The impact of pre-hospital thrombolytic treatment on re-infarction rates: analysis of the Myocardial Infarction National Audit Project (MINAP).
OBJECTIVE
To examine the frequency and determinants of re-infarction after thrombolytic treatment of ST-elevation myocardial infarction (STEMI).


METHODS
Observational study of national registry.


METHODS
Emergency ambulance services and admitting hospitals in England and Wales.


METHODS
35 356 patients with STEMI given thrombolytic treatment in 2005-6.


METHODS
Re-infarction during hospital admission.


RESULTS
For 22 391 patients (63.3%) the presence or absence of re-infarction was recorded, and 1460 (6.5%) had re-infarction. Re-infarction rates with in-hospital treatment were similar for reteplase (6.5%) and tenecteplase (6.4%). When the interval from pre-hospital treatment to hospital arrival was greater than 30 minutes re-infarction rates were 12.5% for reteplase, and 11.4% for tenecteplase. Overall, re-infarction rates were higher after pre-hospital treatment with tenecteplase than reteplase (9.6% vs 6.6%, p = 0.005). After multivariate analysis independent predictors of re-infarction for tenecteplase were pre-hospital treatment, OR 1.44 (95% CI 1.21 to 1.71, p<0.001) and weight in the highest quartile compared to the lowest, OR 1.66 (95% CI 1.19 to 2.31, p = 0.003). For reteplase neither factor predicted re-infarction. Bleeding was less common with pre-hospital treatment-overall 1.8% against 3.1%; intracerebral bleeding 0.4% against 0.7%.


CONCLUSIONS
Pre-hospital treatment with tenecteplase was associated with higher re-infarction rates. Longer intervals from pre-hospital treatment to arrival in hospital were associated with high re-infarction rates for both tenecteplase and reteplase. Differences in the use of adjunctive anti-thrombotic therapy in the two treatment environments may underlie the differences in re-infarction rates and bleeding complications observed between pre-hospital and in-hospital thrombolytic treatment.
Horne
S
S
Emergency Department, Royal Cornwall Hospital, Truro, UK.
Weston
C
C
Quinn
T
T
Hicks
A
A
Walker
L
L
Chen
R
R
Birkhead
J
J
D000368:Aged; D001835:Body Weight; D004638:Emergency Treatment; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D011994:Recombinant Proteins / Q000627:therapeutic use; D012008:Recurrence; D012189:Retrospective Studies; D000077785:Tenecteplase; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D011994:Recombinant Proteins; C087896:reteplase; D010959:Tissue Plasminogen Activator; D000077785:Tenecteplase