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Prehospital Anticoagulants Versus None in STEMI

Question Type:
Intervention
Full Question:
Among adult patients with suspected STEMI outside of hospital transferred for primary PCI  (P), does does any anticoagulant administered prehospital (eg, bivalirudin, dalteparin, enoxaparin, fondaparinux, UFH)   (I), compared with compared with no anticoagulant administered prehospital  (C), change death, ICH, revascularization, major bleeding, stroke, reinfarction (O)?
Consensus on Science:
For the critical outcome of 30-day mortality, we have identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 non-RCT(Zijlstra 2002, 1733-1737) enrolling 1702 patients undergoing PPCI for STEMI showing no benefit of prehospital UFH versus in-hospital UFH (OR, 1.07; 95% CI, 0.595–1.924). For the important outcome of stroke, we have identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 non-RCT(Zijlstra 2002, 1733-1737) enrolling 1702 patients undergoing PPCI for STEMI showing no benefit of prehospital UFH over in-hospital UFH (OR, 0.25; 95% CI, 0.034–3.136) For the important outcome of myocardial infarction, we have identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 non-RCT(Zijlstra 2002, 1733-1737) enrolling 1702 patients undergoing PPCI for STEMI showing no benefit of prehospital UFH over in-hospital UFH (OR, 0.979; 95% CI, 0.366–2.62). For the important outcome of major bleeding, we have identified very-low-quality evidence (downgraded for indirectness and imprecision) from 1 non-RCT(Zijlstra 2002, 1733-1737) enrolling 1702 patients undergoing PPCI for STEMI showing no benefit of prehospital UFH over in-hospital UFH (OR, 0.699; 95% CI, 0.466–1.047). There was no direct evidence of other anticoagulant medications administered in the prehospital setting compared with in-hospital setting for STEMI patients.
Treatment Recommendation:
We suggest that when UFH is given in suspected STEMI patients with a planned primary PCI approach, administration can occur in either the prehospital or in-hospital setting, and there is insufficient evidence to change existing practice (weak recommendation, very-low-quality evidence). Values, Preferences, and Task Force Insights In making this recommendation, we place a higher value on not recommending adding complexity to prehospital treatment regimens over uncertain additional benefit.
CoSTR Attachments:
bias assessment prehosp UFH vs nothing FB_n.xlsx    
prehosp UFH vs nothing bias assessment_n.docx    

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