Prehospital Fibrinolysis with Double Antiplatelet Therapy in Acute STElevation Myocardial Infarction

1
Prehospital Fibrinolysis with Double Antiplatelet
Therapy in Acute ST-Elevation Myocardial
Infarction The Clarity Ambulance Substudy
2
Ambulance Substudy Background

• Fibrinolysis for ST-elevation acute myocardial
  infarction (STEMI) is frequently limited by
  delays of administration as well as incomplete
  reperfusion or reocclusion of the infarct-related
  artery1
• Intensified prehospital management may shorten
  time to treatment and improve outcomes2

1. Brouwer MA et al. Circulation 2002 106
659665. 2. Morrison LJ et al. JAMA 2000 283
26862692.
3
Substudy Sites and Patient Numbers

• France 172 patients
• L Soulat 57
• Y Lambert 48
• F Lapostolle 28
• F Thieuleux 21
• C Gully 10
• D Pollet 5
• D Galley 2
• L Olliver 1

UK 40 patients J Adgey 27 J Purvis 13 Sweden
5 patients J-E Karlsson 5
217 patients in total
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Baseline Characteristics Ambulance vs.
Non-Ambulance
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Patient Management Ambulance vs. Non-Ambulance
p lt0.001 versus ambulance patients values are
median unless otherwise specified
6
Angiographic ECG Parameters Ambulance vs.
Non-Ambulance
Event rate ()
Odds ratio (95 CI)
p value
Ambulance
Non-ambulance
Ambulance better
Non-ambulance better
Complete considered to be gt70
ECGelectrocardiogram
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Primary Outcome Parameters Ambulance vs.
Non-Ambulance
Event rate ()
Odds ratio (95 CI)
p value
Ambulance
Non-ambulance
Non-ambulance better
Ambulance better
Occluded infarct artery (TFG 0/1) death
re-MI prior to angiography NSnot significant
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Baseline Characteristics Ambulance Subgroup
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Primary Outcome Parameters Ambulance Subgroup
Event rate ()
Odds ratio (95 CI)
p value
Clopidogrel
Placebo
Placebo better
Clopidogrel better
Occluded infarct artery (TFG 0/1) death
re-MI prior to angiography
10
Primary Endpoint of TIMI Flow Grade 0/1, MI or
Death
Odds ratio (95 CI)
0.60 (0.30?1.17)
Ambulance
0.65 (0.54?0.77)
Non-ambulance
Overall
0.64 (0.53?0.76)
0
0.5
1.0
1.5
2.0
Clopidogrel better
Placebo better
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Safety Bleeding Complications
TIMIthrombolysis in myocardial infarction
ICHintracranial hemorrhage
12
Conclusions

• Medical reperfusion of STEMI patients with
  fibrinolysis, heparin, ASA and clopidogrel is
  feasible before reaching the hospital in
  medically equipped ambulances without an apparent
  increase in bleeding
• Early management of patients in the ambulance is
  associated with shorter ischaemic times and
  faster reperfusion, with a consistent treatment
  effect in favour of clopidogrel in comparison
  with the overall results