Click to goto CDHA Public Site Click to goto DivEMS Dal Public Site Click to goto EHS Nova Scotia

ACS/Suspected Cardiac Origin

Date Last Search Run: Feb 01, 2022
Table last updated: Sep 29, 2022
Data last added: Sep 29, 2022

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)  
3 (weak evidence exists)    


Interventions

12-Lead ECG
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) 1) Diagnostic accuracy 2)Time to thrombolytics Process PH-Paramedic Ioannidis JPA., Salem D., Chew PW., Lau J. Accuracy & clinical effect of out-of-hospital electrography in the diagnosis of acute cardiac ischemia: A meta-analysis. Ann Emerg Med 2001; 37:461-70. Medline
I Supportive (Green) Prediction of in-hospital mortality Process ED-MD Saw J, Davies C, Fung A, Spinelli JJ, Jue J. Value of ST elevation in lead III greater than lead II in inferior wall acute myocardial infarction for predicting in-hospital mortality and diagnosing right ventricular infarction. Am J Cardiol. 2001 Feb 15;87(4):448-50, A6. Medline
II Supportive (Green) Door to reperfusion time Process PH-Paramedic Adams G., Abusaid G., Lee B., et al. From Theory to Practice: Implementation of pre-hospital electrocardiogram transmission in ST-elevation myocardial infarction - a multicenter experience. J Invasive Cardiol 2010; 22(11):520-5. Medline
II Supportive (Green) Door to reperfusion time Process PH-Paramedic Adams GL., et al. Effectiveness of prehospital wireless transmission of ECGs to cardiologist via hand-held device for patients with AMI (from TIME-NE). Am J Cardiol 2006; 98:1160-4. Medline
II Supportive (Green) Door to Balloon Time Process PH-Paramedic Afolabi BA., Novaro GM., Pinski SL., Fromkin KR., Bush HS. Use of the prehospital ECG improves door-to-balloon times in ST elevation MI irrespective of time or day or day of week. EMJ 2007; 24:588-91. Medline
II Supportive (Green) Reduction in time to reperfusion Process PH-Paramedic Brainard AH., Raynovich W., Tandberg D., Bedrick EJ. The prehospital 12lead ECG effect on time to initiation of reperfusion therapy: A systematic review. Am J Emerg Med 2005; 23:351-6. Medline
II Supportive (Green) DTB time Process PH-Paramedic Brown JP., Mahmud E., Dunford JV., Ben-Yehuda O. Effect of prehospital 12-lead ECG on activation of cardiac cath lab and door to balloon time in STEMI. Am J Cardiol 2008; 101:158-61. Medline
II Supportive (Green) Time to reperfusion Process PH-Paramedic Brown SG., Galloway DM. Effect of ambulance 12-lead ECG recording on times to hospital reperfusion in acute myocardial infarction. Med J Aust 2000; 172(2):81-4. Medline
II Supportive (Green) Time to treatment Process Brunetti ND., De GL., Correale M., Santoro F., Caldarola P., Gaglione A., et al. Pre-hospital electrocardiogram triage with telemedicine near halves time to treatment in STEMI: A meta-analysis and meta-regression analysis of non-randomized studies. Int J Cardiol 2017; 232:5-11. Medline
II Supportive (Green) Positive STEMI interpretation Process Coffey C., Serra J., Goebel M., Espinoza S., Castillo E., Dunford J. Prehospital Acute ST-Elevation Myocardial Infarction Identification in San Diego: A Retrospective Analysis of the Effect of a New Software Algorithm. J Emerg Med 2018; 55(1):71-7. Medline
II Supportive (Green) Positive Predictive Value of paramedic interpretation Process PH-Paramedic Davis DP., Graydon C., Stein R., et al. The positive predictive value of paramedic versus emergency physician interpretation of the prehospital 12-lead electrocardiogram. Prehosp Emerg Care 2007; 11(4):399-402. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic deVilliers JS., et al. Expedited transfer for primary percutaneous coronary intervention: A program evaluation. CMAJ 2007; 176:1833. CMAJ
II Supportive (Green) Door to intervention time Process PH-Paramedic Dhruva VN., et al. ST-segment analysis using wireless technology in AMI (STAT-MI) Trial. J Am Coll Cardiol 2007; 50:509-13. Medline
II Supportive (Green) Mortality Patient Ducas RA., Labos C., Allen D., Golian M., Jeyaraman M., Lys J., et al. Association of Pre-hospital ECG Administration With Clinical Outcomes in ST-Segment Myocardial Infarction: A Systematic Review and Meta-analysis. Can J Cardiol 2016; 32(12):1531-41. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Eckstein M., Cooper E., Nguyen T., Pratt FD. Impact of paramedic transport with prehospital 12lead ECG on door-to-balloon times for patients with STEMI. Prehosp Emerg Care 2009; 13:203-6. Medline
II Supportive (Green) Impaired left ventricular function Patient Fakhri Y., Ersba¸ll M., KA¸ber L., Hassager C., Hesselfeldt R., Steinmetz J., et al. Pre-hospital electrocardiographic severity and acuteness scores predict left ventricular function in patients with ST elevation myocardial infarction. J Electrocardiol 2016; 49(3):284-91. Medline
II Supportive (Green) Identification of AMI Process PH-Paramedic Foster DB., Dufendach JH., Barkdoll CM. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: Impact on in-hospital times to thrombolysis in a rural community hospital. Am J Emerg Med 1994; 12:25-31. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Hutchison AW., Malaiapan Y., Cameron JD., Meredith IT. Pre-hospital 12 lead ECG to triage ST elevation myocardial infarction and long term improvements in door to balloon times: The first 1000 patients from the MonAMI project. Heart Lung Circ 2013; 22(11):910-6. Medline
II Supportive (Green) Time from FMC to reperfusion Process Kahlon TS., Barn K., Akram MM., Blankenship JC., Bower-Stout C., Carey DJ., et al. Impact of pre-hospital electrocardiograms on time to treatment and one year outcome in a rural regional ST-segment elevation myocardial infarction network. Catheterization and cardiovascular interventions: official journal of the Society for Cardiac Angiography & Interventions 2017; 89(2):245-51. Medline
II Supportive (Green) Door to needle time Process PH-Paramedic Karagounis L., Ipsen SK., Jessop MR., et al. Impact of field-transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990; 66:786-91. Medline
II Supportive (Green) First medical contact to needle time Process PH-Paramedic Kereiakes DJ., Gibler B., Martin LH., et al. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: Cincinnati. Am Heart J 1992; 123:835. Medline
II Supportive (Green) Resolution of ST segment elevation Patient PH-Paramedic Kudenchuk PJ., Maynard C., Cobb LA., et al. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: The myocardial infarction triage and intervention (MITI) project. JACC 1998; 32(1):17-27. Medline
II Supportive (Green) Aborted MI Process PH-Paramedic Lamfers EJ., Schut A., Hertzberger DP., et al. Prehospital versus hospital fibrinolytic therapy using automated versus cardiologist electrocardiographic diagnosis of myocardial infarction: Abortion of myocardial infarction and unjustified fibrinolytic therapy. Am Heart J. 2004; 147(3):509-515. Medline
II Supportive (Green) Meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients. Process PH-Paramedic & MD Lazarus G, Kirchner HL, Siswanto BB. Prehospital tele-electrocardiographic triage improves the management of acute coronary syndrome in rural populations: A systematic review and meta-analysis. J Telemed Telecare 2020. Medline
II Supportive (Green) Safety and feasibility Process PH-Paramedic Le May MR., Davies RF., Dionne R., et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol 2006; 98(10):1329-1333. Medline
II Supportive (Green) Accuracy of STEMI detection Process PH-Paramedic LeMay MR., et al. Diagnostic performance and potential clinical impact of ACP interpretation of STEMI in the field. CJEM 2006; 8(6):401-7. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Morrison LJ., Brooks S., Sawadsky B., McDonald A., Verbeek PR. Prehospital 12-lead electrocardiography impact on acute myocardial infarction treatment times and mortality: a systematic review. Acad Emerg Med 2006; 13(1):84-9. Medline
II Supportive (Green) 30 day mortality Patient PH-Paramedic Nam J., Caners K., Bowen JM., Welsford M., O'Reilly D. Systematic review and meta-analysis of the benefits of out-of-hospital 12-lead ECG and advance notification in ST-segment elevation myocardial infarction patients. Ann Emerg Med 2014; 64(2):176-86. Medline
II Supportive (Green) Door to Balloon time Process PH-Paramedic Ong ME., Wong AS., Seet CM., et al. Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission. Ann Emerg Med 2013; 61(3):339-47. Medline
II Supportive (Green) Recognition of STEMI Process Pilbery R., Teare MD., Goodacre S., Morris F. The Recognition of STEMI by Paramedics and the Effect of Computer inTerpretation (RESPECT): a randomised crossover feasibility study. Emergency medicine journal: EMJ 2016; 33(7):471-6. Medline
II Supportive (Green) Process measures and 30 day mortality Patient PH-Paramedic Quinn T., Johnsen S., Gale CP., et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: A linked cohort study from the myocardial ischaemia national audit project. Heart 2014; 100(12):944-50. Medline
II Supportive (Green) door-to-needles times Process PH-Paramedic Rao A., Cardough Y., Darda S., Desai D., et al. Impact of the Prehospital ECH on Door-to-Balloon Time in ST-Elevation Myocardial Infarction. Cath Cardio Interv 2009; 75(2)174-8. Medline
II Supportive (Green) 30 day mortality Patient Rawshani N., Rawshani A., Gelang C., Herlitz J., BÃ¥ng A., Andersson JO., et al. Association between use of pre-hospital ECG and 30-day mortality: A large cohort study of patients experiencing chest pain. Int J Cardiol 2017; 248:77-81. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Rokos IC., French WJ., Koenig WJ., et al. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: Impact on door-to-balloon times across 10 independent regions. JACC Cardiovasc Interv 2009; 2(4):339-46. Medline
II Supportive (Green) Time to treatment Process PH-Paramedic Sejersten M., et al. Effect on treatment delay of prehospital teletransmission of 12-lead ECG to a cardiologist for immediate triage and direct referral… Am J Cardiol 2008; 101:941-6. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Strauss DG., et al. Paramedic transtelephonic communication to cardiologist of clinical and electrographic assessment for rapid reperfusion of STEMI. J Electrocardiology 2007; 40:265-70. Medline
II Supportive (Green) Infarct Diagnosis Patient PH-Paramedic van 't Hof AW., Rasoul S., van de Wetering H., et al. Feasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction. Am Heart J 2006; 151(6):1255.e1-1255.e5. Medline
II Neutral (Yellow) ED performance metric (ASA, B-blocker, heparin use in the ED) Process ED-MD Cudnik MT., Frank Peacock W., Diercks DB., Roe MT., Chen AY. Prehospital electrocardiograms (ECGs) do not improve the process of emergency department care in hospitals with higher usage of ECGs in non-ST-segment elevation myocardial infarction patients. Clin Cardiol 2009; 32(12):668-75. Medline
III Supportive (Green) Sensitivity, specificity and accuracy Process PH-Paramedic & MD Almukhambetova E, Almukhambetov M, Musayev A, Yeshmanova A, Indershiyev V, Kalhodzhaeva Z. Remote Analysis and Transmission System of Electrocardiogram in Prehospital Setting; a Diagnostic Accuracy Study. Arch Acad Emerg Med 2022; 10(1):e5. Medline
III Supportive (Green) Utility Process PH-Paramedic Aufderheide TP., Hendley GE., Thakur RK., et al. The diagnostic impact of prehospital 12-lead electrocardiography. Ann Emerg Med 1990; 19(11):1280-7. Medline
III Supportive (Green) Utility Process Aufderheide TP., Hendley GE., Woo J., et al. A prospective evaluation of prehospital 12-lead ECG application in chest pain patients. J of Electrocardiology (Supplement)1992; 24:8-13. Medline
III Supportive (Green) Quality of prehospital care of ACS Process Brokmann JC., Conrad C., Rossaint R., Bergrath S., Beckers SK., Tamm M., et al. Treatment of Acute Coronary Syndrome by Telemedically Supported Paramedics Compared With Physician-Based Treatment: A Prospective., Interventional., Multicenter Trial. Journal of medical Internet research 2016; 18(12):e314. Medline
III Supportive (Green) Number of STEMI in patients with atypical symptoms for AMI Process Campo Dell' OM., Hamm C., Liebetrau C., Hempel D., Merbs R., Cuca C., et al. Telemetry-assisted early detection of STEMI in patients with atypical symptoms by paramedic-performed 12-lead ECG with subsequent cardiological analysis. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2017; 24(4):272-6. Medline
III Supportive (Green) Identifying and MI Patient PH-Paramedic Di Toro M, Stub D. Acute Myocardial Infarction Identified by Paramedics Using the Smith-Modified Sgarbossa Criteria: A Case Report. Prehosp Emerg Care 2021; 25(6):851–3. Medline
III Supportive (Green) Time to treatment Process PH-Paramedic Diercks DB., Kontos MC., Chen AY., et al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: Data from the NCDR (national cardiovascular data registry) ACTION (acute coronary treatment and intervention outcomes network) registry. J Am Coll Cardiol 2009; 53(2):161-6. Medline
III Supportive (Green) Time to diagnosis and treatment Process PH-Paramedic Drew BJ., Dempsey ED., Joo TH., et al. Pre-hospital synthesized 12-lead ECG ischemia monitoring with trans-telephonic transmission in acute coronary syndromes: Pilot study results of the ST SMART trial. J Electrocardiol 2004; 37(S):214-21. Medline
III Supportive (Green) Recognition Process PH-Paramedic Funder J, Ross L, Ryan S. How effective are paramedics at interpreting ecgs in order to recognise stemi? A systematic review. Australasian J of ParaMed 2020; 17:1-9. Medline
III Supportive (Green) Feasibility Process PH-Paramedic Kotelnik V, Pesce K, Masterton WM, Marshall RT, Pigott G, Bialek N, et al. 12-Lead Electrocardiograms Acquired and Transmitted by Emerg Medical Technicians are of Diagnostic Quality and Positively Impact Patient Care. Prehosp Disaster Med 2020:1-4. Medline
III Supportive (Green) Diagnostic Quality ECG's Process Kotelnik V, Pesce K, Masterton WM, Marshall RT, Pigott G, Bialek N, et al. 12-Lead Electrocardiograms Acquired and Transmitted by Emerg Medical Technicians are of Diagnostic Quality and Positively Impact Patient Care. Prehosp Disaster Med 2020:1-4. Medline
III Supportive (Green) Time to balloon Process PH-Paramedic Report of the European Myocardial Infarction Project (EMIP) Sub-Committee. Potential time saving with pre-hospital intervention in acute myocardial infarction. Euro Heart J 1988; 9:118-24. Medline
III Supportive (Green) Rate of false positive Process Tanguay A., Brassard E., Lebon J., Bégin F., Hébert D., Paradis JM. Effectiveness of a Prehospital Wireless 12-Lead Electrocardiogram and Cardiac Catheterization Laboratory Activation for ST-Elevation Myocardial Infarction. Am J Cardiol 2017; 119(4):553-9. Medline
III Supportive (Green) Sensitivity and specificity Process SIM Trivedi K., Schuur JD., Cone CD. Can paramedics read STEMI on prehospital 12-lead ECG? Prehosp Emerg Care 2009; 13:207-14. Medline
III Neutral (Yellow) Percent of EKGs with changes not on the ED EKG Process PH-Paramedic Davis MT., Dukelow A., McLeod S., Rodriguez S., Lewell M. The utility of the prehospital electrocardiogram. CJEM 2011; 13(6):372-7. Medline
III Neutral (Yellow) Contact-to-balloon time Process PH-Paramedic Martinoni A., De Servi S., Boschetti E., et al. Importance and limits of pre-hospital electrocardiogram in patients with ST elevation myocardial infarction undergoing percutaneous coronary angioplasty. Eur J Cardiovasc Prev Rehabil 2011; 18(3):526-32. Medline
X Not Yet Graded (White) - Nakashima T, Hashiba K, Kikuchi M, Yamaguchi J, Kojima S, Hanada H, Nonogi H. Impact of Prehospital 12-Lead Electrocardiography and Destination Hospital Notification on Mortality in Patients With Chest Pain - A Systematic Review. Circ Rep 2022; 4(5):187–93. Medline

Acetaminophen IV
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Platelet reactivity Process PH-Paramedic Tavenier AH, Hermanides RS, Ottervanger JP, Tolsma R, van Beurden A, Slingerland RJ, Ter Horst PGJ, et al. Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. Eur Hear J Cardiovasc Pharmacother 2022; 8:4–12. Medline

Advanced Notice/Cath Lab Activation by EMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Door to reperfusion time Process PH-Paramedic Adams G., Abusaid G., Lee B., et al. From Theory to Practice: Implementation of pre-hospital electrocardiogram transmission in ST-elevation myocardial infarction - a multicenter experience. J Invasive Cardiol 2010; 22(11):520-5. Medline
II Supportive (Green) major adverse cardiac events Patient PH-Paramedic Blusztein D, Dinh D, Stub D, Dawson L, Brennan A, Reid C, et al. Predictors of hospital prenotification for STEMI and association of prenotification with outcomes. Emerg Med J 2021. Medline
II Supportive (Green) Time to PCI Process PH-Paramedic Brunetti N., De Gennaro L., Correale M., Santoro F., et al. Pre-hospital electrocardiogram triage with telemedicine near halves time to treatment in STEMI: A meta-analysis and meta-regression analysis of non-randomized studies. Int J Cardio 2017; 232:5–11. Medline
II Supportive (Green) Symptom onset to balloon times Process PH-Paramedic Carstensen S., et al. Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome. Eur Heart J 2007; 28:2313-9. Medline
II Supportive (Green) Symptom to reperfusion, Mortality Process PH-Paramedic Dalby M., Kharbanda R., Ghimire G., et al. Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access. Am Heart J 2009; 158(5):829-35. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Le May MR., et al. A City-wide protocol for primary PCI in ST-segment elevation myocardial infarction. NEMJ 2008; 358:231-40. Medline
II Supportive (Green) Onset-to-device (OTD) time Process Mizuguchi Y., Shibutani H., Hashimoto S., Yamada T., Taniguchi N., Nakajima S., et al. Onset-to-device time of patients who arrive at off-hours: Importance of prehospital management and public awareness for patients with ST-segment elevation myocardial infarction. Cardiovascular therapeutics 2016; 34(6):475-81. Medline
II Supportive (Green) Rate of inappropriate activations Process Potter BJ., Matteau A., Mansour S., Naim C., Riahi M., Essiambre R., et al. Sustained Performance of a "Physicianless" System of Automated Prehospital STEMI Diagnosis and Catheterization Laboratory Activation. Can J Cardiol 2017; 33(1):148-54. Medline
II Supportive (Green) Composite endpoint (all cause mortality and recurrence of MI at 1 year) Patient Rigamonti F., Gencer B., Rey F., Chaara J., Tessitore E., Bunwaree S., et al. Pre-hospital alarm activation for STEMI patients undergoing primary percutaneous coronary intervention in the era of transradial procedures. Eur J Intern Med 2016; 35:83-8. Medline
II Supportive (Green) Door to balloon time Patient PH-Paramedic Savage ML, Hay K, Murdoch DJ, Doan T, Bosley E, Walters DL, Denman R, Ranasinghe I, Raffel OC. Clinical Outcomes in Pre-Hospital Activation and Direct Cardiac Catheterisation Laboratory Transfer of STEMI for Primary PCI. Hear Lung Circ 2022. Medline
II Supportive (Green) Door to Balloon Process PH-Paramedic Savage ML., Poon KK., Johnston EM., et al. Pre-hospital ambulance notification and initiation of treatment of ST elevation myocardial infarction is associated with significant reduction in door-to-balloon time for primary PCI. Heart Lung Circ 2014; 23(5):435-43. Medline
II Supportive (Green) First medical contact to balloon-time Process PH-Paramedic Shoaib M, Huish W, Woollard EL, Aguila J, Coxall D, Alexander M, et al. Impact of Pre-Hospital Activation of STEMI on False Positive Activation Rate and Door to Balloon Time. Hear Lung Circ 2022; 31(3 447–455):447–55. Medline
II Supportive (Green) Feasibility Process PH-Paramedic Sillesen M., et al. Referral of patients with STEMI directly to the cath suite based on prehospital teletransmission of 12 lead ECG. J Electrocardiography 2008; 41:49-53. Medline
II Supportive (Green) Mortality at one year post-PCI Patient Studnek JR., Infinger A., Wilson H., Niess G., Jackson P., Swanson D. Decreased Time from 9-1-1 Call to PCI among Patients Experiencing STEMI Results in a Decreased One Year Mortality. Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2018:1-7. Medline
II Supportive (Green) Treatment delay Patient PH-Paramedic Terkelsen CJ., et al. Reduction of treatment delay in patients with STEMI: impact of prehospital diagnosis and direct referral to primary PCI. Eur Heart J 2005; 26:770-7. Medline
II Neutral (Yellow) False positive activations (computer interpretation) Process PH-Paramedic Youngquist ST., Shah AP., Niemann JT., Kaji AH., French WJ. A comparison of door-to-balloon times and false-positive activations between emergency department and out-of-hospital activation of the coronary catheterization team. Acad Emerg Med 2008; 15(8):784-787. Medline
III Supportive (Green) Time to diagnosis and treatment Process PH-Paramedic Drew BJ., Dempsey ED., Joo TH., et al. Pre-hospital synthesized 12-lead ECG ischemia monitoring with trans-telephonic transmission in acute coronary syndromes: Pilot study results of the ST SMART trial. J Electrocardiol 2004; 37(S):214-21. Medline
III Supportive (Green) Door to needle time Process PH-Paramedic Goodacre S., Kelly AM., Kerr D. Potential impact of interventions to reduce times to thrombolysis. Emerg Med J 2004; 21(5):625-9. Medline
X Not Yet Graded (White) - Hamilton GW, Yeoh J, Dinh D, Brennan A, Yudi MB, Freeman M, et al. Reperfusion times and outcomes in patients with ST-elevation myocardial infarction presenting without pre-hospital notification. Cardiovasc Revasc Med 2022. Medline

Anti-platelet (other)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) All-cause mortality at 30-day, 1-year and 5-years. Patient Fabris E., Kilic S., Schellings DAAM., Ten BJ., Kennedy MW., van HK., et al. Long-term mortality and prehospital tirofiban treatment in patients with ST elevation myocardial infarction. Heart 2017; 103(19):1515-20. Medline
I Supportive (Green) ST elevation resolution Patient PH-Paramedic Heestermans T., Suryapranata H., ten Berg JM., et al. Facilitated reperfusion with prehospital glycoprotein Iib/IIIa inhibition: Predictors of complete ST-segment resolution before primary percutaneous coronary intervention in the on-TIME 2 trial: Correlates of reperfusion before primary PCI. J Electrocardiol 2011; 44(1):42-48. Medline
I Supportive (Green) Acute stent thrombosis or 30-day ischemic outcomes after pPCI. Patient Huber K., Ducrocq G., Hamm CW., van 't HA., Lapostolle F., Coste P., et al. Early clinical outcomes as a function of use of newer oral P2Y12 inhibitors versus clopidogrel in the EUROMAX trial. Open heart 2017; 4(2):e000677. Medline
I Supportive (Green) Feasibility and safety Process PH-Paramedic Pels K., Schroder J., Witzenbichler B., et al. Prehospital versus periprocedural abciximab in ST-elevation myocardial infarction treated by percutaneous coronary intervention. Eur J Emerg Med 2008; 15(6):324-9. Medline
I Supportive (Green) Infarct-related artery patency Patient ED-MD Sabatine MS., et al. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005; 352(12):1179-89. Medline
I Supportive (Green) Inhibition of platelet aggregation Patient PH-Paramedic Smit JJ., van Werkum JW., ten Berg J., Slingerland R., Ottervanger JP., Heestermans T., et al. Prehospital triple antiplatelet therapy in patients with acute ST elevation myocardial infarction leads to better platelet aggregation inhibition and clinical outcome than dual antiplatelet therapy. Heart 2010; 96(22):1815-1820. Medline
I Supportive (Green) Clinical outcome at 30 days Patient PH-Paramedic ten Berg JM., van ‘t Hof AW., Dill T., Heestermans T., et al. Effect of early, pre-hospital initiation of high bolus dose tirofiban in patients with ST-segment elevation myocardial infarction on short- and long-term clinical outcome. J Am Coll Cardiol 2010; 55(22)2446-55. Medline
I Supportive (Green) Clinical outcome at 30 days Patient PH-Paramedic ten Berg JM., van 't Hof AW., Dill T., Heestermans T., van Werkum JW., Mosterd A., et al. Effect of early, pre-hospital initiation of high bolus dose tirofiban in patients with ST-segment elevation myocardial infarction on short- and long-term clinical outcome. J Am Coll Cardiol 2010; 55(22):2446-2455. Medline
I Neutral (Yellow) Infarct-related artery patency Process In-Patient Dudek D., Rakowski T., Bartus S., Giszterowicz D., Dobrowolski W., Zmudka K., Zalewski J., Ochala A., Wieja P., Janus B., Dziewierz A., Legutko J., Bryniarski L., Dubiel J. Impact of early abciximab administration on myocardial reperfusion in patients with ST-segment elevation myocardial infarction pretreated with 600 mg of clopidogrel before percutaneous coronary intervention. J Thromb Thrombolysis 2010; 30:347–53. Medline
I Neutral (Yellow) TIMI flow grade 2-3 Process El Khoury C., Dubien PY., Mercier C., et al. Prehospital high-dose tirofiban in patients undergoing primary percutaneous intervention. The AGIR-2 study. Arch Cardiovasc Dis 2010; 103(5):285-92. Medline
I Neutral (Yellow) ST-segment resolution Patient PH-Paramedic Montalescot G., van 't Hof AW., Lapostolle F., et al. Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 2014; 371(11):1016-27. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic & CCT Ohlmann P., Reydel P., Jacquemin L., et al. Prehospital abciximab in ST-segment elevation myocardial infarction: Results of the randomized, double-blind MISTRAL study. Circ Cardiovasc Interv 2012; 5(1):69-76, S1. Medline
I Neutral (Yellow) TIMI flow grade 0 or 1, death or recurrent MI pre-angiography Patient PH-Paramedic Verheugt FW., Montalescot G., Sabatine MS., Soulat L., Lambert Y., Lapostolle F., et al. Prehospital fibrinolysis with dual antiplatelet therapy in ST-elevation acute myocardial infarction: a sub-study of the randomized double blind CLARITY-TIMI 28 trial. J Thromb Thrombolysis 2007; 23(3):173-179. Medline
I Neutral (Yellow) TIMI 3 flow Patient PH-Paramedic & MD Vlachojannis GJ, Wilschut JM, Vogel RF, Lemmert ME, Delewi R, Diletti R, et al. Effect of Prehospital Crushed Prasugrel Tablets in Patients With ST-Segment-Elevation Myocardial Infarction Planned for Primary Percutaneous Coronary Intervention: The Randomized COMPARE CRUSH Trial. Circulation 2020; 142(24):2316-28. Medline
I Neutral (Yellow) TIMI grade 2/3 flow at angiography Process PH-Paramedic Zeymer U., Arntz HR., Mark B., Fichtlscherer S., Werner G., Scholler R., et al. Efficacy and safety of a high loading dose of clopidogrel administered prehospitally to improve primary percutaneous coronary intervention in acute myocardial infarction: the randomized CIPAMI trial. Clin Res Cardiol 2012; 101(4):305-312. Medline
II Supportive (Green) TIMI flow Process ED-Paramedic & MD Fabris E, Menzio S, Gregorio C, Pezzato A, Stolfo D, Aleksova A, et al. Effect of prehospital treatment in STEMI patients undergoing primary PCI. Catheter Cardiovasc Interv 2022. Medline
II Supportive (Green) 1 year cardiovascular mortality Patient Goldstein P., Grieco N., Ince H., Danchin N., Ramos Y., Goedicke J., et al. Mortality in primary angioplasty patients starting antiplatelet therapy with prehospital prasugrel or clopidogrel: a 1-year follow-up from the European MULTIPRAC Registry. Vascular health and risk management 2016; 12:143-51. Medline
II Supportive (Green) Early reperfusion Patient PH-Paramedic Hassan AK., Liem SS., van der Klev F., Bergheanu SC., et al. In-ambulance abciximab administration in STEMI patients prior to primary PCI is associated with smaller infarct size, improved LV function and lower incidence of heart failure: Results from the Leiden MISSION! Acute myocardial infarction treatment optimization program. Cath Cardio Interv 2009; 74(2)335-43. Medline
II Supportive (Green) all-cause mortality Process PH-Paramedic Hautamäki M, Lyytikäinen LP, Eskola M, Lehtimäki T, Nikus K, Oksala N, et al. Prehospital Adenosine Diphosphate Receptor Blocker Use, Culprit Artery Flow, and Mortality in STEMI: The MADDEC Study. Clin Drug Investig 2021; 41(7):605–13. Medline
II Supportive (Green) Bleeding Patient PH-Paramedic Hermanides RS., Ottervanger JP., Dambrink JH., et al. Risk of bleeding after prehospital administration of high dose tirofiban for ST elevation myocardial infarction. Int J Cardiol 2012; 157(1):86-90. Medline
II Supportive (Green) Analgesic effect Patient Hermanides RS., van Werkum JW., Ottervanger JP., et al. The effect of pre-hospital glycoprotein Iib-IIIa inhibitors on angiographic outcome in STEMI patients who are candidates for primary PCI. Catheter Cardiovasc Interv 2012; 79(6):956-64. Medline
II Supportive (Green) TIMI Flow Process Lupi A., Schaffer A., Lazzero M., Tessitori M., De ML., Rognoni A., et al. Pre-hospital ticagrelor in patients with ST-segment elevation myocardial infarction with long transport time to primary PCI facility. Cardiovascular revascularization medicine: including molecular interventions 2016; 17(8):528-34. Medline
II Supportive (Green) Stent thrombosis Patient ED-MD Wang H, Pang X, Yang J, Shao J, Zhang J, Wang L, et al. Effect of Pre-Hospital Ticagrelor in Primary Percutaneous Coronary Intervention on Patients with ST-Segment Elevation Myocardial Infarction: A systematic review and meta-analysis. JPMA 2019; 69(9):1344-8. Medline
II Supportive (Green) Early reperfusion and short-term heart function Process In-Patient Zhang Y, Hui J, Chen X. Preprocedural Ticagrelor Treatment was Associated with Improved Early Reperfusion and Reduced Short-term Heart Failure in East-Asian ST-segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention. Int J Gen Med 2021; 14():1927–38. Medline
II Neutral (Yellow) Bleeding Patient PH-Paramedic Bergmeijer TO, van Oevelen M, Janssen PWA, Godschalk TC, Lichtveld RA, Kelder JC, et al. Safety of Ticagrelor Compared to Clopidogrel after Prehospital Initiation of Treatment. TH open 2018; 2(4):e357-68. Medline
II Neutral (Yellow) Net adverse clinical events (NACE) at 30 days Patient PH-Paramedic Hermanides RS., Ottervanger JP., ten Berg JM., et al. Net clinical benefit of prehospital glycoprotein Iib/IIIa inhibitors in patients with ST-elevation myocardial infarction and high risk of bleeding: Effect of tirofiban in patients at high risk of bleeding using CRUSADE bleeding score. J Invasive Cardiol 2012; 24(3):84-9. Medline
II Neutral (Yellow) ST resolution post PCI Patient PH-Paramedic Hermanides RS., van Houwelingen G., Ottervanger JP., et al. The impact of age on effects of pre-hospital initiation of high bolus dose of tirofiban before primary angioplasty for ST-elevation myocardial infarction. Cardiovasc Drugs Ther 2011; 25(4):323-30. Medline
II Neutral (Yellow) 30 day mortality Patient Kilic S., Fabris E., Van't HA., Hamm CW., Lapostolle F., Lassen JF., et al. Thrombus aspiration and prehospital ticagrelor administration in ST-elevation myocardial infarction: Findings from the ATLANTIC trial. Am Heart J 2018; 196:1-8. Medline
II Neutral (Yellow) IRV patency, mortality and recurrent myocardial infarction at 30-days and at one year Patient PH-Paramedic Postma S., Dambrink JH., Ottervanger JP., et al. Early ambulance initiation versus in-hospital initiation of high dose clopidogrel in ST-segment elevation myocardial infarction. Thromb Haemost 2014; 112(3):606-13. Medline
II Neutral (Yellow) ST segment resolution Patient PH-Paramedic Van't Hof AW., Ten Berg J., Heestermans T., Dill T., Funck RC., van Werkum W., et al. Prehospital initiation of tirofiban in patients with ST-elevation myocardial infarction undergoing primary angioplasty (On-TIME 2): a multicentre, double-blind, randomised controlled trial. Lancet 2008; 372(9638):537-546. Medline
III Supportive (Green) Pre-PCI ST-segment resolution Patient Bagai A., Goodman SG., Cantor WJ., Vicaut E., Bolognese L., Cequier A., et al. Duration of ischemia and treatment effects of pre- versus in-hospital ticagrelor in patients with ST-segment elevation myocardial infarction: Insights from the ATLANTIC study. Am Heart J 2018; 196:56-64. Medline
III Supportive (Green) Reperfusion Patient Cayla G., Lapostolle F., Ecollan P., Stibbe O., Benezet JF., Henry P., et al. Pre-hospital ticagrelor in ST-segment elevation myocardial infarction in the French ATLANTIC population. Int J Cardiol 2017; 244:49-53. Medline
III Supportive (Green) ST segment resolution Patient Fabris E., Van't HA., Hamm CW., Lapostolle F., Lassen JF., Goodman SG., et al. Impact of presentation and transfer delays on complete ST-segment resolution before primary percutaneous coronary intervention: insights from the ATLANTIC trial. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 2017; 13(1):69-77. Medline
III Supportive (Green) 30 day mortality Patient PH-Paramedic Heestermans T., de Boer MJ., van Werkum JW., et al. Higher efficacy of pre-hospital tirofiban with longer pre-treatment time to primary PCI: Protection for the negative impact of time delay. EuroIntervention 2011; 7(4):442-8. Medline
III Supportive (Green) ST segment resolution Patient PH-Paramedic Timmer JR., ten Berg J., Heestermans AA., et al. Pre-hospital administration of tirofiban in diabetic patients with ST-elevation myocardial infarction undergoing primary angioplasty: A sub-analysis of the on-time 2 trial. EuroIntervention 2010; 6(3):336-342. Medline
III Neutral (Yellow) TIMI flow Process Auffret V., Oger E., Leurent G., et al. Efficacy of pre-hospital use of glycoprotein Iib/IIIa inhibitors in ST-segment elevation myocardial infarction before mechanical reperfusion in a rapid-transfer network (from the acute myocardial infarction registry of brittany). Am J Cardiol 2014; 114(2):214-23. Medline
III Neutral (Yellow) Composite clinical end point Process PH-Paramedic Hanefeld C., Sirtl C., Spiecker M., et al. Prehospital therapy with the platelet glycoprotein Iib/IIIa inhibitor eptifibatide in patients with suspected acute coronary syndromes: The bochum feasibility study. Chest 2004; 126(3):935-41. Medline
III Neutral (Yellow) Infarct size at 6 months Patient ED-MD Petronio AS., De Carlo M., Strata E., et al. Impact of early abciximab administration on infarct size in patients with ST-elevation myocardial infarction. Int J Cardiol 2012; 155(2):230-5. Medline

ASA/Aspirin
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Death Patient ED-MD ISIS-2. Collaborative Group: Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17 187cases of suspected acute myocardial infarction. Lancet 1988; 349-60. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Barbash I., Freimark D., Gottlieb S., et al. Outcome of myocardial infarction in patients treated with aspirin is enhanced by pre-hospital administration. Cardiology 2002; 98(3):141-7. Medline
II Supportive (Green) Mortality Patient ED-MD Frilling B., Schiele R., Gitt AK., Zahn R., Schneider S., Glunz HG., et al. Characterization and clinical course of patients not receiving aspirin for acute myocardial infarction: results from the MITRA and MIR studies. Am Heart J 2001; 141(2):200-5. Medline
III Supportive (Green) Adverse events Patient PH-Paramedic Quan D., LoVecchio F., Clark B., Gallagher JV., 3rd. Prehospital use of aspirin rarely is associated with adverse events. Prehosp Disaster Med 2004; 19(4):362-5. Medline
III Neutral (Yellow) Protocol compliance for ASA administration Process PH-Paramedic Woollard M., Smith A., Elwood P. Pre-hospital aspirin for suspected myocardial infarction and acute coronary syndromes: A headache for paramedics? Emerg Med J 2001; 18(6):478-481. Medline
X Not Yet Graded (White) - Fabris E, Menzio S, Gregorio C, Pezzato A, Stolfo D, Aleksova A, et al. Effect of prehospital treatment in STEMI patients undergoing primary PCI. Catheter Cardiovasc Interv 2022. Medline

Beta Blockers
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Infarct size Patient ED-MD Ibanez B., Macaya C., Sanchez-Brunete V., et al. Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: The effect of metoprolol in cardioprotection during an acute myocardial infarction (METOCARD-CNIC) trial. Circulation 2013; 128(14):1495-1503. Medline
I Supportive (Green) Mortality within 1 wk Patient ED-MD ISIS-1. Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction. Lancet 1986; 12:57-66. Medline
I Neutral (Yellow) Chest pain severity Patient PH-Paramedic Gardtman M., Dellborg M., Brunnhage C., Lindkvist J., Waagstein L., Herlitz J. Effect of intravenous metoprolol before hospital admission on chest pain in suspected acute myocardial infarction. Am Heart J 1999; 137(5):821-9. Medline
I Neutral (Yellow) Mortality Patient ED-MD MIAMI Trial Research Group. Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. European Heart J 1985; 6:199-226. Medline
I Neutral (Yellow) Myocardial infarct size Patient Roolvink V., Ibáñez B., Ottervanger JP., Pizarro G., van RN, Mateos A., et al. Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction Before Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2016;67(23):2705-15. Medline
II Supportive (Green) Death within 48h Patient PH-Paramedic Hirschl MM., Wollmann CG., Erhart F., Brunner W., Pfeffel F., Gattermeier M., Steger F., Mayr H. Benefit of Immediate Beta-Blocker Therapy on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. Crit Care Med 2013; 41(6):1396-404 Medline
II Neutral (Yellow) Troponin rise Patient ED-MD Ibrahim M., Maselli DJ., Hasan R., Hamilton A. Safety of beta-blockers in the acute management of cocaine-associated chest pain. Am J Emerg Med 2013; 31(3):613-6. Medline
II Neutral (Yellow) Infarct size on cardiac MRI at 30days Patient Roolvink V., Ibáñez B., Ottervanger JP., Pizarro G., van RN., Mateos A., et al. Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction Before Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2016; 67(23):2705-15. Medline
III Supportive (Green) Pain relief Patient PH-Paramedic Zedigh C., Alho A., Hammar E., et al. Aspects on the intensity and the relief of pain in the prehospital phase of acute coronary syndrome: Experiences from a randomized clinical trial. Coron Artery Dis 2010; 21(2):113-120. Medline
III Neutral (Yellow) Feasibility Process PH-Paramedic EMIP-BB Study group. Pre-hospital treatment of patients with suspected acute myocardial using a beta-blocking agent: A double-blind feasibility study. Clin Trials Metaanal 1994; 29(2-3):125-38. Medline
III Neutral (Yellow) Incidence of major adverse cardiac events at 1 year Patient Roolvink V., Ottervanger JP., Ibáñez B., Dambrink JH., Gosselink M., Kedhi E., et al. One year clinical outcome of early administration of intravenous beta-blockers in patients with ST-segment elevation myocardial infarction before primary percutaneous coronary reperfusion. One year results from the EARLY-BAMI trial. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 2017. Medline

Bypass/Direct to PCI
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) 30 day Mortality Patient PH-Paramedic Armstrong P. A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST study. European Heart Journal 2006; 27:1530-8. Medline
I Supportive (Green) Survival Patient PH-Bystander Bata I., Armstrong PW., Westerhout CM., Travers A., Sookram S., Caine E., et al. Time from first medical contact to reperfusion in ST elevation myocardial infarction: a Which Early ST Elevation Myocardial Infarction Therapy (WEST) substudy. Can J Cardiol 2009; 25(8):463-8. Medline
I Supportive (Green) Mortality at 5 years Patient PH-Paramedic Bonnefoy E., Steg PG., Boutitie F., et al. Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: A 5-year follow-up. Eur Heart J 2009; 30(13):1598-606. Medline
I Supportive (Green) Reinfarction, Stroke, All-cause mortality Patient ED-MD Dalby M., et al. Transfer for PCI versus immediate thrombolysis for AMI: a meta-analysis. Circulation 2003; 108:1809-14. Medline
I Supportive (Green) All cause mortality at 30 days Patient Postma S., Kolkman E., Rubinstein SM., Jansma EP., De LG., Suryapranata H., et al. Field triage in the ambulance versus referral via non-percutaneous coronary intervention centre in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: A systematic review. European heart journal Acute cardiovascular care 2017; 6(5):396-403. Medline
I Neutral (Yellow) Survival Patient PH-Paramedic Brooks S. Prehospital Triage and Direct Transport of Patients with ST-elevation Myocardial Infraction to Primary Percutaneous Coronary Intervention Centres: a systematic review and meta-analysis. CJEM 2009; 11(5):481-92. Medline
II Supportive (Green) Mortality Patient Almawiri A., Jan V., Ziad A., Martin J., Josef S. Mortality benefit of primary transportation to a PCI-capable center persists through an eight-year follow-up in patients with ST-segment elevation myocardial infarction. J Interv Cardiol 2017; 30(6):522-6. Medline
II Supportive (Green) Pain to needle time Process PH-Paramedic Amit G., Cafri C., Gilutz H., Ilia R., Zahger D. Benefit of direct ambulance to CCU admission of AMI patients undergoing PCI. International J of Cardiol 2007; 119:355-8. Medline
II Supportive (Green) Time to reperfusion Process Bata A., Quraishi AUR., Love M., Title L., Beydoun H., Lee T., et al. Initial experience with pre-activation of the cardiac catheterization lab and emergency room bypass for patients with ST-elevation myocardial infarction in Halifax, Nova Scotia. Int J Cardiol 2016; 222:645-7. Medline
II Supportive (Green) Symptom onset to balloon times Process PH-Paramedic Carstensen S., et al. Field triage to primary angioplasty combined with emergency department bypass reduces treatment delays and is associated with improved outcome. Eur Heart J 2007; 28:2313-9. Medline
II Supportive (Green) Symptom to reperfusion, Mortality Process PH-Paramedic Dalby M., Kharbanda R., Ghimire G., et al. Achieving routine sub 30 minute door-to-balloon times in a high volume 24/7 primary angioplasty center with autonomous ambulance diagnosis and immediate catheter laboratory access. Am Heart J 2009; 158(5):829-35. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Eckstein M., Koenig W., Kaji A., Tadeo R. Implementation of specialty centers for patients with STEMI: The Los Angeles STEMI receiving center project. Prehosp Emerg Care 2009; 13:215-22. Medline
II Supportive (Green) Time to reperfusion Process PH-Paramedic Fosbol EL., Granger CB., Jollis JG., et al. The impact of a statewide pre-hospital STEMI strategy to bypass hospitals without percutaneous coronary intervention capability on treatment times. Circulation 2013; 127(5):604-12. Medline
II Supportive (Green) EMS call to needle time Process PH-Paramedic Kelly AM., Kerr D., Patrick I., Walker T. Call-to-needle times for thrombolysis in AMI in Victoria. MJA 2003; 178:381-5. Medline
II Supportive (Green) In-hospital mortality Patient PH-Paramedic Kritikou I., Chalkias A., Koutsovasilis A., Xanthos T. Characteristics and survival to discharge of patients with STEMI between a PPCI-capable hospital and a non-PPCI hospital: A prospective observational study. Acute Card Care 2014; 16(4):118-22. Medline
II Supportive (Green) Patient stability Patient Kwong JL., Ross G., Turner L., Olynyk C., Cheskes S., Thurston A., et al. Evaluation of a primary care paramedic STEMI bypass guideline. CJEM. 2018; 20(6):850-856. Medline
II Supportive (Green) Safety and feasibility Process PH-Paramedic Le May MR., Davies RF., Dionne R., et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol 2006; 98(10):1329-1333. Medline
II Supportive (Green) Safety and feasibility Process PH-Paramedic Le May MR., Davies RF., Dionne R., et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol 2006; 98(10):1329-1333. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Le May MR., et al. A City-wide protocol for primary PCI in ST-segment elevation myocardial infarction. NEMJ 2008; 358:231-40. Medline
II Supportive (Green) Mortality at 180 days Patient PH-Paramedic Le May MR., Wells GA., So DY., et al. Reduction in mortality as a result of direct transport from the field to a receiving center for primary percutaneous coronary intervention. J Am Coll Cardiol 2012; 60(14):1223-1230. Medline
II Supportive (Green) Symptom to needle time Process PH-Paramedic Leleu H., Capuano F., Ferrua M., Nitenberg G., Minvielle E., Schiele F. Symptom-to-needle times in ST-segment elevation myocardial infarction: Shortest route to a primary coronary intervention facility. Arch Cardiovasc Dis 2013; 106(3):162-168. Medline
II Supportive (Green) Symptom to needle time Process PH-Paramedic Leleu H., Capuano F., Ferrua M., Nitenberg G., Minvielle E., Schiele F. Symptom-to-needle times in ST-segment elevation myocardial infarction: Shortest route to a primary coronary intervention facility. Arch Cardiovasc Dis 2013; 106(3):162-168. Medline
II Supportive (Green) death, non-fatal myocardial infarction, and stroke Patient PH-Paramedic Machecourt J., et al. Primary angioplasty is cost-minimizing compared with pre-hospital thrombolysis for patients within 60 min of a PCI center. J Am Coll Cardiol 2005; 45:515-24. Medline
II Supportive (Green) Door to balloon time Process PH-Paramedic Rokos IC., French WJ., Koenig WJ., et al. Integration of pre-hospital electrocardiograms and ST-elevation myocardial infarction receiving center (SRC) networks: Impact on door-to-balloon times across 10 independent regions. JACC Cardiovasc Interv 2009; 2(4):339-46. Medline
II Supportive (Green) Mortality post-1 yr Patient PH-Paramedic Savage ML, Hay K, Murdoch DJ, Doan T, Bosley E, Walters DL, Denman R, Ranasinghe I, Raffel OC. Clinical Outcomes in Pre-Hospital Activation and Direct Cardiac Catheterisation Laboratory Transfer of STEMI for Primary PCI. Hear Lung Circ 2022. Medline
II Supportive (Green) time to device Process Shavelle DM., Bosson N., Thomas JL., Kaji AH., Sung G., French WJ., et al. Outcomes of ST Elevation Myocardial Infarction Complicated by Out-of-Hospital Cardiac Arrest (from the Los Angeles County Regional System). Am J Cardiol 2017; 120(5):729-33. Medline
II Supportive (Green) Feasibility Process PH-Paramedic Sillesen M., et al. Referral of patients with STEMI directly to the cath suite based on prehospital teletransmission of 12 lead ECG. J Electrocardiography 2008; 41:49-53. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Stenestrand U., Lindback J., Wallentin L., RIKS-HIA Registry. Long-term outcome of primary percutaneous coronary intervention vs prehospital and in-hospital thrombolysis for patients with ST-elevation myocardial infarction. JAMA 2006; 296(14):1749-1756. Medline
II Supportive (Green) Treatment delay Patient PH-Paramedic Terkelsen CJ., et al. Reduction of treatment delay in patients with STEMI: impact of prehospital diagnosis and direct referral to primary PCI. Eur Heart J 2005; 26:770-7. Medline
II Supportive (Green) Infarct Diagnosis Patient PH-Paramedic van 't Hof AW., Rasoul S., van de Wetering H., et al. Feasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction. Am Heart J 2006; 151(6):1255.e1-1255.e5. Medline
II Supportive (Green) 30 day primary endpoint (death, re-infarction, shock, CHF) Patient Welsh RC., Goldstein P., Sinnaeve P., Ostojic MC., Zheng Y., Danays T., et al. Relationship between community hospital versus pre-hospital location of randomisation and clinical outcomes in ST-elevation myocardial infarction patients: insights from the Stream study. European heart journal Acute cardiovascular care 2017:2048872617700872. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Zahn R., Schiele R., Gitt AK., et al. Impact of prehospital delay on mortality in patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis. Am Heart J 2001; 142(1):105-111. Medline
II Neutral (Yellow) ST segment resolution Patient Fabris E., Van't HA., Hamm CW., Lapostolle F., Lassen JF., Goodman SG., et al. Impact of presentation and transfer delays on complete ST-segment resolution before primary percutaneous coronary intervention: insights from the ATLANTIC trial. EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 2017; 13(1):69-77. Medline
II Neutral (Yellow) FMC to Device time Process Fordyce CB., Cairns JA., Singer J., Lee T., Park JE., Vandegriend RA., et al. Evolution and Impact of a Regional Reperfusion System for ST-Elevation Myocardial Infarction. Can J Cardiol 2016; 32(10):1222-30. Medline
III Supportive (Green) Reduction in door-to-balloon time Process PH-Paramedic Van de Loo A., Saurbier B., Kalbhenn J., Koberne F., Zehender M. Primary PCI in AMI: Direct transportation to catheterization laboratory in emergency teams reduces door-to-balloon time. Clin Cardiol 2006; 29:112-6. Medline

Chest pain prediction tool
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) NPV as measures of ability to rule out MI. Process ED-MD Bang C, Anderson CF, Lauridsen KG, Frederiksen CA, Schmidt M, Jensen T, et al. Rapid Rule-Out of Myocardial Infarction After 30 Minutes as an Alternative to 1 Hour: The RACING-MI Cohort Study. Ann Emerg Med 2021. Medline
II Supportive (Green) Predictive Value Patient PH-Paramedic & MD Wibring K, Lingman M, Herlitz J, Amin S, Bång A. Prehospital stratification in acute chest pain patient into high risk and low risk by emergency medical service: a prospective cohort study. BMJ Open 2021; 11(4):e044938. Medline
II Neutral (Yellow) Major adverse cardiac event (MACE)/ mortality Patient PH-Paramedic Sagel D, Vlaar PJ, van Roosmalen R, Waardenburg I, Nieuwland W, Lettinga R, et al. Prehospital risk stratification in patients with chest pain. Emerg Med J 2021; 38(11):814–9. Medline
II Neutral (Yellow) 30 day MACE outcomes Patient ED-MD Schrader CD, Kumar D, Zhou Y, Meyering S, Saltarelli N, Alanis N, et al. Using HEART2 score to risk stratify chest pain patients in the Emergency Department: an observational study. BMC Cardiovasc Disord 2022; 22(1):79. Medline
II Neutral (Yellow) Risk stratification Patient PH-Paramedic Stopyra JP, Snavely AC, Ashburn NP, O'Neill J, Paradee BE, Hehl B, Vorrie J, Wells M, Nelson RD, Hendley NW, Miller CD, Mahler SA. Performance of Prehospital Use of Chest Pain Risk Stratification Tools: The RESCUE Study. Prehosp Emerg Care 2022; 1–6. Medline
III Supportive (Green) Major adverse cardiac events Patient PH-Paramedic Cooper JG, Ferguson J, Donaldson LA, Black KMM, Livock KJ, Horrill JL, et al. The Ambulance Cardiac Chest Pain Evaluation in Scotland Study (ACCESS): A Prospective Cohort Study. Ann Emerg Med 2021; 77(6):575-88. Medline
III Supportive (Green) Risk Classification Process Other Wibring K, Lingman M, Herlitz J, Ashfaq A, Bång A. Development of a prehospital prediction model for risk stratification of patients with chest pain. Am J Emerg Med 2022; 51:26–31. Medline
X Not Yet Graded (White) - Demandt JPA, Zelis JM, Koks A, Smits GHJM, van der Harst P, Tonino PAL, Dekker LRC, van Het Veer M, Vlaar PJ. Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. BMJ Open 2022; 12(4):e057305. Medline
X Not Yet Graded (White) - Khaleghi Rad M, Pirmoradi MM, Doosti-Irani A, Thiruganasambandamoorthy V, Mirfazaelian H. The performance of HEAR score for identification of low-risk chest pain: a systematic review and meta-analysis. Eur J Emerg Med 2022; 29(3):173–87. Medline

Drip and ship
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Reperfusion Patient Dobrzycki S., Mezynski G., Kralisz P., et al. Is transport with platelet GP Iib/IIIa inhibition for primary percutaneous coronary intervention more efficient than on-site thrombolysis in patients with STEMI admitted to community hospitals? Randomised study. Early results. Kardiol Pol. 2006; 64(8):793-9, discussion 800-1. Medline
III Supportive (Green) Time to intervention Process Dieker HJ., Liem SS., El Aidi H., et al. Pre-hospital triage for primary angioplasty: Direct referral to the intervention center versus interhospital transport. JACC Cardiovasc Interv 2010; 3(7):705-11. Medline

Fentanyl
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Platelet reactivity Process PH-Paramedic Tavenier AH, Hermanides RS, Ottervanger JP, Tolsma R, van Beurden A, Slingerland RJ, Ter Horst PGJ, et al. Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. Eur Hear J Cardiovasc Pharmacother 2022; 8:4–12. Medline
I Opposes (Red) Ticagrelor blood concentration during the 24 hours after loading Patient OR Ibrahim K, Shah R, Goli RR, et al. Fentanyl Delays the Platelet Inhibition Effects of Oral Ticagrelor: Full Report of the PACIFY Randomized Clinical Trial. Thromb Haemost. 2018;118(8):1409–1418. doi:10.1055/s-0038-1666862 Medline
II Opposes (Red) Ticagrelor plasma concentration Patient In-Patient Goli RR, Ibrahim K, Shah R, et al. The Dose and Timing of Fentanyl Impacts on Ticagrelor Absorption and Platelet Inhibition During Percutaneous Coronary Intervention: The PACIFY Randomized Clinical Trial. J Invasive Cardiol. 2019;31(9):265–271. Medline
III Supportive (Green) Analgesia Patient PH-Paramedic Weldon ER, Ariano RE, Grierson RA. Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain. PEC 2016; 20(1) 45-51. Medline

Fibrinolysis
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) 30 day Mortality Patient PH-Paramedic Armstrong P. A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST study. European Heart Journal 2006; 27:1530-8. Medline
I Supportive (Green) 30 day Mortality Patient Armstrong PW., Gershlick AH., Goldstein P., et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med 2013; 368(15):1379-87. Medline
I Supportive (Green) exclude Process PH-Paramedic Bata I., Armstrong PW., Westerhout CM., Travers A., Sookram S., Caine E., et al. Time from first medical contact to reperfusion in ST elevation myocardial infarction: a Which Early ST Elevation Myocardial Infarction Therapy (WEST) substudy. Can J Cardiol 2009; 25(8):463-8. Medline
I Supportive (Green) 30 day survival. Patient PH-Paramedic Boissel JP. The European myocardial infarction project: An assessment of pre-hospital thrombolysis. Internat J Card 1995; 49(suppl):S29-37. Medline
I Supportive (Green) Composite of death, non-fatal reinfarction, and non-fatal disabling stroke at 30 days. Patient PH-Paramedic Bonnefoy E., et al. Primary angioplasty versus prehospital fibrinolysis in AMI: A randomised study. Lancet 2002; 360:825-9. Medline
I Supportive (Green) Mortality at 5 years Patient PH-Paramedic Bonnefoy E., Steg PG., Boutitie F., et al. Comparison of primary angioplasty and pre-hospital fibrinolysis in acute myocardial infarction (CAPTIM) trial: A 5-year follow-up. Eur Heart J 2009; 30(13):1598-606. Medline
I Supportive (Green) Event-free survival at 2 years Patient PH-Paramedic Brouwer MA., et al. Influence of early prehospital thrombolysis on mortality & event-free survival (The myocardial infarction triage and intervention [MITI] randomized trial). Am J Cardiol 1996; 78:497-502. Medline
I Supportive (Green) Initiation of therapy Process Dussoix P., Reuille O., Verin V., Gaspoz JM., Unger PF. Time savings with prehospital thrombolysis in an urban area. Eur J Emer Med 2003; 10:2-5. Medline
I Supportive (Green) Resolution of ST segment elevation Patient PH-Paramedic Kudenchuk PJ., Maynard C., Cobb LA., et al. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: The myocardial infarction triage and intervention (MITI) project. JACC 1998; 32(1):17-27. Medline
I Supportive (Green) All-cause hospital mortality Patient PH-Paramedic Morrison LJ., Verbeek PR., McDonald AC., Sawadsky BV., Cook DJ. Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis. JAMA 2000; 283(20):2686-92. Medline
I Supportive (Green) - Patient Morrison LJ., Verbeek R., McDonald A., et al. Mortality and prehospital thromblysis for acute myocardial infarction. JAMA 2000; 283:2686-92. Medline
I Supportive (Green) Survival Patient PH-Paramedic Rawles J. GREAT: 10 year survival of patients with AMI in a randomized comparison of prehospital and hospital thrombolysis. Heart 2003; 89:563-4. Medline
I Supportive (Green) Survival Patient PH-Paramedic Rawles JM. Quantification of the benefit of earlier thrombolytic therapy: Five year results of the Grampian Region Early Anistreplase Trial (GREAT). JACC 1997; 30(5):1181-6. Medline
I Supportive (Green) 30 day mortality Patient PH-Paramedic Steg PG., et al. Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty (CAPTIM). Circulation 2003; 108:2851-2856. Medline
I Supportive (Green) Infarct size, functional coronary intervention in acute myocardial infarction. Eur Heart J Patient PH-Paramedic Thiele H., Engelmann L., Elsner K., et al. Comparison of pre-hospital combination-fibrinolysis plus conventional care with pre-hospital combination-fibrinolysis plus facilitated percutaneous coronary intervention in acute myocardial infarction. Eur Heart J 2005; 26(19):1956-1963. Medline
I Supportive (Green) Complete ST-segment recovery Patient PH-Paramedic Thiele H., et al. ST-segment recovery and prognosis in patients with STEMI reperfused by prehospital combination fibrinolysis, prehospital initiated facilitated percutaneous coronary intervention, or PCI. Am J Cardiol 2006; 98:1132-9. Medline
I Supportive (Green) Complete ST-segment recovery Patient PH-Paramedic Thiele H., et al. ST-segment recovery and prognosis in patients with STEMI reperfused by prehospital combination fibrinolysis, prehospital initiated facilitated percutaneous coronary intervention, or PCI. Am J Cardiol 2006; 98:1132-9. Medline
I Supportive (Green) Reduction in infarct size Patient PH-Paramedic Weaver DW., Cerqueira M., Hallstrom AP., et al. Prehospital-initiated vs hospital-initiated thrombolytic therapy. JAMA 1993; 270(10):1211-1216. Medline
I Supportive (Green) 1 year mortality Patient PH-Paramedic Westerhout CM., Bonnefoy E., Welsh RC., Steg PG., Boutitie F., Armstrong PW. The influence of time from symptom onset and reperfusion strategy on 1-year survival in ST-elevation myocardial infarction: A pooled analysis of an early fibrinolytic strategy versus primary percutaneous coronary intervention from CAPTIM and WEST. Am Heart J 2011; 161(2):283-290. Medline
II Supportive (Green) Survival Patient PH-Paramedic Bjorklund E., Stenestrand U., Lindback J., et al. Prehospital diagnosis and start of treatment reduces time delay and mortality in real-life patients with STEMI. J Electrocardiol 2005; 38(S4):186. Medline
II Supportive (Green) 30 day and 1 year mortality Patient PH-Paramedic Björklund E., Stenestrand U., Lindbäck J., Svensson L., Wallentin L., Lindahl B. Pre-hospital thrombolysis delivered by paramedics is associated with reduced time delay and mortality in ambulance-transported real-life patients with ST-elevation myocardial infarction. Eur Heart J 2006; 27:1146-52. Medline
II Supportive (Green) Mortality Patient Grijseels EWM., Bouten MJM., Lenderink T., et al. Pre-hospital thrombolytic therapy with either alteplase or streptokinase. Euro Heart J 1995; 16:1833-8. Medline
II Supportive (Green) Artery patency Patient PH-Paramedic Juliard JM., Himbert D., Cristofini P., et al. A matched comparison of the combination of prehospital thrombolysis and standby rescue angioplasty with primary angioplasty. Am J Card 1999; 83:305-10. Medline
II Supportive (Green) Aborted MI Process PH-Paramedic Lamfers EJ., Schut A., Hertzberger DP., et al. Prehospital versus hospital fibrinolytic therapy using automated versus cardiologist electrocardiographic diagnosis of myocardial infarction: Abortion of myocardial infarction and unjustified fibrinolytic therapy. Am Heart J. 2004; 147(3):509-515. Medline
II Supportive (Green) Aborted MI Process PH-Paramedic Lamfers EJ., Schut A., Hertzberger DP., et al. Prehospital versus hospital fibrinolytic therapy using automated versus cardiologist electrocardiographic diagnosis of myocardial infarction: Abortion of myocardial infarction and unjustified fibrinolytic therapy. Am Heart J. 2004; 147(3):509-515. Medline
II Supportive (Green) Time to treatment Process PH-Paramedic Lamfers EJ., Schut A., Hooghoudt TE., et al. Prehospital thrombolysis with reteplase: The Nijmegen/Rotterdam study. Am Heart J. 2003; 146(3):479-483. Medline
II Supportive (Green) DTB time Process PH-Paramedic Mockel M., Bocksch W., Strohm S., et al. Facilitated percutaneous coronary intervention (PCI) in patients with acute ST-elevation myocardial infarction: Comparison of prehospital tirofiban versus fibrinolysis before direct PCI. Int J Cardiol 2005; 103(2):193-200. Medline
II Supportive (Green) Amount of time saved by prehospital administration of rPA Process PH-Paramedic Morrow DA., Antman EM., Sayah A., et al. Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: Results of the early retavase-thrombolysis in myocardial infarction (ER-TIMI) 19 trial. J Am Coll Cardiol 2002; 40(1):71-7. Medline
II Supportive (Green) Adverse effects occurring in ambulance. Patient PH-Paramedic Ranchord AM., Prasad S., Matsis P., Harding SA. Paramedic-administered prehospital thrombolysis is safe and reduces time to treatment. N Z Med J 2009; 122(1302):47-53. Medline
II Supportive (Green) Mortality Patient Roule V., Ardouin P., Blanchart K., Lemaitre A., Wain-Hobson J., Legallois D., et al. Prehospital fibrinolysis versus primary percutaneous coronary intervention in ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Crit Care 2016; 20(1):359. Medline
II Supportive (Green) 30 day mortality Patient Solhpour A., Chang KW., Arain SA., Balan P., Zhao Y., Loghin C., et al. Comparison of 30-day mortality and myocardial scar indices for patients treated with prehospital reduced dose fibrinolytic followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocard. Catheterization and cardiovascular interventions: official journal of the Society for Cardiac Angiography & Interventions 2016; 88(5):709-15. Medline
II Supportive (Green) Feasibility Patient PH-Paramedic Svensson L., Karlsson T., Nordlander R., Wahlin M., Zedigh C., Herlitz J. Safety and delay time in prehospital thrombolysis of acute myocardial infarction in urban and rural areas in sweden. Am J Emerg Med 2003; 21(4):263-270. Medline
II Supportive (Green) quality of life Patient Vaisanen O., Makijarvi M., Silfvast T. Quality of life of elderly patients after prehospital thrombolytic therapy. Resuscitation 2005; 66(2):183-188. Medline
II Supportive (Green) Feasibility Patient PH-Paramedic Welsh RC., Travers A., Senaratne M., Williams R., Armstrong PW. Feasibility & applicability of paramedic-based prehospital fibrinolysis in a large North American center. Am Heart J 2006; 152:1007-14. Medline
II Supportive (Green) Mortality Patient PH-Paramedic Zahn R., Schiele R., Gitt AK., et al. Impact of prehospital delay on mortality in patients with acute myocardial infarction treated with primary angioplasty and intravenous thrombolysis. Am Heart J 2001; 142(1):105-111. Medline
II Neutral (Yellow) Death re-MI and stroke Patient PH-Paramedic Bonnefoy E., Steg PG., Chabaud S., et al. Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial. Eur Heart J 2005; 26(17):1712-8. Medline
II Neutral (Yellow) Identification of AMI reperfusion candidates Process PH-Paramedic Gibler WB., et al. Prehospital diagnosis and treatment of AMI: A North-South perspective. Am Heart J 1991; 121:1-11. Medline
II Neutral (Yellow) Frequency and determinants of re-infarction Process PH-Paramedic Horne S., Weston C., Quinn T., et al. The impact of pre-hospital thrombolytic treatment on re-infarction rates: Analysis of the myocardial infarction national audit project (MINAP). Heart 2009; 95(7):559-63. Medline
II Neutral (Yellow) Aborted myocardial infarction Patient PH-Paramedic Jackson L., Kendall J., Castle N. Does prehospital thrombolysis increase the proportion of patients who have an aborted myocardial infarction? Emerg Med J 2009; 26(3):206-9. Medline
II Neutral (Yellow) Survival Patient PH-Paramedic Ryynanen OP., Iirola T., Reitala J., Palve H., Malmivaara A. Is advanced life support better than basic life support in prehospital care? A systematic review. Scand J Trauma Resusc Emerg Med 2010; 18:62-7241-18-62. Medline
III Supportive (Green) Reperfusion Patient ED-MD Kosits L. Administration of tenecteplase after prolonged cardiopulmonary resuscitation in a 46-year-old man with ventricular fibrillation. J Emerg Nurs 2003; 29(6):507-10. Medline
III Supportive (Green) Mortality at 1 and 12 months Patient PH-Paramedic McLean S., Wild S., Connor P., Flapan AD. Treating ST elevation myocardial infarction by primary percutaneous coronary intervention, in-hospital thrombolysis and prehospital thrombolysis. An observational study of timelines and outcomes in 625 patients. Emerg Med J 2011; 28(3):230-6. Medline
III Supportive (Green) call to needle time) Process PH-Paramedic Pedley DK., et al. Prospective observation cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ 2003; 327(405):22-6. Medline
III Supportive (Green) Feasibility Patient PH-Paramedic Rosenberg DG., Levin E., Lausell A., et al. Feasibility and timing of prehospital administration of reteplase in patients with acute myocardial infarction. J Thromb Thrombolysis 2002; 13(3):147-53. Medline
III Supportive (Green) 70% or greater reduction of ST elevation Patient PH-Paramedic Smalling RW. Pre-hospital reduced-dose fibrinolysis coupled with urgent PCI reduces time to reperfusion and improves angiographic perfusion score compared with prehospital fibrinolysis alone or primary PCI. J Am Coll Card 2007; 50:1612-3. Medline
III Neutral (Yellow) Safety Patient PH-Paramedic Tatu-Chitoiu G., Oprisan M., Cismara O., Marinescu R., Marinescu A. Streptokinase and enoxaparin in the pre-hospital management of the ST-segment elevation acute myocardial infarction. Rom J Intern Med 2002; 40(1-4):11-25. Medline

GIK (Glucose-Insulin-Potassium)
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Progression to MI Patient PH-Paramedic Selker HP., Beshansky JR., Sheehan PR., et al. Out-of-hospital administration of intravenous glucose-insulin-potassium in patients with suspected acute coronary syndromes: The IMMEDIATE randomized controlled trial. JAMA 2012; 307(18):1925-1933. Medline
I Neutral (Yellow) 1 yr survival Patient PH-Paramedic Selker HP., Udelson JE., Massaro JM., et al. One-year outcomes of out-of-hospital administration of intravenous glucose, insulin, and potassium (GIK) in patients with suspected acute coronary syndromes (from the IMMEDIATE [immediate myocardial metabolic enhancement during initial assessment and treatment in emergency care] trial). Am J Cardiol 2014; 113(10):1599-1605. Medline

HEMS
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) Out-of-hospital time Process ED-Paramedic & MD Stowell A, Bobbia X, Cheret J, Genre Grandpierre R, Moreau A, Pommet S, et al. Out-of-hospital Times Using Helicopters Versus Ground Services for Emergency Patients. Air Med J 2019; 38(2):100-5. Medline
II Neutral (Yellow) Adverse events at 30 days post intervention Patient Baylous D., Tillman HJ., Smith MW. Air versus ground transport for patients with st-elevation myocardial infarction: Does transport type affect patient outcomes? J Emerg Nurs 2013; 39(5):e65-74. Medline

Heparin
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) 30 day mortality Patient PH-Paramedic Wallentin L., Goldstein P., et al. Efficacy and Safety of Tenecteplase in Combination with the Low-Molecular-Weight Heparin Enoxaprin or Unfractionated Heparin in the prehospital Setting. Circulation 2003; 108(2):135-142. Medline
II Supportive (Green) Basal TIMI flow Process PH-Paramedic Fabris E, Menzio S, Gregorio C, Pezzato A, Stolfo D, Aleksova A, et al. Effect of prehospital treatment in STEMI patients undergoing primary PCI. Catheter Cardiovasc Interv 2022. Medline
II Supportive (Green) 1 year mortality Patient Fabris E., Kilic S., Van't HA., Ten BJ., Ayesta A., Zeymer U., et al. One-Year Mortality for Bivalirudin vs Heparins Plus Optional Glycoprotein IIb/IIIa Inhibitor Treatment Started in the Ambulance for ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of the EUROMAX Randomized Clinical Trial. JAMA cardiology 2017; 2(7):791-6. Medline
II Supportive (Green) Anti-Xa levels Patient ICU Welsh RC., Gordon P., Westerhout CM., Buller CE., O'Neill B., Armstrong PW. A novel enoxaparin regime for ST elevation myocardial infarction patients undergoing primary percutaneous coronary intervention: a WEST sub-study. Catheter Cardiovasc Interv 2007; 70(3):341-348. Medline
II Neutral (Yellow) Feasibility and safety Patient PH-Paramedic Sejersten M., Nielsen SL., Engstrom T., Jorgensen E., Clemmensen P. Feasibility and safety of prehospital administration of bivalirudin in patients with ST-elevation myocardial infarction. Am J Cardiol 2009; 103(12):1635-1640. Medline
III Neutral (Yellow) Safety Patient PH-Paramedic Tatu-Chitoiu G., Oprisan M., Cismara O., Marinescu R., Marinescu A. Streptokinase and enoxaparin in the pre-hospital management of the ST-segment elevation acute myocardial infarction. Rom J Intern Med 2002; 40(1-4):11-25. Medline

Ketamine
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Reduction in pain Patient ED-MD Goltser A., Soleyman-Zomalan E., Kresch F., Motov S. Short (low-dose) ketamine infusion for managing acute pain in the ED: Case-report series. Am J Emerg Med 2015; 33(4):e5-7. Medline

Lidocaine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Early death (death or VF within first 2 hours after injection) Patient PH-Paramedic Valentine PA., Frew JL., Mashford ML., Sloman JG. Lidocaine in the prevention of sudden death in the pre-hospital phase of acute infarction. A double-blind study. N Engl J Med 1974; 291(25):1327-1331. Medline
I Neutral (Yellow) 24 h mortality Patient ED-MD Alexander J., Granger C., Sadowski Z., et al. Prophylactic lidocaine use in acute myocardial infarction: Incidence and outcome from two international trials. Am Heart J 1999; 137:799-805. Medline
I Neutral (Yellow) Occurrence of V-Fib Process PH-Paramedic Berntsen RF., Rasmussen K. Lidocaine to prevent ventricular fibrillation in the prehospital phase of suspected acute myocardial infarction: The North-Norwegian Lidocaine Intervention Trial. Am Heart J 1992; 124:1478-83. Medline
I Neutral (Yellow) Occurrence of V-fib Process PH-Paramedic Bertini G., Giglioli C., Rostagno C., et al. Early out-of-hospital lidocaine administration decreases the incidence of primary ventricular fibrillation in acute myocardial infarction. J Emerg Med 1993; 11:667-72. Medline
I Neutral (Yellow) Prevent life threatening dysrhythmias Process PH-Paramedic Hargarten K., Chapman PD., Stueven HA., et al. Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain. Ann Emerg Med 1990; 19(11):1274-9. Medline
I Neutral (Yellow) Prevent life threatening dysrhythmias Process PH-Paramedic Hargarten K., Chapman PD., Stueven HA., et al. Prehospital prophylactic lidocaine does not favorably affect outcome in patients with chest pain. Ann Emerg Med 1990; 19(11):1274-9. Medline
I Neutral (Yellow) Mortality Patient PH-Paramedic Hine LK., Laird N., Hewitt P., Chalmers TC. Meta-analytic evidence against prophylactic use of lidocaine in acute myocardial infarction. Arch Intern Med 1989 Dec; 149(12):2694-8. Medline
III Supportive (Green) Reduction in primary ventricular fibrillation Patient PH-Paramedic Koster RW., Dunning AJ. Intramuscular lidocaine for prevention of lethal arrhythmias in the prehospitalization phase of acute myocardial infarction. N Engl J Med 1985; 313(18):1105-10. Medline
III Supportive (Green) Incidence of ventricular tachyarrhythmias Patient PH-Paramedic Wennerblom B., Holmberg S., Ryden L., Wedel H. Antiarrhythmic efficacy and side-effects of lidocaine given in the prehospital phase of acute myocardial infarction. Eur Heart J 1982; 3(6):516-24. Medline

Magnesium
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Mortality at 5 weeks Patient ED-MD ISIS-4. A randomized factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58 050 patients with suspected acute myocardial infarction. Lancet 1995; 345:669-85. Medline

Morphine
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Analgesia Process Other Charpentier S, Galinski M, Bounes V, Ricard-Hibon A, El-Khoury C, Elbaz M, et al. Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study. Scandinavian J of trauma, resuscitation and Emerg Med 2020; 28(1):36. Medline
I Supportive (Green) Pain relief Patient ED-MD Everts B., Karlson B., Abdon J., Herlitz J., Hedner T. A comparison of metoprolol and morphine in the treatment of chest pain in patients with suspected acute myocardial infarction - the MEMO study. Journal of Internal Medicine 1999; 245:133-41. Medline
I Supportive (Green) Pain relief Patient Niemi-Murola L., Unkuri J., Hamunen K. Parenteral opioids in emergency medicine - A systematic review of efficacy and safety. Scandinavian journal of pain 2017; 2(4):187-94. Medline
I Supportive (Green) Pain relief Patient PH-Paramedic Sundstrom BW., Bang A., Karlsson T., Winge K., Lundberg C., Herlitz J. Anxiolytics in patients suffering a suspected acute coronary syndrome: Multi-centre randomised controlled trial in emergency medical service. Int J Cardiol 2013; 168(4):3580-3587. Medline
II Supportive (Green) 1-year mortality Patient Puymirat E., Lamhaut L., Bonnet N., Aissaoui N., Henry P., Cayla G., et al. Correlates of pre-hospital morphine use in ST-elevation myocardial infarction patients and its association with in-hospital outcomes and long-term mortality: the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) pr. Eur Heart J 2016; 37(13):1063-71. Medline
II Supportive (Green) Analgesia Patient PH-Paramedic Ricard-Hibon A., et al. Compliance with a morphine protocol and effect on pain relief in out-of-hospital patients. J Emerg Med 2008; 34:305-10. Medline
II Neutral (Yellow) Patient characteristics Patient Other Lapostolle F, Van't Hof AW, Hamm CW, Stibbe O, Ecollan P, Collet JP, et al. Morphine and Ticagrelor Interaction in Primary Percutaneous Coronary Intervention in ST-Segment Elevation Myocardial Infarction: ATLANTIC-Morphine. American J of Cardiovascular Drugs, Drugs, Devices, and Other Interventions 2019; 19(2):173-83. Medline
II Opposes (Red) Mortality Patient ED-MD Meine TJ., Roe MT., Chen AY., et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the crusade quality improvement initiative. American Heart Journal 2005; 149(6):1043-9. Medline
III Supportive (Green) Appropriate administration, complications Process PH-Paramedic Bruns BM., Dieckmann R., Shagoury C., et al. Safety of prehospital therapy with morphine sulfate. Am J Emerg Med 1992; 10(1):53-7. Medline
III Supportive (Green) Changes in arterial blood pressure, heart rate, respiratory rate and pain. Patient PH-Paramedic Silfvast T., Saarnivaara L. Comparison of alfentanil and morphine in the prehospital treatment with patients with acute ischaemic-type chest pain. Eur J Emerg Med 2001; 8(4)275-8. Medline
III Supportive (Green) Analgesia Patient PH-Paramedic Weldon ER, Ariano RE, Grierson RA. Comparison of Fentanyl and Morphine in the Prehospital Treatment of Ischemic Type Chest Pain. PEC 2016; 20(1) 45-51. Medline
III Supportive (Green) Pain relief Patient PH-Paramedic Zedigh C., Alho A., Hammar E., et al. Aspects on the intensity and the relief of pain in the prehospital phase of acute coronary syndrome: Experiences from a randomized clinical trial. Coron Artery Dis 2010; 21(2):113-120. Medline

Nitrates
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Reduction in chest pain, Decrease in ST-Depression Process PH-Paramedic Cotter G., Faibel H., Barash P., et al. High-dose nitrates in the immediate management of unstable angina: Optimal dosage, route of administration, and therapeutic goals. Am J Emerg Med 1998; 16(3):219-24. Medline
II Supportive (Green) Reduction in subjective pain Patient PH-Paramedic Todoroski KB. The timing of administering aspirin and nitroglycerin in patients with STEMI ECG changes alter patient outcome. BMC Emerg Med 2021; 21(1):137. Medline
II Neutral (Yellow) Hypotension Patient Proulx MH., de ML., Ross D., Vacon C., Juste LE., Segal E. Prehospital Nitroglycerin in Tachycardic Chest Pain Patients: A Risk for Hypotension or Not? Prehospital emergency care: official journal of the National Association of EMS Physicians and the National Association of State EMS Directors 2016; 21(1):68-73. Medline
III Supportive (Green) Pain relief (NRS or VAS) Patient PH-Paramedic Engleberg S., Singer AJ., Moldashel JG., et al. Effects of prehospital nitroglycerine on hemodynamics and chest pain intensity. PEC 2000; 4:290. Medline
III Supportive (Green) Adverse events, ECG rhythm change Process PH-Paramedic Wuerz R., Swope G., Meador S., et al. Safety of prehospital nitroglycerin. Ann Emerg Med 1994; 23(1):31-36. Medline
III Neutral (Yellow) Hypotension Patient PH-Paramedic Boyle MJ. A dramatic drop in blood pressure following prehospital GTN administration. Emerg Med J 2007; 24(3):225-6. Medline

Nitrous Oxide
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Analgesia Process Other Charpentier S, Galinski M, Bounes V, Ricard-Hibon A, El-Khoury C, Elbaz M, et al. Nitrous oxide/oxygen plus acetaminophen versus morphine in ST elevation myocardial infarction: open-label, cluster-randomized, non-inferiority study. Scandinavian J of trauma, resuscitation and Emerg Med 2020; 28(1):36. Medline
III Supportive (Green) Patient satisfaction Patient PH-Paramedic Johnson JC., Atherton Gl. Effectiveness of Nitrous Oxide in a rural EMS System. The Journal of Emergency Medicine 1991; 9:45-53. Medline

Oxygen-high flow
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Myocardial salvage index Patient Khoshnood A., Akbarzadeh M., Carlsson M., Sparv D., Bhiladvala P., Mokhtari A., et al. Effect of oxygen therapy on chest pain in patients with ST elevation myocardial infarction: results from the randomized SOCCER trial. Scand Cardiovasc J 2018; 52(2):69-73. Medline
I Neutral (Yellow) 30 day mortality Patient Other Stewart RAH, Jones P, Dicker B, Jiang Y, Smith T, Swain A, et al. High flow oxygen and risk of mortality in patients with a suspected acute coronary syndrome: pragmatic, cluster randomised, crossover trial. BMJ 2021; 372:n355. Medline
I Opposes (Red) Mortality Patient ED-MD Wijesinghe M., et al. Routine use of Oxygen in the Treatment of Myocardial Infarction: Systematic Review. Heart 2009; 95:198-202. Medline
II Neutral (Yellow) Wall-Motion Score Index Process Khoshnood A., Akbarzadeh M., Roijer A., Meurling C., Carlsson M., Bhiladvala P., et al. Effects of oxygen therapy on wall-motion score index in patients with ST elevation myocardial infarction-the randomized SOCCER trial. Echocardiography (Mount Kisco, NY) 2017; 34(8):1130-7. Medline
II Neutral (Yellow) Mortality Patient ICU Rawles J., et al. Controlled Trial of Oxygen in Uncomplicated Myocardial Infarction. Br Med J 1976; 8(1):1121-3. Medline
II Opposes (Red) Coronary blood flow Process In-Patient Farquahar H., et al. Systematic Review of Studies of the effect of Hyperoxia on Coronary Blood Flow. Am Heart J 2009; 158(3):371-7. Medline
III Neutral (Yellow) 30 day mortality and infarct size Patient Ranchord A., Argyle R., Beynon R. et al. High-concentration versus titrated oxygen therapy in ST-elevation myocardial infarction: A pilot randomized controlled trial. The American Heart Journal 2012; 163(2):168-175 Medline

Oxygen-titrated
Level Direction Primary Outcome Patient/Process Setting Reference
I Opposes (Red) Myocardial infarct size Patient Nehme Z., Stub D., Bernard S., Stephenson M., Bray JE., Cameron P., et al. Effect of supplemental oxygen exposure on myocardial injury in ST-elevation myocardial infarction. Heart 2016; 102(6):444-51. Medline
I Opposes (Red) Mortality Patient ED-MD Wijesinghe M., et al. Routine use of Oxygen in the Treatment of Myocardial Infarction: Systematic Review. Heart 2009; 95:198-202. Medline
II Neutral (Yellow) Mortality Patient ICU Rawles J., et al. Controlled Trial of Oxygen in Uncomplicated Myocardial Infarction. Br Med J 1976; 8(1):1121-3. Medline
III Neutral (Yellow) 30 day mortality and infarct size Patient Ranchord A., Argyle R., Beynon R. et al. High-concentration versus titrated oxygen therapy in ST-elevation myocardial infarction: A pilot randomized controlled trial. The American Heart Journal 2012; 163(2):168-175 Medline

PAI-ASA
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Feasibility Process PH-Paramedic Barron T., Clawson J., Scott G., et al. Aspirin administration by emergency medical dispatchers using a protocol-driven aspirin diagnostic and instruction tool. Emerg Med J 2013; 30(7):572-8. Medline

Pharmacoinvasive approach
Level Direction Primary Outcome Patient/Process Setting Reference
II Supportive (Green) 30 day mortality Patient Solhpour A., Chang KW., Balan P., et al. Comparison of outcomes for patients >/=75 years of age treated with pre-hospital reduced-dose fibrinolysis followed by percutaneous coronary intervention versus percutaneous coronary intervention alone for treatment of ST-elevation myocardial infarction. Am J Cardiol 2014; 113(1):60-63. Medline

Point of Care Troponin
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Prediction of NSTEMI Process PH-Paramedic Demandt JPA, Zelis JM, Koks A, Smits GHJM, van der Harst P, Tonino PAL, Dekker LRC, van Het Veer M, Vlaar PJ. Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis. BMJ Open 2022; 12(4):e057305. Medline
II Supportive (Green) Correlation with lab results Process ED-MD Juliano M., Wason C. Comparison of Point-of-Care Versus Laboratory Troponin Testing in an Emergency Department Setting. Mil Med 2017; 182(7) e1938-40. Medline
II Supportive (Green) Systematic measurement bias Process Sardi AR., Lamoureux JA., Cohn TM., Phillip-Samuel SG. Point-of-Care Testing of Troponin Levels Compared With Automated Laboratory Evaluation: A Reliability Study. Crit Care Nurs Q 2016; 39(4):345-51. Medline
II Supportive (Green) Hospital diagnosis of NSTEMI Process Slagman A., von RJ., Möckel M., Holert F., Meyer ZB., Müller C., et al. Diagnostic performance of a high-sensitive troponin T assay and a troponin T point of care assay in the clinical routine of an Emergency Department: A clinical cohort study. Int J Cardiol 2017; 230:454-60. Medline
II Supportive (Green) Length of stay Process PH-Paramedic Stopyra JP, Snavely AC, Ashburn NP, Nelson RD, McMurray EL, Hunt MR, et al. EMS blood collection from patients with acute chest pain reduces emergency department length of stay. Am J Emerg Med 2021; 47:248-52. Medline
II Neutral (Yellow) Predictionof MACE: major adverse cardiac events Process PH-Paramedic Stopyra JP, Snavely AC, Smith LM, David Harris R, Nelson RD, Winslow JE, et al. Prehospital use of a modified HEART Pathway and point-of-care troponin to predict cardiovascular events. PLoS ONE 2020; 15(10). Medline
II Opposes (Red) Diagnostic prediction Process Ter AE., Visser A., Reitsma B., Breedveld R., Wolthuis A. Point-of-care troponin T is inferior to high-sensitivity troponin T for ruling out acute myocardial infarction in the emergency department. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2016; 23(2):95-101. Medline
III Supportive (Green) Prediction of 28 day in-hospital mortality Process PH-Paramedic Martín-Rodríguez F, Sanz-García A, Castro-Portillo E, Delgado-Benito JF, Del Pozo Vegas C, Ortega Rabbione G, et al. Prehospital troponin as a predictor of early clinical deterioration. Eur J Clin Invest 2021; 51(11):e13591. Medline
III Neutral (Yellow) Accuracy Process Prottengeier J., Jess N., Harig F., Gall C., Schmidt J., Birkholz T. Can we rely on out-of-hospital blood samples? A prospective interventional study on the pre-analytical stability of blood samples under prehospital emergency medicine conditions. Scand J T R EM 2017; 25(1):24. Medline
X Not Yet Graded (White) - Pavlovsky T, Obadia M, Ragot S, Douay B, Casalino E, Ghazali DA. Predictors of Risk Stratification and Value of Point-of-Care of High-Sensitivity Cardiac Troponin-I in EMS Management of Non-ST-Segment Elevation Myocardial Infarction: A Retrospective Study. Prehosp Disaster Med 2022; 37(3):365–72. Medline

RIC (remote ischemic conditioning)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Myocardial salvage index at 30 days Patient ED-MD Botker HE., Kharbanda R., Schmidt MR., Bottcher M., Kaltoft AK., Terkelsen CJ., et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: A randomised trial. Lancet 2010; 375(9716):727-34. Medline
I Supportive (Green) MI size Patient ICU White SK., Frohlich GM., Sado DM., Maestrini V., Fontana M., Treibel TA., et al. Remote ischemic conditioning reduces myocardial infarct size and edema in patients with ST-segment elevation myocardial infarction. JACC Cardiovasc Interv 2015; 8(1 Pt B):178-188. Medline
II Supportive (Green) Myocardial Salvage Patient McLeod S., Iansavichene A., Cheskes S., et al. Remote Ischemic Perconditioning to Reduce Reperfusion Injury During Acute ST-Segment–Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2017; 6(5)1-12 Medline
II Supportive (Green) Myocardial salvage Patient Pryds K., Terkelsen CJ., Sloth AD., Munk K., Nielsen SS., Schmidt MR., et al. Remote ischaemic conditioning and healthcare system delay in patients with ST-segment elevation myocardial infarction. Heart 2016; 102(13):1023-8. Medline
III Supportive (Green) Completion of at least 3 cycles of RIPC prior to pPCI Process PH-Paramedic Martin-Gill C., Wayne M., Guyette FX., Olafiranye O., Toma C. Feasibility of Remote Ischemic Peri-conditioning during Air Medical Transport of STEMI Patients. Prehosp Emerg Care 2016; 20(1):82-9. Medline
III Supportive (Green) Completion of at least 3 cycles of RIPC prior to pPCI Process PH-Paramedic Martin-Gill C., Wayne M., Guyette FX., Olafiranye O., Toma C. Feasibility of Remote Ischemic Peri-conditioning during Air Medical Transport of STEMI Patients. Prehosp Emerg Care 2016; 20(1):82-9. Medline


[ PEP Database - Table of Contents ] [ Email: PEP@Dal.ca ]