Time to treatment and the impact of a physician on prehospital management of acute ST elevation myocardial infarction: insights from the ASSENT-3 PLUS trial

• Published in: Heart (British Cardiac Society) Vol. 91; no. 11; pp. 1400 - 1406
• Main Authors: Welsh, R C, Chang, W, Goldstein, P, Adgey, J, Granger, C B, Verheugt, F W A, Wallentin, L, Van de Werf, F, Armstrong, P W
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and British Cardiovascular Society 01-11-2005; BMJ; BMJ Publishing Group LTD; Copyright 2005 by Heart
• Subjects: acute myocardial infarction; Age Factors; ASSENT; assessment of the safety and efficacy of a new thrombolytic; Biological and medical sciences; Blood Pressure - physiology; CAPTIM; Cardiology. Vascular system; Cardiovascular Medicine; comparison of angioplasty to prehospital thrombolysis trial in myocardial infarction; Confidence intervals; Coronary heart disease; Diagnosis, Differential; Drug Therapy, Combination; early retavase-thrombolysis in myocardial infarction; emergency medical services; Emergency Medical Services - organization & administration; Emergency Medical Services - standards; Emergency Medical Services/organization & administration/standards; EMS; Enoxaparin - administration & dosage; ER-TIMI-23; Europe; Female; Fibrinolytic Agents - administration & dosage; Heart; Heart attacks; Heart Rate - physiology; Humans; Infusions, Intravenous; international variation; Male; Medical sciences; Middle Aged; MITI; Molecular weight; Mortality; Myocardial Infarction - diagnosis; Myocardial Infarction - drug therapy; Myocardial Infarction - mortality; myocardial infarction triage and intervention; Myocardial Infarction/diagnosis/drug therapy/mortality; Myocarditis. Cardiomyopathies; North America; Patients; PCI; percutaneous coronary intervention; Physicians - supply & distribution; PRAGUE-2; prehospital care; primary angiography in patients transferred from general community hospitals to specialized PTCA units with or without emergency thrombolysis; Regression Analysis; ST elevation myocardial infarction; STEMI; Survival Rate; Thrombolytic Therapy - methods; Thrombolytic Therapy - mortality; Thrombolytic Therapy/methods/mortality; Time Factors; Tissue Plasminogen Activator - administration & dosage; Myocardial infarction; Health staff; Acute; Physician; Cardiovascular disease; Time; Myocardial disease; Phlebology; ST elevation; Treatment; Heart disease; Circulatory system; Cardiology; Research Support; Differential; Intravenous; Combination; Drug Therapy; Infusions; Diagnosis; Non-U.S. Gov't
• ISSN: 1355-6037; 1468-201X; 1468-201X
• DOI: 10.1136/hrt.2004.054510

Objectives: To assess the impact of variation in prehospital care across distinct health care environments in ASSENT (assessment of the safety and efficacy of a new thrombolytic) -3 PLUS, a large (n  =  1639) contemporary multicentred international trial of prehospital fibrinolysis. Specifically, the objectives were to assess predictors of time to treatment, whether components of time to treatment vary across countries, and the impact of physician presence before hospitalisation on time to treatment, adherence to protocol, and clinical events. Methods: Patient characteristics associated with early treatment (⩽ 2 hours), comparison of international variation in time to treatment, and components of delay were assessed. Trial specific patient data were linked with site specific survey responses. Results: Younger age, slower heart rate, lower systolic blood pressure, and prior percutaneous coronary intervention were associated with early treatment. Country of origin accounted for the largest proportion of variation in time. Intercountry heterogeneity was shown in components of elapsed time to treatment. Physicians in the prehospital setting enrolled 63.8% of patients. The presence of a physician was associated with greater adherence to protocol mandated treatments and procedures but with delay in time to treatment (120 v 108 minutes, p < 0. 001). Conclusion: Country of enrolment accounted for the largest proportion of variation in time to treatment and intercountry heterogeneity modulated components of delay. The effectiveness and safety of prehospital fibrinolysis was not influenced by the presence of a physician. These data, acquired in diverse health care environments, provide new understanding into the components of prehospital treatment delay and the opportunities to further reduce time to fibrinolysis for patients with ST elevation myocardial infarction.