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 1·0m V), eligible patients received either 100 mg alteplase (n=246)or 50 mg alteplase in the ambulance followed by 0·75x 10⁶ IE streptokinase in hospital (n=90), or 1·5 x 10⁶IE 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.