Early Thrombolysis: Time to Change? A Discussion Paper

UK Department of Health standards for the management of out-of-hospital thrombolysis require a call to thrombolysis time of 60 minutes or less, but suggest that administration of such treatment in the pre-hospital setting should be limited to cases where the journey time to hospital exceeds 30 minutes. This policy was set despite more than 50% of patients in an urban setting having a call to hospital door time of more than 30 minutes, rising to more than 80% in rural areas, and that all published evidence suggests symptom to treatment time is the critical interval. Maximum benefits are derived from thrombolytic agents if they are delivered early. Administration within 30 minutes of symptom onset can result in total abortion of a myocardial infarction, and each minutes delay to treatment is equivalent to an average of 11 days of life lost. Pre-hospital lysis within two hours of symptom onset results in a significantly lower incidence of cardiogenic shock than percutaneous coronary intervention within the same time frame, suggesting greater salvage of cardiac muscle. The available evidence suggests that pre-hospital thrombolysis is at least as safe as in-hospital administration, regardless of the qualifications and experience of the practitioner providing the treatment. All patients benefit from the shortest possible interval from symptom onset to recanalization: minutes do count. UK standards should be amended to reflect this evidence and to mandate the administration of thrombolytic agents to all eligible patients as soon as they are identified in the pre-hospital setting, regardless of distance to hospital.