FINAL SCOPE: Early thrombolysis for the treatment of acute myocardial infarction (AMI)
Objective: To advise on the clinical and cost effectiveness of available drugs for early thrombolysis in AMI in two settings: i) pre-hospital, and ii) hospital, and to produce guidance to the NHS in England and Wales.
Background: It is estimated that over 240,000 people suffer an AMI in England & Wales each year1. The British Heart Foundation estimate that around 72,000 people die before they reach hospital, and that in total 120,000 die within 30 days.
In England the National Service Framework for Coronary Heart Disease and the NHS Plan have set a standard for reduction in 'call to thrombolysis' time to 60 minutes. Components of this includes patients receiving thrombolysis within 20 minutes of reaching hospital, and provision of pre-hospital thrombolysis where ambulance 'call to hospital' times are greater than 30 minutes.
The NHS Plan for Wales - Improving Health in Wales, has also made a commitment for patients to receive thrombolysis within 20 minutes of reaching hospital.
Technology: Thrombolytic therapy is an established proven component of treatment for AMI.
Streptokinase is the most commonly used drug in the majority of hospitals in England2.
Newer thrombolytics, such as alteplase/tissue plasminogen activator (tPA) and reteplase are available as alternatives, and though more costly, have some advantages in administration.
The emergence of another new thrombolytic - tenecteplase, administered as a single bolus injection, will provide further choice and like some of the other drugs may be of particular relevance in pre-hospital settings.
In addition, urokinase (available though not licensed for AMI) and anistreplase (not currently available) will be considered as background in the appraisal, as they may contribute valuable research evidence on pre-hospital thrombolysis.
i) Pre-hospital thrombolysis
| Intervention |
tenecteplase |
| Population |
Patients with (recent on-set) AMI, confirmed by ECG, without contraindications to thrombolytic therapy. |
| Current standard treatments (comparators) |
Comparisons will be made between the alternative drugs outlined above, & with no pre-hospital thrombolysis. |
| Administration - settings & professionals | Settings:Ambulances, home/community, GP surgeries, community hospitals, & minor injury units.Professionals:GPs, nurses, paramedics. |
| Other considerations |
Relevant outcomes: survival, further coronary events, time from on-set of symptoms to thrombolysis, call to thrombolysis time, measures of cardiac function & reperfusion, time to reperfusion, quality of life, & major adverse events.Additional infrastructure and training required for the optimal delivery of thrombolytic therapy. Research evidence on anistreplase & urokinase will be included as background (though not as currently available interventions). |
ii) Hospital thrombolysis
| Intervention |
tenecteplase |
| Population |
Patients with (recent on-set) AMI, confirmed by ECG, without contraindications to thrombolytic therapy. |
| Current standard treatments (comparators) |
Comparisons will be made between the alternative drugs outlined above. |
| Administration - settings & professionals | Settings:Accident & emergency units, acute admission/assessment wards, acute medical wards, & coronary care units.All relevant professional groups in these settings. |
| Other considerations |
Relevant outcomes: survival, further coronary events, time from on-set of symptoms to thrombolysis time, call to thrombolysis time, measures of cardiac function & reperfusion, time to reperfusion, quality of life, & major adverse events.Additional infrastructure and training required for the optimal delivery of thrombolytic therapy. |
This page was last updated: 30 March 2010