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Dr Simon Horne Specialist Registrar Emergency Medicine Torbay Hospital

The impact of pre-hospital thrombolytic treatment on re-infarction rates: Analysis of the Myocardial Infarction National Audit project (MINAP). Dr Simon Horne Specialist Registrar Emergency Medicine Torbay Hospital. Background to the study.

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Dr Simon Horne Specialist Registrar Emergency Medicine Torbay Hospital

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  1. The impact of pre-hospital thrombolytic treatment on re-infarction rates:Analysis of the Myocardial Infarction National Audit project (MINAP) Dr Simon Horne Specialist Registrar Emergency Medicine Torbay Hospital

  2. Background to the study • Pre-hospital thrombolysis allows earlier treatment of Acute Myocardial Infarction (AMI). • This in turn improves outcome. • Ambulance systems allow real time observation of the pre-hospital ECG in the Emergency department. • Anecdotal evidence suggested a high rate of re-infarction after pre-hospital treatment.

  3. What is re-infarction? “Ischaemic pain or other symptoms consistent with acute cardiac ischaemia …accompanied by new electrocardiographic changes (elevation or depression of the ST segment or T waves changes) in the territory of the initial event”

  4. Why re-infarction is important

  5. Study hypothesis • That pre-hospital thrombolysis has a higher rate of re-infarction than in-hospital thrombolysis.

  6. Methods • Use of the MINAP database of 35,356 patients thrombolysed in 2005-6. • Comparison of pre-hospital and in-hospital groups to identify differences in baseline characteristics and re-infarction rate. • Use of multivariate linear regression to identify factors predictive of re-infarction.

  7. Baseline characteristics

  8. Re-infarction rate by agent * † * † *p=0.001 † p=0.005

  9. Re-infarction rate by time from administration to time of arrival at hospital † p=0.001 † †

  10. Predictors of re-infarction • For Tenecteplase: • Weight OR 1.67 (95%CI 1.27-2.27) • Pre-hospital OR 1.44 (95%CI 1.21-1.71) • Previous AMI OR 1.23 (95%CI 0.99-1.25) • For Reteplase: • Previous AMI OR 2.74 (95%CI 2.02-3.72) • CRF OR 2.6 (95%CI 1.14-4.8)

  11. Why might this happen? • Chance? • A difference between the groups that we have no data about? • Anticoagulation?

  12. Limitations of the study • Use of a dataset for a specific question for which it was not designed. • No randomisation to reduce bias. • Data quality is an issue. • No direct evidence of cause, only effect. but • Complete picture for England and Wales. • Robust evidence that something about pre-hospital thrombolysis is suboptimal.

  13. Conclusions • Pre-hospital thrombolysis with Tenecteplase is associated with an increased risk of re-infarction. • Re-infarction more than doubles mortality from AMI. • As time from treatment to hospital increases, so does the rate of re-infarction. • The anticoagulation regimen is an obvious difference between the groups that might explain the results.

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