Paramedic administration of glycoprotein inhibitors for ST elevation myocardial infarction

For many patients suffering from an acute coronary syndrome (ACS) within the pre-hospital setting, paramedics are the first contact within the scope of emergency healthcare. Patients suffering from an acute ST segment elevation myocardial infarction (STEMI) are cared for in the community by such healthcare workers on a frequent basis. Care pathways for these patients have evolved over the recent decade with the introduction of thrombolytic therapy; although this has now been superseded with primary percutaneous coronary intervention (PPCI). PPCI is now widely accepted as the reperfusion therapy of choice when placed next to thrombolysis for STEMI (Keeley et al, 2003).

As a result of research supporting the use of PPCI, the paradigm of care is ultimately moving to one of emergency ambulance transfer to a regional intervention centre. However, ambulance crews are now transporting these patients without a reperfusion strategy or indeed an adjunct for PPCI in place. Although such a venture is clearly plausible and empirically supported, it should be recognized that many ambulance services face challenges associated to the extended transfer times of rural locations. It would be unwise to accept that all STEMI patients are stable, at low risk of deterioration, and can tolerate excessive symptom and journey times. The early indications are that pre-hospital administration of a glycoprotein inhibitor (GPI) may well be the answer to improving the clinical outcome of the STEMI patient experiencing lengthened transfer time to hospital for target vessel re-canalisation (TVR). As a result, it is the purpose of this article to discuss and consider the possibility of the paramedic based community administering a glycoprotein inhibitor IIb/IIIa for STEMI within the out-of-hospital context.