title: Comparison of pre-hospital combination-fibrinolysis plus conventional care with pre-hospital combination-fibrinolysis plus facilitated percutaneous coronary intervention in acute myocardial infarction.
abstract: OBJECTIVE
  Early and complete reperfusion is the main treatment goal in ST-elevation myocardial infarction (STEMI). The timely optimal reperfusion strategy might be a pre-hospital initiated pharmacological reperfusion with subsequent facilitated percutaneous coronary intervention (PCI). This approach has been compared with pre-hospital combination-fibrinolysis only to determine whether either one of these methods offer advantages with respect to final infarct size.
  
  
  RESULTS
  Patients with STEMI were randomized to either pre-hospital combination-fibrinolysis (half-dose reteplase+abciximab) with standard care (n=82) or pre-hospital combination-fibrinolysis with facilitated PCI (n=82). Primary endpoint was the infarct size assessed by delayed enhancement magnetic resonance. Secondary endpoints were ST-segment resolution at 90 min and a composite of death, re-myocardial infarction, major bleeding, and stroke at 6 months. The infarct size was lower after facilitated PCI with 5.2% [interquartile range (IQR) 1.3-11.2] as opposed to 10.4% (IQR 3.4-16.3) after pre-hospital combination-fibrinolysis (P=0.001). Complete ST-segment resolution was 80.0% after facilitated PCI vs. 51.9% after pre-hospital combination-fibrinolysis (P<0.001). After facilitated PCI, there was a trend towards a lower event rate in the combined clinical endpoint (15 vs. 25%, P=0.10, relative risk 0.57, 95% CI 0.28-1.13).
  
  
  CONCLUSIONS
  In patients with STEMI, additional facilitated PCI after pre-hospital combination-fibrinolysis results in an improved tissue perfusion with subsequent smaller infarct size as opposed to pre-hospital combination-fibrinolysis alone. This translates into a trend towards a better clinical outcome.
authors.affiliation: Department of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Strümpellstr. 39, 04289 Leipzig, Germany. thielh@medizin.uni-leipzig.de
authors.forename: Holger
authors.initials: H
authors.lastname: Thiele
authors.forename: Lothar
authors.initials: L
authors.lastname: Engelmann
authors.forename: Kathleen
authors.initials: K
authors.lastname: Elsner
authors.forename: Mathias J
authors.initials: MJ
authors.lastname: Kappl
authors.forename: Wulf-Hinrich
authors.initials: WH
authors.lastname: Storch
authors.forename: Kazem
authors.initials: K
authors.lastname: Rahimi
authors.forename: Andreas
authors.initials: A
authors.lastname: Hartmann
authors.forename: Dietrich
authors.initials: D
authors.lastname: Pfeiffer
authors.forename: Georg D
authors.initials: GD
authors.lastname: Kneissl
authors.forename: Dieter
authors.initials: D
authors.lastname: Schneider
authors.forename: Thomas
authors.initials: T
authors.lastname: Möller
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Heberling
authors.forename: Ina
authors.initials: I
authors.lastname: Weise
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schuler
mesh_terms: D000328:Adult; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000379:methods*; D003131:Combined Modality Therapy; D004632:Emergency Medical Services / Q000379:methods*; D004638:Emergency Treatment; D005260:Female; D006760:Hospitalization; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome