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European Heart Journal Advance Access published online on August 1, 2005
European Heart Journal, doi:10.1093/eurheartj/ehi432
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European Heart Journal © The European Society of Cardiology 2005; all rights reserved
Received January 3, 2005
Revised June 16, 2005
Accepted June 30, 2005

Clinical research

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

Holger Thiele 1*, Lothar Engelmann 2, Kathleen Elsner 1, Mathias J. Kappl 1, Wulf-Hinrich Storch 3, Kazem Rahimi 1, Andreas Hartmann 4, Dietrich Pfeiffer 2, Georg D. Kneissl 5, Dieter Schneider 6, Thomas Möller 7, Hans J. Heberling 8, Ina Weise 9, Gerhard Schuler 1, and for the Leipzig Prehospital Fibrinolysis Group

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

* To whom correspondence should be addressed.
Holger Thiele, E-mail: thielh{at}medizin.uni-leipzig.de


  Abstract

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.

Keywords: Acute myocardial infarction; Fibrinolysis; Pre-hospital treatment; Percutaneous coronary intervention; Facilitated angioplasty.
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