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Related Experiment Videos

The level I cardiovascular center: is it time?

Richard W Smalling1, Gregory Giesler

  • 1Division of Cardiovascular Medicine, The University of Texas Medical School at Houston and The Memorial Hermann Heart Center, Houston, TX 77030, USA. richard.w.smalling@uth.tmc.edu

The American Heart Hospital Journal
|April 9, 2005
PubMed
Summary

Expedited treatment for acute myocardial infarction (AMI) using prehospital thrombolysis and rapid percutaneous coronary intervention (PCI) can significantly reduce mortality. This strategy has the potential to save thousands of lives daily in the US.

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Area of Science:

  • Cardiology
  • Emergency Medicine
  • Clinical Trials

Background:

  • Acute myocardial infarction (AMI) affects 1.5 million Americans annually with no uniform treatment approach.
  • Current treatment rates for ST-elevation AMI with reperfusion therapies (thrombolysis or PCI) are suboptimal, leaving many patients at higher risk.
  • Existing trauma systems efficiently manage critically injured patients, highlighting a need for similar efficiency in AMI care.

Purpose of the Study:

  • To evaluate the efficacy of prehospital thrombolytic therapy followed by immediate transfer for facilitated percutaneous coronary intervention (PCI) in reducing mortality for ST-elevation AMI patients.
  • To propose a randomized clinical trial, the Prehospital Administration of Thrombolytic Therapy With Urgent Culprit Artery Revascularization (PATCAR) trial, to validate this expedited treatment strategy.

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Main Methods:

  • Review of findings from trials such as ER-TIMI 19, SPEED, and PAMI investigating early reperfusion strategies.
  • Analysis of time to treatment, ST-elevation resolution, infarct-related artery flow rates (TIMI 3), and in-hospital mortality.
  • Proposed model: Prehospital, partial-dose thrombolysis followed by direct transport to a Level I cardiovascular center for facilitated PCI.

Main Results:

  • ER-TIMI 19 showed a 32-minute reduction in treatment time and ST-elevation resolution with prehospital thrombolysis, associated with 4.7% in-hospital mortality.
  • SPEED investigators demonstrated improved infarct-related artery TIMI 3 flow (86%) with facilitated PCI and combination therapy.
  • PAMI data indicate <1% 6-month mortality for patients achieving TIMI 3 flow during primary PCI.

Conclusions:

  • Implementing a strategy of prehospital thrombolysis and facilitated PCI at a specialized center could reduce ST-elevation AMI mortality from 6%-10% to <4%.
  • This approach has the potential to save approximately 500 lives per day in the United States.
  • A randomized clinical trial (PATCAR) is necessary to confirm the benefits of this proposed AMI treatment pathway.