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Prehospital ADP-Receptor Antagonists in STEMI

Question Type:
Intervention
Full Question:
Among adult patients with suspected STEMI outside of the hospital  (P), does does prehospital administration of an ADP-receptor antagonist (clopidogrel, prasugrel, or ticagrelor) in addition to usual therapy  (I), compared with compared with administration of an ADP-receptor antagonist in-hospital  (C), change death, Intracranial Hemorrhage, revascularization, stroke, major bleeding, reinfarction (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified very-low-quality evidence (downgraded for imprecision and reporting bias) from 3 RCTs(Zeymer 2012, 305-312; Ducci 2013, 4814-4816; Montalescot 2014, 1016-1027) enrolling 2365 patients showing no additional benefit with prehospital administration of an ADP-receptor antagonist compared with in-hospital administration (OR, 1.58; 95% CI, 0.90–2.78) (Figure 4). For the important outcome of major bleeding, we have identified very-low-quality evidence (downgraded for imprecision and reporting bias) from 3 RCTs(Zeymer 2012, 305-312; Ducci 2013, 4814-4816; Montalescot 2014, 1016-1027) enrolling 2365 patients showing no additional benefit with prehospital administration of an ADP-receptor antagonist compared with in-hospital administration (OR, 1.12; 95% CI, 0.72–1.74).
Treatment Recommendation:
We suggest that when ADP-receptor antagonists are given to suspected STEMI patients with a planned primary PCI approach, administration can occur in either the prehospital or in-hospital setting, but there is insufficient evidence to change existing practice (very-low-quality evidence, weak recommendation). Values, Preferences, and Task Force InsightsIn making this recommendation we place a higher value on not recommending adding complexity to prehospital treatment regimens over uncertain benefits. There was no difference in mortality or major bleeding with either prehospital or in-hospital administration. We acknowledge, however, that although stent thrombosis was not considered as an outcome a priori, 1 study did report lower early (≤24 hours) stent thrombosis rates with prehospital (0.8%) versus in-hospital administration (0%).(Montalescot 2014, 1016-1027) However, there were no differences in mortality, or their composite ischemic end points in this trial. The relevance of this very rare occurrence of early stent thromobosis in balance with the rare occurrence of additional bleeding if the patient underwent an emergency surgical strategy rather than PCI will need to be elucidated in further studies. Therefore, we find that the relative benefit to administering these agents prehospital versus in-hospital is marginal at best and may be offset by additional harms that could only be evaluated by larger RCTs that include these additional patient-oriented outcomes.
CoSTR Attachments:
ACS 335_Evidence Profile tables_n.docx    
AMSTAR_ACS 335.pdf    

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