Pre-hospital thrombolysis: end of an era?

A 54-year-old male smoker living in a rural community over one hour from the regional cardiac centre has chest pain and after 15 minutes calls the emergency services. An ambulance arrives 8 minutes later. The paramedics confirm a diagnosis of myocardial infarction by recording an ECG, which shows ST segment elevation in the anterior chest leads (Figure 1). They give the patient aspirin and, after establishing that there are no contraindications to thrombolysis, administer tenecteplase 15 minutes after arrival on scene. His pain to needle time is 38 minutes. He is pain free on arrival to hospital and his ECG has returned to virtually normal (Figure 2). The following day he has coronary angiography, which reveals a tight stenosis in his LAD, which is treated by stent insertion. Echocardiography is normal and blood tests show a trivial elevation in Troponin T. He is discharged the following day with a diagnosis of aborted myocardial infarction. He has been very well served by prehospital thrombolysis (PHT) but in most parts of the UK this therapy is being abandoned for all but exceptional circumstances in favour primary percutaneous coronary intervention (PPCI), in this case a journey of one hour away. Why is this?