Pre-hospital thrombolysis vs. PPCI – a regional Australian experience

The Hunter New England Local Health District developed a system of care for STEMI patients based on their individual estimated travel time to the nearest cath. lab. If the total travel time was more than 60 minutes, pre-hospital thrombolysis was administered. If the travel time was thought to be shorter than 60 minutes, or if fibrinolysis was contraindicated, PPCI was the reperfusion therapy of choice. Patients with successful reperfusion after thrombolysis were not required to be transferred to the cath lab immediately, but rather at the earliest possible convenience provided they remained clinically stable.

The analysis summarised here is based on 484 consecutive, non-randomised STEMI patients treated between August 2008 and August 2013 at the John Hunter Hospital, Newcastle, Australia. 150 patients received pre-hospital thrombolysis and 334 underwent PPCI.

All-cause mortality at 12 months was the primary efficacy endpoint. Safety was assessed based on bleeding.

The median time from FMC to reperfusion therapy was 35 min (IQR, 28-43 min) for the pre-hospital thrombolysis group and 130 min (IQR, 100-150 min) for the PPCI group.

There were no significant differences in mortality at 12 months between the two types of reperfusion therapies. 6.7% (10/150) of the pre-hospital thrombolysis patients and 7.2% (24/334) of the PPCI patients died within 12 months (RR, 0.93; 95% CI: 0.45-1.9; p=0.84). 1.3% of patients in the pre-hospital thrombolysis group had a major bleeding event. No patients in the PPCI group had a major bleed.

Using a time-based approach to make a choice regarding type of reperfusion therapy has been shown to be safe and effective.