Читать книгу Emergency Medical Services - Группа авторов - Страница 234

Since fibrinolytics were introduced to emergency cardiac care in the mid‐1980s, some have proposed initiating the drug in the prehospital setting. Several studies published in the early 1990s showed that the strategy was feasible and that it could decrease mortality from STEMI in settings that had relatively long EMS response and/or transport intervals [44, 45]. Additional studies reinforced the original findings. A meta‐analysis of pooled results from six randomized trials enrolling more than 6,000 subjects concluded that prehospital initiation of fibrinolytics decreased all‐cause mortality by shortening initiation of fibrinolytics by 58 minutes [46].

Prehospital fibrinolysis has not been used commonly in the United States compared to Europe, where there are often physician‐staffed ambulances [47]. However, even in Europe prehospital fibrinolysis has been replaced by primary PCI for treatment of STEMI. In a prospective observational cohort study of 26,205 consecutive patients with STEMI in Sweden, representing about 95% of the population of STEMI patients in the country, those who were treated with primary PCI had lower 30‐day mortality than those treated with fibrinolytics in the hospital (4.9% versus 11.4%) [48]. Primary PCI patients also had lower mortality than those treated with prehospital fibrinolytics (4.9% versus 7.6%).

Several large clinical trials examined the strategy of transferring patients to PCI‐capable institutions from local hospitals compared with administration of fibrinolytics at the local hospitals [49, 50]. For situations in which transfer directly to a center capable of primary PCI is not possible in a timely fashion, a strategy of fibrinolysis at a non‐PCI hospital followed by transport to a regional PCI center may be necessary.