Prehospital thrombolysis in rural emergency room and subsequent transport to a coronary care unit: Ravenna myocardial infarction (RaMI) trial

Objective: To assess the feasibility, safety and efficacy of thrombolysis in the Emergency Room of a Rural Hospital with no Coronary Care Unit, and subsequent transfer to the Coronary Care Unit of a City Hospital. Design: Prospective study, controlled with two parallel groups of consecutive patients (Group 1: Rural Hospital, Group 2: CCU Ravenna) and administration of Anistreplase 30 intravenous unit. Setting: Rural Emergency Rooms which transmitted the electrocardiogram by cardiotelephone to the Ravenna Coronary Care Unit (average distance 35 km; range: 17-50 km). Patients: 280 (Group 1: 102 patients, Group 2: 178 patients) with suspected acute myocardial infarction and with no contra-indications to fibrinolysis, within 6 h of onset of symptoms. Main outcome measures: time saving, accuracy of diagnosis, adverse events, left ventricular function and survival. Results: the median pain to needle time was 90′ in Group 1 and 165′ in Group 2 (P < 0.001). Accuracy of diagnosis for acute myocardial infarction was 91% and 100%, respectively. Complications were rare and none occurred during transfer. The creatine phosphokinase peak of Group 1 was lower than Group 2 (1389 vs. 2186 IU/1; P < 0.001). The echocardiographic Wall Motion Abnormality Score Index of Group 1 was lower than Group 2 (3.571 vs. 5.589; P < 0.001). Mortality at 35 days in Group 1 was 7.5% vs. 10.7% in Group 2 (-30%; P = n.s.). Conclusions: The Emergency Room physician, in close collaboration with the cardiologist, supplied a very high standard of pre-Coronary Care Unit diagnosis and therapy. Administration of Anistreplase in the rural Emergency Room brought about a significant reduction of pain to needle time, a significant improvement in left ventricular function and a reduction in mortality.