Recommendation ID
CG167/1
Question
Primary PCI and fibrinolysis in people with acute STEMI who present very early:- If a person with acute STEMI presents within 1 hour of the onset of symptoms, is it better for that person to be given fibrinolysis with a short call to needle time rather than to be transferred to a centre that carries out primary PCI for primary PCI with a delay of up to 120 minutes?
Any explanatory notes
(if applicable)
Why this is important:- Fibrinolytic drugs are administered intravenously and can be given out of hospital by an ambulance crew or in the emergency department of a hospital. Benefit from fibrinolysis declines significantly with time from onset of symptoms. Primary PCI, on the other hand, requires transfer to an interventional cardiology service, which inevitably delays the start of reperfusion treatment. Regardless of the reperfusion method used, delays to treatment are associated with an increased risk of impaired left ventricular systolic function and death.
It is unclear whether people with acute STEMI with a very short presentation delay would benefit more from immediate fibrinolysis (usually pre-hospital for people who do not self-present to hospital emergency departments) compared with transfer to a centre that carries out primary PCI.
To answer this question, a randomised controlled trial of pre-hospital fibrinolysis versus primary PCI in people with acute STEMI who have a short presentation delay of 1 hour or less is needed. Primary end points would include cardiovascular and all-cause mortality and other major adverse cardiovascular events. The STREAM study has recruited people who present early (less than 3 hours from onset of symptoms), and those presenting very early (less than 1 hour) could be analysed as a subgroup. However, it is not known whether this cohort will be big enough to allow a statistically significant conclusion to be drawn.

Source guidance details

Comes from guidance
Myocardial infarction with ST-segment elevation: acute management
Number
CG167
Date issued
July 2013

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 31/07/2013