Is there a need for prehospital fibrinolysis

Introduction: Acute coronary syndrome represents a group of several different clinical conditions, all caused by acute myocardial ischemia and/or necrosis. It includes: unstable angina pectoris, non ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). Being a part of the 'Vojvodina STEMI network' since 2014. Emergency Medical Service of Sombor provides early pre-hospital diagnostic, initial therapy and transport of STEMI patients (with constant monitoring of vital parameters) to the Institute of Cardiovascular Diseases of Vojvodina in Sremska Kamenica for primary percutaneous coronary intervention (pPCI). Object: The object of this paper is to analyze the possibility of providing prehospital thrombolytic therapy for STEMI patients transported to the ICVDV Sremska Kamenica, within current standard protocol. Methodology: For the purpose of this research, a retrospective analysis of the registry 'Time management protocol for STEMI patients' was made from January 1st, 2014 to December 31st, 2017. These time frames were examined: duration from the onset of pain to the established diagnosis, duration of transport to the Institute and overall duration time from the onset of pain to pPCI. Furthermore, patients were divided into four groups according to the time duration from the onset of pain to the established diagnosis: less than 1 hour, less than 2 hours, less than 3 hours and more than 3 hours. Results: 34, 18% of the analyzed patients were diagnosed as STEMI patients within one hour from the onset of pain, 36.71% within two hours, 10.13% within three hours and 18.99% needed more than three hours. For all of those that got their STEMI diagnosis within one, two and three hours, the average time was 71.47 minutes (1 hour and 11 minutes) and for those who got diagnosed after three hours that time was 318.13 minutes (5 hours and 18 minutes). Summarized average time from the onset of pain to the establishing of STEMI diagnosis was 194.80 minutes (3 hours and 14 minutes) for both groups. The average transportation time was 71.32 minutes (1 hour and 11 minutes), shortest being 47 minutes and the longest 88 minutes. For all those in the group that needed less than three hours for STEMI diagnosis, the average time from the onset of pain to the ICVDV was 158.08 minutes (2 hours and 38 minutes), and for those who needed more than 3 hours to get diagnosed the average time from the onset of pain to the ICVDV was 416.57minutes (6 hours and 56 minutes). The overall average time for all analyzed patients, from the onset of pain to the catheterization lab of the ICVDV was 295.13 minutes (4 hours and 55 minutes). Conclusion: Taking into account these results, it becomes reasonable to apply fibrinolytic therapy before transporting, keeping in mind at all times current standard protocols and safety precautions for possible fibrinolytic therapy contraindications. If transport of a STEMI patient to the PCI lab is not likely to happen within the first 120 min, because of some kind of technical disability or catheterization lab overload, and that patient is presented to the EMS within the first three hours from the beginning of pain, fibrinolytic therapy should be used in order to establish reperfusion and to buy some time until transport to the pPCI