Prehospital reteplase speeds time to treatment for STEMI: ER-TIMI 19

Fran Lowry

July 02, 2002

Bethesda, MD - Prehospital administration of the bolus fibrinolytic reteplase (rPA) (Retavase,  Centocor) by paramedics accelerates reperfusion in patients with ST-elevation myocardial infarction (STEMI) and may improve their clinical outcome, investigators for the Early Retavase-Thrombolysis In Myocardial Infarction (ER-TIMI) 19 trial say[1].

Early lysis given by trained emergency medical crews cut the time required to begin treatment for STEMI in half, Dr David Morrow (Brigham and Women's Hospital, Boston) et al write in the July 3, 2002 issue of the Journal of the American College of Cardiology.

"This study shows us that, even in the setting of contemporary cardiac care, with all the improvements we've made in shortening door-to-drug times and emergency transport times, that we can still save more time. In systems where the infrastructure exists so that we can do prehospital ECGs, there is little or no reason to delay appropriate therapy for these patients," Morrow remarked to heartwire .

ER-TIMI 19 evaluated 313 patients from 20 geographically diverse North American emergency medical services (EMS). Enrollment for the study occurred between May 1999 and July 2001. Ten systems were located in urban areas, 6 were in semiurban areas, and 4 were in rural areas; 10 of the systems were routinely performing prehospital 12-lead electrocardiography before their participation in the present study.

The time from emergency personnel arrival to administration of a fibrinolytic was compared between study patients and historical controls who had received fibrinolysis in the hospital 6 to 12 months before the start of ER-TIMI 19.

For patients receiving prehospital rPA, the median time from arrival of EMS to start of the first bolus of rPA was half that of those who received in-hospital fibrinolysis. In addition, significantly more patients received fibrinolysis within 30 minutes after the first medical contact in the ER-TIMI 19 group compared with controls, Morrow et al report.

Outcomes in ER-TIMI 19 group vs controls

End point Prehospital rPA(n=313) In-hospital fibrinolysis(n=630) p
Time to fibrinolysis (median) 31 minutes 63 minutes 0.0001
Fibrinolysis within 30 minutes 49% 5% 0.0001

Morrow said the fact that ER-TIMI 19 was done in a variety of settings, across a broad spectrum of emergency medical systems throughout the US and Canada, is one of its major strengths.

"We had a very diverse group of systems, from academic hospitals to community hospitals in rural, suburban, and urban areas. We also had systems with varied experience in terms of specialized training. But we found that with a relatively straightforward training program, the paramedics, who were working in conjunction with a hospital-based physician, were able to rapidly identify patients with symptoms suggestive of an MI who were eligible for fibrinolytic therapy and then administer reteplase rapidly," he told heartwire .

Although ER-TIMI 19 was not designed to examine the effect of prehospital fibrinolysis on survival, Morrow says it is reasonable to expect that accelerating reperfusion time would result in improved clinical outcomes.

"We've spent enormous sums of money on trying to develop more effective thrombolytics but so far we have not been able to show any improvement in survival, and we need to think more broadly about other innovations we could make to improve outcomes. Time is one very important factor that we can influence," he said.

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