical outcome.

Key Words: Acute myocardial infarction • Fibrinolysis • Pre-hospital treatment • Percutaneous coronary intervention • Facilitated angioplasty


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