Pre-hospital thrombolytic therapy with either alteplase or streptokinase: Practical applications, complications and long-term results in 529 patients

OBJECTIVE: To assess the practical application, safety and long-term outcomeof pre-hospital thrombolytic intervention with either alteplaseor streptokinase in patients with extensive myocardial infarction. DESIGN: Prospective study. SUBJECTS: Patients with chest pain of more than 30 min duration, presentingwithin 6 h of symptom onset and with electrocardiographic evidenceof extensive evolving myocardial infarction. METHODS: Eligibility of patients was established by the general practitioneror the ambulance nurse using a standardized questionnaire with(contra-) indications for thrombolytic therapy. ComputerizedECG was recorded by ambulance nurses. In the presence of extensiveST segment elevation (sum ST deviation of at least 1.0 m V),eligible patients received either 100 mg alteplase (n=246) or50 mg alteplase in the ambulance followed by 0.75 x 10⁶ IE streptokinasein hospital (n=90), or 1.5 x 10⁶ IE streptokinase intravenously(n=193). MAIN OUTCOME MEASUREMENTS: Death and life-threatening complications (ventricular fibrillation,cardiac arrest) and side effects (hypotension, allergic reactions)during transportation to hospital and in the first 24 h followinghospitalization, and survival up to 5 years follow-up. RESULTS: From 1988–1993, 529 patients received thrombolytic treatmentinitiated pre-hospital. The time gained by pre-hospital administrationof thrombolysis amounted to 50 min. The rate of complicationsduring transportation and during the first 24 h after hospitalizationwas low. Hospital mortality was 2% and 1-year mortality 3%.Cumulative survival at 5 years was 92%. This was superior tothe 84% 5-year survival observed in a matched group of 239 patientswith similar baseline characteristics treated with alteplasein hospital. CONCLUSIONS: Pre-hospital administration of either alteplase or streptokinaseis feasible and safe and results in significant time gain. Thelong-term prognosis is excellent in spite of extensive evolvingmyocardial infarction upon admission.