Paramedic cat (critically appraised topic) worksheet

Paramedic - Evidence Based Medicine (P-EBP) Program Paramedic CAT (Critically Appraised Topic) Worksheet
Title: Pre-hospital Administration of Plavix in STEMI + Patients

Report By: Robert Leduc, ACP
2nd Party Appraiser: Rose Mengual, ACP, MD

Clinical Scenario:
A 55 year old male patient develops chest pain while playing hockey. The paramedics arrive at the arena,
determine the chest pain is ischemic in nature and administer sublingual nitroglycerin, ASA and morphine as per their chest pain
protocol. The 12-lead ECG reveals a STEMI. Would the administration of pre-hospital clopidogrel (Plavix) decrease mortality?

PICO (Population - Intervention - Comparison - Outcome) Question:
In the management of prehospital adult ST elevation MI (STEMI), would the addition of clopidogrel (Plavix) to prehospital standard
care (Oxygen, ASA, nitroglycerin, and parenteral opioid) compared with standard care alone lead to a decrease in patient mortality?

Search Strategy:

Most Recent Queries
#3 Search #1 and #2
#2 Search Plavix OR clopidogrel
#1 Search paramedic* OR emergency medical technician* OR emergency medical service*
OR EMS OR prehospital OR out-of-hospital

Search Outcome: This search yielded 35 papers. Two papers were considered relevant to this PICO question.
Paramedic - Evidence Based Medicine (P-EBP) Program Relevant Papers:
received delayed clopidogrel treatment at the time of PCI. vs. 22.3% in the placebo group (trend prehospital fibinolytic administration may lead to improved outcomes. Paramedic - Evidence Based Medicine (P-EBP) Program
These two studies seem to indicate that early administration of clopidogrel as part of an STEMI management strategy that includes
thrombolysis, ASA, and heparin results in greater coronary artery patency compared to placebo, without an apparent increase in
bleeding complications. The second study demonstrates a trend towards improved coronary patency when clopidogrel is administered
in the prehospital setting. In both studies the standard care included fibrinolytics therapy and heparin, which is not the standard care in
most Canadian EMS systems and may not be the primary treatment modality in urban hospital facilities.

Clinical Bottom Line:
Clinical benefit of prehospital administration of clopidogrel in addition to standard care consisting of only ASA, oxygen, and
parenteral opioid administration remains to be established. A large prospective, randomized placebo controlled trial comparing the
addition of clopidogrel to Canadian prehospital STEMI care vs. standard care is required.

Verheugt 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: 173-179.
Sabatine MS, et al. Effect of Clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation
myocardial infarction treated with fibrinolytics.
JAMA 2005; 294: 1224-1232.


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