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Prehospital Triage to PCI Center Versus Prehospital Fibrinolysis

Question Type:
Intervention
Full Question:
Among adult patients with suspected STEMI outside of a hospital  (P), does does direct triage and transport to a PCI center  (I), compared with compared with prehospital fibrinolysis  (C), change medium term mortality (30 day), ICH, long term mortality (6-60 months), major bleeding (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 4 RCTs(Bonnefoy 2002, 825-829; Armstrong 2006, 1530-1538; Thiele 2011, 605-614; Armstrong 2013, 1379-1387) enrolling 2887 STEMI patients showing no differential benefit to either therapy (direct triage and transport to a PCI center compared with prehospital fibrinolysis) (OR, 1.03; 95% CI, 0.72–1.46) (Figure 7). For the critical outcome of 1-year mortality, we have identified moderate-quality evidence (downgraded for imprecision) from 2 RCTs(Armstrong 2006, 1530-1538; Sinnaeve 2014, 1139-1145) enrolling 1877 STEMI patients showing no difference between direct triage and transport to a PCI center compared with prehospital fibrinolysis (OR, 0.88; 95% CI, 0.60–1.27). For the critical outcome of intracranial hemorrhage, we have identified moderate-quality evidence (downgraded for imprecision) from 4 RCTs(Bonnefoy 2002, 825-829; Armstrong 2006, 1530-1538; Thiele 2011, 605-614; Armstrong 2013, 1379-1387) enrolling 2887 STEMI patients showing less harm with direct triage and transport to a PCI center compared with prehospital fibrinolysis (OR, 0.21; 95% CI, 0.05–0.84).
Treatment Recommendation:
We suggest that where PCI facilities are available in a geographic region, that direct triage and transport for PCI is preferred (weak recommendation, low-quality evidence). There is moderate evidence that mortality is not reduced and low-quality evidence of harm from fibrinolysis. We suggest that where PCI facilities are not available in a geographic region, that prehospital fibrinolysis is a reasonable alternative to triage and transport directly to PCI. Values, Preferences, and Task Force Insights In making this recommendation, we are placing a higher value on avoiding iatrogenic harm and a lower value on uncertain benefits on survival. Given the lack of mortality benefit, we are not suggesting the addition of new PCI facilities for this indication and recognize that concentration in fewer high-volume centers may provide better outcomes.
CoSTR Attachments:
341 SOF Table.pdf    
ILCOR Data Collection Form PH Lysis vs PCI2.xls    
Summary of Bias Assessments Direct to PPCI vs PH lysis MW8_n.xlsx    

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