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Prehospital Fibrinolysis Versus ED Fibrinolysis

Question Type:
Intervention
Full Question:
Among adults who are suspected of having STEMI outside of a hospital  (P), does does prehospital fibrinolysis  (I), compared with compared with in-hospital fibrinolysis (C), change death, ICH, revascularization, major bleeding, stroke, reinfarction (O)?
Consensus on Science:
For the critical outcome of hospital mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 3 RCTs(Castaigne 1989, 30A-33A; Schofer 1990, 1429-1433; Weaver 1993, 1211-1216) enrolling 531 patients showing benefit for prehospital fibrinolysis compared with in-hospital fibrinolysis (OR, 0.46; 95% CI, 0.23–0.93) (Figure 6). For the critical outcome of intracranial hemorrhage, we have identified low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Schofer 1990, 1429-1433; Weaver 1993, 1211-1216) enrolling 438 patients showing no additional harm from prehospital fibrinolysis compared with in-hospital fibrinolysis (OR, 2.14; 95% CI, 0.39–11.84). For the important outcome of bleeding, we have identified low-quality evidence (downgraded for imprecision) from 2 RCTS(Schofer 1990, 1429-1433; Weaver 1993, 1211-1216) enrolling 438 patients showing no additional harm from prehospital fibrinolysis compared with in-hospital fibrinolysis (OR, 0.96; 95% CI, 0.40–2.32). For other outcomes (revascularization, reinfarction, and ischemic stroke), no evidence from RCTs was found.
Treatment Recommendation:
When fibrinolysis is the planned treatment strategy, we recommend using prehospital fibrinolysis in comparison with in-hospital fibrinolysis for STEMI in systems where the transport times are commonly greater than 30 minutes and can be accomplished by prehospital personnel using well-established protocols, comprehensive training programs, and quality assurance programs under medical oversight (strong recommendation, moderate-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on the reduction of mortality compared with no increased evidence of complications and consideration of the significant resource implications to implement a prehospital fibrinolysis program. With the advent of more PPCI availability, in some areas the comparison of prehospital fibrinolysis to PPCI is more relevant (see the next systematic review on this topic). The 3 studies that formed this evidence were all conducted more than 20 years ago. Since those studies showed combined benefit in mortality, no further RCTs have directly addressed this same question. To determine if there was more recent non-RCT evidence that might support or refute these early studies, a post hoc review was done and 1 relevant non-RCT was found from the last 5 years.(Zeymer 2009, 402-406) The review of this study confirmed the inherent risk of bias of a non-RCT. However, the study had similar findings of no greater harm from prehospital fibrinolysis, although it did not show the same potential mortality benefit. The real advantage of prehospital fibrinolysis is where transport times are greater than 30 minutes. These RCTs were conducted in healthcare settings with a difference in time between prehospital treatment and in-hospital treatment of 33 to 52 minutes. Transport times to hospital were 38 to 60 minutes. As the transport time shortens, any expected advantage is lost. The systems in the included studies included physician and other prehospital professionals who administered fibrinolysis by using well-established protocols, comprehensive training programs, and quality assurance programs under medical oversight.
CoSTR Attachments:
ac338revisedept.jpeg    
acs338alloutcomesfebePT.jpeg    
all outcomes.jpeg    
forest plot bleeding.pdf    
forest plot CVA.pdf    
forest plot ICH.pdf    
Forest plot survival.pdf    
grade table summary.jpeg    

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