***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: This r and omized , double‐blind trial in 311 patients with acute myocardial infa rct ion has shown that very early therapy with anistreplase outside the hospital is not only feasible , but provides a major survival advantage . The difference in the median delay to treatment between the group treated in the hospital and those treated earlier was 2 1/4 h. After 30 months , mortality in the early group was less than half that in the later group , so that every hour of delay beyond 2 h result ed in almost 7 additional deaths per 100 patients treated . This is a greater percentage loss of life than would have result ed from a similar delay in the provision of resuscitation for the prehospital cardiac arrest . Multivariate analysis showed that age , treatment delay , and time of presentation were significant risk factors , with patients presenting at 1 h having more than twice the mortality of those presenting at 4 h ; the sicker the patient , the earlier the presentation . By 5 years , prehospital administration of anistreplase , by saving 2 h , result ed in an additional 57 % of a year 's survival per patient . This compares favorably with the projected 14 % of a year survival per patient reported with TPA versus streptokinase in GUSTO . Prehospital therapy with anistreplase was highly cost effective when compared with streptokinase given in hospital , and the marginal cost‐effectiveness ratio was much lower than that for TPA versus streptokinase derived from GUSTO Summary In order to assess the feasibility and outcome of using prehospital thrombolysis in acute myocardial infa rct ion in a rural community , we performed an open r and omized study of patients with symptoms of acute myocardial infa rct ion of less than 6 hours . One hundred and forty-five patients with acute myocardial infa rct ion were allocated to receive IV streptokinase prehospital by means of a mobile coronary care unit ( MCCU ) ( n=43 ) or to receive IV streptokinase in hospital ( n=102 ) . The mean delay time to treatment was 138 minutes ( MCCU group ) and 172 minutes ( hospital group ) ( p<0.02 ) . Reperfusion time was 88 minutes for the MCCU group and 92 minutes for the hospital group . Mortality at 14 days was 2.3 % for the MCCU group and 11.7 % for the hospital group ( p<0.05 ) . Six month mortality was 4.9 % for the MCCU group and 17.3 % for the hospital group ( p=0.03 ) . Mortality at 1 year was 6.1 % for the MCCU group and 20.0 % for the hospital group ( p=0.04 ) . There were no significant adverse events in either treatment group . Thus , prehospital thrombolysis by streptokinase is feasible and allows significant reduction in the delay time to treatment initiation . There are encouraging improvements in both short- and long-term survival with no apparent reduction in safety profile BACKGROUND AND OBJECTIVES To investigate out-of-hospital treatment , including fibrinolysis , in patients with ST-elevation acute myocardial infa rct ion and to determine the 1-year survival rate . METHODS Prospect i ve cohort study based on an ongoing out-of-hospital registry of patients with ST-elevation acute myocardial infa rct ion who were treated by out-of-hospital emergency teams in And alusia , Spain during 2001 - 2004 . Patients were followed up in hospital and one year after the acute episode . RESULTS The study involved 2372 patients . Out-of-hospital fibrinolysis was used in 467 ( 19.7 % ) . Among these , 20.7 % received treatment within the first hour , 68 % within the first 2 hours , and 2 ( 0.4 % ) hemorrhagic strokes occurred . Episodes of ventricular fibrillation were recorded in 158 patients ( 6.7 % ) , 106 ( 67 % ) of whom were discharged . In addition , 386 ( 16.3 % ) patients died in the short term ( both out of and in hospital ) , with 26 ( 1.1 % ) dying before they reached hospital . The cumulative 1-year mortality rate was 22.4 % ( 531 patients ) overall , and 6.6 % ( 29 patients ) in the out-of-hospital fibrinolysis group . Increased survival at 1 year was associated with out-of-hospital fibrinolysis ( odds ratio [OR]=0.368 ; 95 % confidence interval [ CI ] , 0.238 - 0.566 ) and percutaneous coronary intervention during admission ( OR=0.445 ; 95 % CI , 0.268 - 0.740 ) . CONCLUSIONS In routine clinical practice , out-of-hospital fibrinolysis was performed safely , reduced short-term mortality , and improved the 1-year survival rate . The combination of appropriate out-of-hospital treatment , including early defibrillation and fibrinolysis within the first three hours , together with the systematic application of percutaneous coronary intervention during hospital admission is a suitable treatment strategy for the comprehensive care of patients with ST-elevation acute myocardial infa rct ion OBJECTIVES The Early Retavase-Thrombolysis In Myocardial Infa rct ion ( ER-TIMI ) 19 trial tested the feasibility of prehospital initiation of the bolus fibrinolytic reteplase ( rPA ) and determined the time saved by prehospital rPA in the setting of contemporary emergency cardiac care . BACKGROUND Newer bolus fibrinolytics have undergone only limited evaluation for prehospital administration . In addition , as door-to-drug times have decreased , the relevance of findings from prior trials of prehospital fibrinolysis has become less certain . METHODS Patients ( n = 315 ) with ST-elevation myocardial infa rct ion ( STEMI ) were enrolled in 20 emergency medical systems in North America . The time from emergency medical service ( EMS ) arrival to administration of a fibrinolytic was compared between study patients receiving prehospital rPA  and sequential control patients from 6 to 12 months before the study who received a fibrinolytic in the hospital . RESULTS Acute myocardial infa rct ion was confirmed in 98 % . The median time from EMS arrival to initiation of rPA was 31 min ( 25th to 75th percentile , 24 min to 37 min ) . The time from EMS arrival to in-hospital fibrinolytic  for 630 control patients was 63 min ( 25th to 75th percentile , 48 min to 89 min ) , result ing in a time saved of 32 min ( p < 0.0001 ) . By 30 min after first medical contact , 49 % of study patients had received the first bolus of fibrinolytic compared with only 5 % of controls ( p < 0.0001 ) . In-hospital mortality was 4.7 % . Intracranial hemorrhage occurred in 1.0 % . CONCLUSIONS Prehospital administration of rPA is a feasible approach to accelerating reperfusion in patients with STEMI . Valuable time savings can be achieved in the setting of contemporary transport and door-to-drug times and may translate into an improvement in clinical outcomes One of the major questions remaining in thrombolysis is which drug we should be using . In terms of “ head to head ” comparisons there are few data . Streptokinase and tissue plasminogen activator have been compared in terms of patency and tissue plasminogen activator has been shown to be superior ( 1 , 2 ) . However , patency can not be directly extrapolated to patient benefit and direct comparisons of the effects of these drugs on left ventricular function and mortality are required . Left ventricular function can be considered as a surrogate for mortality but in addition the assessment of left ventricular function also evaluates the capacity of a patient to exercise , and relates to quality of life . In this study the effects of streptokinase and tissue plasminogen activator on left ventricular function were compared OBJECTIVES Our aim was to determine the time saved by administration of thrombolytic therapy at home rather than in the hospital and to assess whether earlier thrombolysis result ed in decreased mortality from acute myocardial infa rct ion . BACKGROUND There is much theoretic , experimental and trial evidence to indicate that in acute myocardial infa rct ion the earlier that thrombolytic therapy is given , the greater its efficacy . However , the clinical importance of this time effect is uncertain . METHODS In a r and omized double-blind parallel-group clinical trial , 311 patients with suspected acute myocardial infa rct ion seen by their general practitioners within 4 h of symptom onset were given intravenous anistreplase ( 30 U ) either at home or later , after arrival in the hospital . RESULTS Anistreplase was given at home or in the hospital at median times of 101 and 240 min , respectively , after symptom onset . The median time saved by domiciliary thrombolysis was 130 min . By the end of 1 year after trial entry , 17 ( 10.4 % ) of 163 patients given anistreplase at home died compared with 32 ( 21.6 % ) of 148 in those allotted anistreplase in the hospital ( relative reduction 52 % , 95 % confidence interval 14 % to 89 % , p = 0.007 ) . CONCLUSIONS In this trial the time saved by domiciliary thrombolysis by primary care physicians was > 2 h. It is likely that a similar time saving would be achieved if prehospital thrombolysis were to become established practice . Prehospital thrombolysis result ed in a halving of the mortality rate from acute myocardial infa rct ion Introduction : Prehospital thrombolysis has been shown to improve patient outcomes in clinical trials and this has been confirmed in the ongoing large national myocardial infa rct ion registry ( Myocardial Infa rct ion National Audit Project ; MINAP ) reports . This paper describes a system to improve the delivery of prehospital thrombolysis and the associated governance requirements to gain maximum patient benefit . Methods : Demographic data were prospect ively collected on all patients treated by the East Anglian Ambulance Trust with bolus thrombolytics for a presumed diagnosis of ST elevation myocardial infa rct ion between November 2003 and February 2007 .  Survival status was determined from the NHS strategic tracing service . Results : 1062 patients ( mean age 64.0 years ( SD 10.6 ) , 795 men ) were treated in this time period . There were 71 deaths in this group , with actuarial survival of 93.9 % ( SE 0.9 % ) at 30 days , 91.7 % ( SE 1.0 % ) at 6 months and 90.8 % ( SE 1.1 % ) at 12 months after treatment . Age and cardiac arrest were most strongly associated with mortality ( both p<0.001 ) . Twelve ( 1.2 % ) patients received thrombolysis that on review was considered inappropriate . There were no deaths in this subgroup . Conclusions : Prehospital thrombolysis can be administered safely by ambulance staff supported by a Trust clinical support system with excellent clinical outcomes The benefit and risk of prehospital thrombolysis for acute myocardial infa rct ion ( AMI ) were evaluated in a double-blind r and omized trial . Patients presenting less than 4 hours after symptom onset received 2 million units of urokinase as an intravenous bolus either before ( group A , n = 40 ) or after ( group B , n = 38 ) hospital admission . The mean time interval from onset of symptoms to thrombolytic therapy was 85 + /- 51 minutes in group A and 137 + /- 50 minutes in group B ( p less than 0.0005 ) . In 91 % of the patients , thrombolytic therapy was administered less than 3 hours after symptom onset . Complication rates during the pre- and in-hospital period were low and did not differ between groups . Three patients died ( 1 in group A , 2 in group B ) from reinfa rct ion 7 to 14 days after admission . Left-sided cardiac catheterization before discharge revealed a patency rate in the infa rct -related artery of 61 % in group A and 67 % in group B ( difference not significant ) . Global left ventricular function and regional wall motion at the infa rct site did not differ significantly between group A and B ( ejection fraction 51 + /- 10 % , n = 28 vs 53 + /- 14 % , n = 28 ; wall motion -2.3 + /- 1.3 vs -2.2 + /- 1.1 st and ard deviation , respectively ) . Also , peak creatine kinase did not differ significantly ( 838 + /- 634 U/liter in group A vs 924 + /- 595 U/liter in group B ) . Prehospital thrombolysis using a bolus injection of urokinase has a low risk when performed by a trained physician with a mobile care unit . The saving of 45 minutes in the early stage of an acute infa rct ion through prehospital thrombolysis did not appear to be important for salvage of myocardial function Objectives : To evaluate the potential of a continuous telemetry system linking rural ambulances to a coronary care unit to reduce call to thrombolysis times . Methods : This prospect i ve r and omised controlled trial recruited patients using the 999 ambulance service in a rural 
    Output:
    
Pre-hospital thrombolysis reduces time to treatment , based on studies conducted in higher income countries .
In setting s where it can be safely and correctly administered by trained staff , pre-hospital thrombolysis may be an appropriate intervention .
Pre-hospital thrombolysis has the potential to reduce the burden of STEMI in lower- and middle-income countries , especially in individuals who have limited access to in-hospital thrombolysis or percutaneous coronary interventions .
We found no r and omised controlled trials evaluating the efficacy of pre-hospital thrombolysis for STEMI in lower- and middle-income countries .
Large high- quality multicentre r and omised controlled trials implemented in re source -constrained countries will provide additional evidence for the efficacy and safety of this intervention .