Introduction

The purpose of this paper is to critically analyse an area of current clinical practice by focusing on its effectiveness, limitations and strengths. The focus area of this paper is STE-ACS. It compares the prehospital thrombolysis and Primary Percutaneous Coronary Intervention (PCCI) as the interventions for STE-ACS based on strengths, advantages, and limitations along with the current practices supported with the relevant evidence.

It has been found that prehospital thrombolysis and PCCI can be performed in an OOH setting; however, PCCI requires trained professionals, tools, facilities and resources. While prehospital thrombolysis has the potential to delay the risks for patients with STE-ACS [1]. This paper also evaluates the pathology of these interventions based on functions and time required in the intervention.

Discussion

Background Of The Intervention And Pathology

Elevated Acute coronary syndrome (ACS) or STE-ACS is a serious cardiac condition that stops cardiac functions or severely reduces blood from flowing to the muscle of the heart [2]. Hence, out-of-hospital (OOH) intervention such as prehospital thrombolysis is essential to treat patients and prevent the risks such as abnormal heart rates, cardiac arrest, failure, and death [3]. Kenjaev and Alyavi (2022) described the pathology of prehospital thrombolysis that focuses on dissolving the blood thrombus.

They explained that thrombolytics (clot-dissolvent) medications are administered by health professionals to prevent the risks and complications associated with ACS; for example, prevention of myocardial infarction before patients are transported to hospitals [4]. Thrombolytics provided in the prehospital thrombolysis help in restoring blood flow to the heart that prevents further damage.

The pathology behind this practice is the presence of blood clots which are also called “thrombus” in a coronary artery that reduces the supply of blood [5]. However, current practices in prehospital thrombolysis focus on reducing the thrombus and restoring blood flow to ensure the recovery of the patient.

In comparison, PCCI in the ACS is also used to prevent complications and risks such as myocardial infarction. The pathology behind this procedure also focuses on the blockage or thrombus [6]. Sabatine et al. (2021) further explained the pathology of PCCI in ACS, they defined that patients who have STE-ACS develop blockage in one or more coronary arteries with the formation of thrombus that narrow arteries and reduce the blood flow to a portion of heart muscle which further leads to tissue damage.

As a result, patients with elevated ACS may have abnormal heart rhythms, and death due to myocardial infarction [7]. Unlike the medication interventions in prehospital thrombolysis, PCCI focuses on surgical interventions to reduce thrombus. For example, health professionals or physicians insert a catheter through a blood vessel in the groin or wrist towards the blocked coronary artery. This intervention is a mechanical procedure to open the blocked artery using various techniques such as balloon angioplasty and stent placement [8]. Hence, health professionals open the blockage through a surgical procedure.

Therefore, based on the pathology behind these two interventions, it can be analysed that both PCCI and prehospital thrombolysis are two different interventions that can be considered according to the situation, resources and condition of patients. PCCI can only be performed with the required facilities, resources and tools while medications in thrombolytic are a preferred way when patients are transported to hospitality facilities to avoid risks until they receive surgical interventions.

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Positives and negatives of current practice

According to Lavonas et al. (2015), prehospital thrombolysis is an effective OOH intervention that can be performed in emergency situations. It includes neurosurgical evaluation and treatment with damage control surgery, therapy for advanced heart failure and care. It is performed to prevent the risks before patients are transported to a PCI facility [9].

On the other hand, Jentzer et al. (2018) explained that PCCI is also considered a preferred intervention for STE-ACS cases as it can be performed within 90 minutes and provide better results compared to OOH interventions with lower rates of complications compared to thrombolysis [10].

However, the decisions of health professionals between prehospital thrombolysis and PCCI depend on a number of factors such as the condition of patients, time to treatment and available resources to provide treatment.

Similarly, PCCI cannot be performed due to prolonged transport times to a suitable facility [11]. Therefore, PCCI is considered over the prehospital thrombolysis in the cases when health professionals have resources while in the absence of resources, prehospital thrombolysis is followed.

There are positive and negative sides to the current practices related to these two interventions. For example, the current practice related to prehospital thrombolysis includes the use of medications that has both positive and negative sides. Positive sides and strengths of prehospital thrombolysis include time-saving, cost-effectiveness and use as it can be used in OOH setting [12].

Trained health professionals in paramedics can save time as well as improve the condition of patients compared to transportation to a hospital for PPCI. Similarly, drugs or medication used as thrombolytics are less expensive compared to the PCCI procedure [13].

Apart from this, one of the major advantages of prehospital thrombolysis is that it can be performed in OOH or in remote settings where PPCI and other interventions are limited [14]. The negative sides of prehospital thrombolysis are limited effects and high risk of recurrent heart attacks and increased risk of bleeding and patients’ situation as it cannot benefit all patients [13, 14].

In comparison, PCCI has a higher success rate compared to prehospital thrombolysis in achieving complete reperfusion and restoring blood flow, lower risk of myocardial infarction and accurate diagnosis that enables health professionals to identify complex lesions and provide appropriate treatment (15).

Similarly, there are limitations or disadvantages such as time; for example, PCCI required a certain time including the reach time to facilities where interventions are provided. Hence, it can lead to delays and risks. Moreover, PCCI required clinical facilities and resources that cannot be performed in remote areas [16]. Therefore, decisions between PCCI and prehospital thrombolysis depend on the strengths and limitations considering the situation of patients.

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Critical Analysis Of Current Practices

According to Vlachojannis et al. (2020), the current practices under prehospital thrombolysis and PCCI show that health professionals prepare patients for PCCI and prevent risks by providing thrombolytics under prehospital thrombolysis intervention.

They also explained that crushed prasugrel tablets are provided by health professionals to prepare patients for PCCI; however, results of the research show that crushed prasugrel tablets do not improve thrombolysis in myocardial infarction (TIMI) before PCCI [17].

On the other hand, Vlachojannis et al. (2020) also found that there is a difference between the impact of pre-hospital crushed vs. uncrushed Prasugrel tablets on the ACS. It has been also found that crushed tablet provides faster platelet inhibition compared to the usual treatment.

Hence, both positive and negative outcomes have been identified by Vlachojannis et al. (2020) in different studies; however, prehospital thrombolysis has proven an effective treatment option to prepare patients for PCCI that can help in challenging situations [18].

For example, research by Mujtaba et al. (2021) shows that patients with elevated ACS face challenges due to the pre-hospital delays in developing countries that lead to serious complications [19]. Hence, prehospital thrombolysis would be an effective option to prevent such delay.

Paramedics' beliefs and attitudes towards prehospital thrombolysis show that the majority of paramedics support the idea of medical direction provided to patients for treating serious health conditions such as STE-ACS and preventing the risks such as myocardial infarction [20].

Despite the benefits of medication in prehospital thrombolysis it is continued to be underused and followed later such as after the admission to hospital [21]. Toshima et al. (2021) explained that STE-ACS lead to acute myocardial infarction (AMI) which is a serious condition and many people die before they reach the hospital due to this health condition [22]. Thus, the use of prehospital thrombolysis would be effective in those cases to prevent the risks and deaths.

Conclusion

Based on the above analysis it can be concluded that STE-ACS is a medical emergency that creates the risk of myocardial infarction. Hence, rapid reperfusion therapies are required to prevent such conditions as prehospital thrombolysis and PCCI. The pathology of these two interventions shows that STE-ACS cause thrombus in the blood that reduce the flow of blood to the heart.

Hence, these interventions focus on reducing thrombus. prehospital thrombolysis interventions include the use of medication which is an effective OOH practice to prevent the risks and prepare patients to transport hospital for further intervention.

On the other hand, PCCI can be used in serious conditions when prehospital thrombolysis is not effective as reduce the thrombus through the catheter. However, it cannot be performed without facilities and resources.

The current practices related to these two interventions show that prehospital thrombolysis is used to prepare patients for further interventions such as PCCI; however, it can be an effective OHH intervention that can reduce the impact of delays.

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References

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