Time delays in provision of thrombolytic treatment in six district hospitals. Joint Audit Committee of the British Cardiac Society and a Cardiology Committee of Royal College of Physicians of London.

OBJECTIVE--To measure the delays between onset of symptoms and admission to hospital and provision of thrombolysis in patients with possible acute myocardial infarction. DESIGN--Observational study of patients admitted with suspected myocardial infarction during six months. SETTING--Six district general hospitals in Britain. SUBJECTS--1934 patients admitted with suspected myocardial infarction. MAIN OUTCOME MEASURES--Route of admission to hospital and time to admission and thrombolysis. RESULTS--Patients who made emergency calls did so sooner after onset of symptoms than those who called their doctor (median time 40 (95% confidence interval 30 to 52) minutes v 70 (60 to 90) minutes). General practitioners took a median of 20 (20 to 25) minutes to visit patients, rising to 30 (20 to 30) minutes during 0800-1200. The median time from call to arrival in hospital was 41 (38 to 47) minutes for patients who called an ambulance from home and 90 (90 to 94) minutes for those who contacted their doctor. The median time from arrival at hospital to thrombolysis was 80 (75 to 85) minutes for patients who were treated in the cardiac care unit and 31 (25 to 35) minutes for those treated in the accident and emergency department. CONCLUSION--The time from onset of symptoms to thrombolysis could be reduced substantially by more effective use of emergency services and faster provision of thrombolysis in accident and emergency departments.     

Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

ProblemDelay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.DesignAudit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.

Background and setting

The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.

Key measures for improvement

Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes

Strategies for change

In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).

Effects of change

Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.

Lessons learnt

Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework''s targets for door to needle times can be achieved.     

Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis.

OBJECTIVE--To evaluate the impact of a fast track triage system for patients with acute myocardial infarction. DESIGN--Comparison of delays in admission to hospital and in receiving thrombolytic treatment before and after introducing fast track system with delays recorded in 1987-8. Patients fulfilling clinical and electrocardiographic criteria for myocardial infarction were selected for rapid access to the cardiac care team, bypassing evaluation by the medical registrar. SETTING--Major accident and emergency, cardiac and trauma centre. SUBJECTS--359 patients admitted to the cardiac care unit during 1 February to 31 July 1990 with suspected acute infarction. MAIN OUTCOME MEASURES--Accuracy of diagnosis and delay from arrival at hospital to thrombolytic treatment. RESULTS--248 of the 359 patients had myocardial infarction confirmed, of whom 127 received thrombolytic treatment. The fast track system correctly identified 79 out of 127 (62%) patients who subsequently required thrombolytic treatment. 95% (79/83) of patients treated with thrombolysis after fast track admission had the diagnosis confirmed by electrocardiography and enzyme analysis. The median delay from hospital admission to thrombolytic treatment fell from 93 minutes in 1987-8 to 49 minutes in fast track patients (p less than 0.001). Delay in admission to the cardiac care unit was reduced by 47% for fast tract patients (median 60 minutes in 1987-8 v 32 minutes in 1990, p less than 0.001) and by 25% for all patients (60 minutes v 45 minutes, p less than 0.001). CONCLUSION--This fast track system requires no additional staff or equipment, and it halves inhospital delay to thrombolytic treatment without affecting the accuracy of diagnosis among patients requiring thrombolysis.     

Guidelines for the early management of patients with myocardial infarction. British Heart Foundation Working Group.

In light of recent publications relating to resuscitation and pre-hospital treatment of patients suffering acute myocardial infarction of British Heart Foundation convened a working group to prepare guidelines outlining the responsibilities of general practitioners, ambulance services, and admitting hospitals. The guidelines emphasise the importance of the rapid provision of basic and advanced life support; adequate analgesia; accurate diagnosis; and, when indicted, thrombolytic treatment. The working group developed a standard whereby patients with acute myocardial infarction should receive thrombolysis, when appropriate, within 90 minutes of alerting the medical or ambulance service--the call to needle time. Depending on local circumstances, achieving this standard may involve direct admissions to coronary care units, "fast track" assessments in emergency departments, or pre-hospital thrombolytic treatment started by properly equipped and trained general practitioners.     

Value of thallium-201 imaging in detecting adverse cardiac events after myocardial infarction and thrombolysis: a follow up of 100 consecutive patients.

OBJECTIVE: To determine the prognostic role of thallium-201 imaging compared with that of exercise electrocardiography in patients with acute myocardial infarction treated by thrombolysis. DESIGN: Patients who remained free of adverse cardiac events six weeks after myocardial infarction had stress and rest 201TI imaging and exercise electrocardiography and were followed up for 8-32 months. Adverse cardiac events (death, reinfarction, unstable angina, and congestive heart failure) were documented. SETTING: Large district general hospital, Middlesex. SUBJECTS: 100 consecutive male and female patients who were stable six weeks after thrombolysis for myocardial infarction. MAIN OUTCOME MEASURES: Prediction of occurrence of adverse cardiac events after myocardial infarction by exercise cardiography and 201TI myocardial perfusion imaging. RESULTS: Reversible ischaemia on 201TI imaging predicted adverse cardiac events in 33 out of 37 patients with such events during follow up (hazard ratio 8.1 (95% confidence interval 2.7 to 23.8), P < 0.001). Exercise electrocardiography showed reversible ischaemia in 33 patients, of whom 13 had subsequent events, and failed to predict events in 24 patients (hazard ratio 1.1 (0.56 to 2.2), P = 0.8). CONCLUSION: 201TI imaging is a sensitive predictor of subsequent adverse cardiac events in patients who have received thrombolysis after acute myocardial infarction, whereas exercise electrocardiography fails to predict outcome.     

Short and long term prognosis of acute myocardial infarction since introduction of thrombolysis.

OBJECTIVE--To record prognosis and determinants of outcome in patients with acute myocardial infarction since thrombolysis was introduced. DESIGN--Observational study. SETTING--London district general hospital. PATIENTS--608 consecutive patients admitted to the coronary care unit with acute myocardial infarction between 1 January 1988 and 31 December 1991. MAIN OUTCOME MEASURE--All cause mortality, non-fatal ischaemic events (myocardial infarction, unstable angina), and revascularisation. RESULTS--Of the 608 patients, 89 (14.6%) died in hospital. 507 [corrected] patients were followed up after discharge from hospital. Mortality (95% confidence interval) at 30 days, one year, and three years was 16.0% (13.4% to 19.2%), 21.7% (18.6% to 25.2%), and 29.4% (25.3% to 33.9%) respectively. Event free survival (survival without a non-fatal ischaemic event) was 80.4% (77.0% to 83.4%) at 30 days, 66.8% (62.8% to 70.5%) at one year, and 56.1% (51.3% to 60.6%) at three years. Survival in patients treated with thrombolysis was considerably higher than in those not given thrombolysis (three year survival: 76.7% v 54.3%), although the incidence of non-fatal ischaemic events was the same in the two groups. Multivariate determinants of six month survival were left ventricular failure, treatment with thrombolysis and aspirin, smoking history, bundle branch block, and age. For patients who survived six months, age was the only factor related to long term survival. CONCLUSIONS--Although patients treated by thrombolysis had a relatively good prognosis, long term mortality and the incidence of non-fatal recurrent ischaemic events remained high. Effective strategies for the identification and treatment of high risk patients need to be reassessed.     

Specific and gender differences between hospitalized and out of hospital mortality due to myocardial infarction

In this paper, the authors evaluate gender related differences of myocardial infarction mortality before and after hospital admittance. Myocardial infarction mortality in the Clinical Hospital Split in the seven years period between 2000 and 2006, have been analyzed together with out of hospital sudden death patients with acute myocardial infarction established during autopsy. During the seven year period between 2000 and 2006, 3434 patients were treated for myocardial infarction in the Split Clinical Hospital, 2336 (68%) males and 1098 (32%) females with a 12% total mortality (427 patients). The annual number of hospitalized persons has been increasing during that period (474 in yr. 2000 us. 547 in yr. 2006), while mortality decreased from 15% in 2000 to 9.6% in 2006. Female patients had significantly higher hospital mortality than male patients, (228 or 21% vs. 202 or 9%, p<0.05). Women also had significantly higher total AMI mortality (23.7% vs. 15,7%, p <0.05). Anterior myocardial infarction with ST elevation in precordial leads had significantly higher mortality (19%) compared to patients with lateral (11%), inferior (10%) myocardial infarction with ST elevation and also NSTEMI (4%) mortality p<0.05. Female patients more frequently die in hospital, 84% (230) than out of hospital 16% (43). From the total number of AMI deaths (388) in male patients, 56% (217) were in hospital and 44% (171) out of hospital (p<0.001). Men had significantly higher prehospital mortality rate than women (81% vs. 19%, p<0.05). Men also more frequently died from ventricular fibrillation (22% vs. 10%, p<0.05), while women died more frequently of heart failure, cardiogenic shock, and myocardial rupture (33% vs. 15% p<0.05). Regarding the total number of deaths from myocardial infarction men had significantly higher prehospital mortality compared to women (178 or 7.3% vs. 43 or 3.7%, p<0.05). Anterior myocardial infarction had a significantly higher rate in patients dying pre-hospital (58%), in contrast to inferior (36%) and lateral myocardial infarction with ST elevation (6%) p<0.05. We have concluded that male patients die more frequently within the first few hours of AMI mostly due to malignant arrhythmias, while female patients died in sub acute stage due to heart failure while being hospitalized. Nevertheless total mortality of AMI remains significantly higher in women.     

Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction.

OBJECTIVES--To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy. DESIGN--Cohort follow up study. SETTING--The four coronary care units in Auckland, New Zealand. SUBJECTS--All 3014 patients presenting to the units with suspected myocardial infarction in 1993. MAIN OUTCOME MEASURES--Eligibility for reperfusion with thrombolytic therapy (presentation within 12 hours of the onset of ischaemic chest pain with ST elevation > or = 2 mm in leads V1-V3, ST elevation > or = 1 mm in any other two contiguous leads, or new left bundle branch block); proportions of (a) patients eligible for reperfusion and (b) patients with contraindications to thrombolysis; death (including causes); definite myocardial infarction. RESULTS--948 patients had definite myocardial infarction, 124 probable myocardial infarction, and nine ST elevation but no infarction; 1274 patients had unstable angina and 659 chest pain of other causes. Of patients with definite or probable myocardial infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite contraindications to thrombolysis (risk of bleeding). Hence 49.7% of patients (537/1081) were eligible for thrombolysis and 43.5% (470) received this treatment. Hospital mortality among patients eligible for reperfusion was 11.7% (55/470 cases) among those who received thrombolysis and 17.0% (18/106) among those who did not. CONCLUSIONS--On current criteria about half of patients admitted to coronary care units with definite or probable myocardial infarction are eligible for thrombolytic therapy. Few eligible patients have definite contraindications to thrombolytic therapy. Mortality for all community admissions for myocardial infarction remains high.     

院前急救联合绿色通道模式对急性心肌梗死PPCI术患者救治效果和术后不良心血管事件的影响

摘要 目的：探讨院前急救联合绿色通道模式对行急诊经皮冠状动脉介入术（PPCI）的急性心肌梗死（AMI）患者救治效果和术后不良心血管事件的影响。方法：选取2017年1月~2019年6月期间我院收治的行PPCI术的AMI患者200例,采用随机数字表法将患者分为对照组（n=100）和研究组（n=100）,对照组患者予以传统急诊模式,研究组患者予以院前急救联合绿色通道模式,比较两组患者救治效果、满意度、确诊时间、心肌再灌注治疗时间、住院时间、术后不良心血管事件。结果：研究组抢救时间、急救反应时间、确诊时间、心肌再灌注治疗时间以及住院时间均短于对照组（P<0.05）。研究组治疗后的临床总有效率高于对照组（P<0.05）。研究组的总满意度为91.00%（91/100）,高于对照组的76.00%（76/100）（P<0.05）。研究组术后不良心血管发生事件发生率为2.00%（2/100）,低于对照组的17.00%（17/100）（P<0.05）。结论：行PPCI术的AMI患者给予院前急救联合绿色通道模式,救治效果显著,可有效提高患者满意度,减少术后不良心血管事件的发生率。     

Feasibility,safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group.

OBJECTIVE--To assess the feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners. DESIGN--Randomised double blind parallel group trial of anistreplase 30 units intravenously and placebo given either at home or in hospital. SETTING--29 rural practices in Grampian admitting patients to teaching hospitals in Aberdeen (average distance 36 (range 16-62) miles). PATIENTS--311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic therapy seen at home within four hours of onset of symptoms. MAIN OUTCOME MEASURES--Time saving, adverse events, Q wave infarction, left ventricular function. RESULTS--Anistreplase was administered at home 101 minutes after onset of symptoms, while anistreplase was given in hospital 240 minutes after onset of symptoms (median times). Adverse events after thrombolysis were infrequent and, apart from cardiac arrest, not a serious problem when they occurred in the community: seven of 13 patients were resuscitated after cardiac arrest out of hospital. By three months after trial entry the relative reduction of deaths from all causes in patients given thrombolytic therapy at home was 49% (13/163 (8.0%) v 23/148 (15.5%); difference -7.6% (95% confidence interval -14.7% to -0.4%), p = 0.04). Full thickness Q wave infarction was less common in patients with confirmed infarction receiving treatment at home (65/122 (53.3%) v 76/112 (67.9%); difference -14.6% (95% confidence interval -27.0% to -2.2%), p = 0.02). CONCLUSIONS--General practitioners provided rapid pre-hospital coronary care of a high standard. Compared with later administration in hospital, giving anistreplase at home resulted in reduction in mortality, fewer cardiac arrests, fewer Q wave infarcts, and better left ventricular function. Benefits were most marked where thrombolytic therapy was administered within two hours of the onset of symptoms.     

Attitudes of general practitioners to prehospital thrombolysis.

OBJECTIVE--To investigate reasons for general practitioners not giving thrombolytic treatment to eligible patients with acute myocardial infarction. DESIGN--Postal questionnaires were sent to 424 general practitioners. SUBJECTS--97 general practitioners who had taken part in the Grampian region early anistreplase trial, 185 whose practices in Scotland were at least 24 km from a district general hospital, and 142 who had attended postgraduate conferences at which thrombolysis had been discussed; 87, 158, and 125 respectively responded. MAIN OUTCOME MEASURES--Answers to questions about readiness to use thrombolytic treatment. RESULTS--Response rate was 87% (370/424). Almost all respondents (350) were convinced of benefits of thrombolysis for acute myocardial infarction, and 277 were convinced that there were additional benefits from its administration in the community at first opportunity. Most doctors working 16 km or more from hospital thought that giving treatment at home would appreciably save time (200/274). Most doctors agreed that they could make time to give thrombolytic treatment (278), and would be willing to record an electrocardiogram (284), and would be able to interpret it (280). Sixty four respondents (17%) reported using thrombolytic treatment in previous year. Among non-users, 150 (49%) were unwilling to use thrombolytic treatment without further training. While many non-users (210 (69%)) were willing to use thrombolytic treatment without encouragement from Department of Health, 184 (60%) were unwilling to use it unless encouraged to do so by their local cardiologist. CONCLUSIONS--The need to become better informed about thrombolysis and lack of encouragement from local cardiologists were important factors preventing wider use of thrombolytic treatment in the community by general practitioners.     

Time to treatment with thrombolytic therapy: determinants and effect on short-term nonfatal outcomes of acute myocardial infarction

OBJECTIVES: To characterize the extent of delay in administration of thrombolytic therapy to patients with acute myocardial infarction (AMI) in Canada, to examine patient-specific predictors of such delay and to measure the effect of delay on short-term nonfatal cardiac outcomes. DESIGN: Secondary cohort analysis of data from the first international Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries (GUSTO-I) trial. SETTING: Sixty-three acute care hospitals across Canada. SUBJECTS: All 2898 Canadian patients with an AMI enrolled in GUSTO-I. MAIN OUTCOMES: Time before arrival at a hospital ("symptom-to-door" time) and time from arrival to administration of therapy ("door-to-needle" time) for patients who had an AMI outside of a hospital, in clinically relevant categories; proportions of patients with nonfatal, serious cardiac events, including shock, sustained ventricular tachycardia, ventricular fibrillation and asystole. RESULTS: Of the total number of patients enrolled, records were complete for 2708; 2542 of these patients (93.9%) had an AMI outside of a hospital. These 2542 patients presented a median 81 (interquartile range 50 to 130) minutes after the onset of symptoms, and the median time to treatment in hospital was 85 (interquartile range 61 to 115) minutes. Whereas a greater proportion of Canadian patients than of patients enrolled in GUSTO-I in other countries reached hospital within 2 hours of symptom onset (71.5% v. 61.2%, p < 0.001), a greater proportion of Canadian patients experienced in-hospital treatment delays of more than 1 hour (75.3% v. 57.1%, p < 0.001). In an analysis of all 2708 patients with complete records, both the unadjusted and adjusted odds of nonfatal cardiac events for those treated 4 to 6 hours after symptom onset were significantly higher than for those treated within 2 hours (odds ratio 1.60, 95% confidence interval 1.09 to 2.37). CONCLUSION: After arrival at a hospital, Canadian patients enrolled in GUSTO-I received thrombolytic therapy more slowly than trial enrollees in other countries. Such delays are already known to decrease the rate of short-term survival after AMI. The findings further show that long time to treatment also increases the odds of nonfatal, serious cardiac events. Hospitals and physicians caring for patients with AMI should routinely assess whether and how they can improve door-to-needle times.     

静脉溶栓时机对急性ST段抬高型心肌梗死患者溶栓效果及主要不良心脏事件发生率的影响

目的:探讨静脉溶栓时机对急性ST段抬高型心肌梗死患者溶栓效果及主要不良心脏事件发生率的影响。方法:将2016年1月至2017年12月我院接诊的314例急性ST段抬高型心肌梗死患者纳入本研究,按照溶栓治疗时间不同分为A组(发病至溶栓时间6 h)172例、B组(发病至溶栓时间为6～12 h)102例和C组(发病至溶栓时间12 h)40例,比较三组患者溶栓效果、溶栓后ST段回落情况以及住院期间主要不良心脏事件发生情况。结果:A组患者梗死冠脉溶通率、溶栓后ST段回落幅度高于B组和C组,且B组高于C组,差异均有统计学意义(P0.05)。A组患者治疗后ST段回落最大幅度所需时间、住院期间主要不良心脏事件总发生率低于B组和C组,且B组低于C组,差异均有统计学意义(P0.05)。结论:急性ST段抬高型心肌梗死患者发病后6 h内静脉溶栓治疗梗死冠脉溶通率更高、ST段回落效果更好,可降低住院期间主要不良心脏事件发生风险。     

Patient and general practitioner delays in acute myocardial infarction

The longest component of the total delay in coming under coronary care is patient delay, and it has been suggested that public education might be used to make it shorter. The patterns of patient delay were studied in 450 patients with acute myocardial infarction uncomplicated by cardiac arrest out of hospital, of whom 243 had a previous history of ischaemic heart disease. Patient delays had a skewed distribution with a modal delay of up to one hour, a median delay of two hours, and a mean delay of 10 hours. Two thirds of patients had sought help from their general practitioners within four hours of the onset of symptoms. During the first four hours the longer that patients delayed the lower was the subsequent mortality (27%, 18%, and 9% for delays of one hour or less, up to two hours, and up to four hours, respectively), but patients who delayed four to eight hours had the highest mortality of all (38%). Neither the median value nor the pattern of patient delays was altered by a previous history of ischaemic heart disease.There were pronounced differences in doctor delays, depending on the patient''s age, delay time, and ultimate place of treatment, showing that the doctors'' behaviour was influenced before they had seen their patients. Nevertheless, the median total delay for patients aged up to 70 was one hour 35 minutes, and a higher proportion of patients were seen early after infarction than in recent hospital trials of thrombolytic treatment.These findings suggest that the patients'' call for help and the doctors'' response may be at an instinctive level according to the patients'' distress; these patterns of behaviour may be difficult to modify by public education.     

小剂量重组组织纤溶酶原激活剂治疗急性心肌梗死临床研究概况

1990年代中期以来,国内130多家医院入组9378例急性心肌梗死患者,其中用小剂量（50mg）重组组织纤溶酶厚激活剂（rt-PA）治疗6693例,阻塞相关血管开通5318俐,开通率为79.46％;死亡293倒,病死率为4.38％;出血550俐,出血率勾8.22％,其中重度出血7例,颅内出血21例（0.31％）,再次梗塞60例（0.90％）。超过40家医院对rt-PA（50mg）与尿激酶治疗急性心肌梗死疗效进行了比较,共计入组3449倒急性心肌梗死患者,rt-PA治疗1689例,先静脉推注8mg,其余42mg在30或60和90min滴注;尿激酶治疗1760例,150万U位滴注30min。结果显示,阻塞相关冠脉血管开通率分别为79.40％（1341例）和5733％（1009例）,相差非常显著（P〈0.001）。12家医院研究了rt-PA50-9100mg治疗急性心肌梗死的效果,共计入组1054例患者,其中50mg组487例,100mg组567例,阻塞相关血管开通率分别为78.85％和82.36％。另有22家医院入组1017倒病人,行rt-PA50mg30rain给药临味试验,冠脉开通率达80.53％;18家医院行rt-PA50mg 60min给药临床试验,入组942例病人,阻塞相关血管开通率为77.92％;50家医院用rt-PA50mg 90min给药方案治疗急性心肌梗死患者,入组2768例患者,冠脉开通率为77.89％。6家医院对用rt-PA（50mg）与链激酶治疗急性心肌梗死的疗效进行了对比,结果表明相关血管开通率分别为81.4％和65.2％22家医院比较了小剂量rt-PA对急性心肌梗死患者症状发作不同时间的治疗效果,表明症状发作时间越短,用药的溶栓效果越好。刘光对入院前和入院后用小剂量rt-PA溶栓进行了比较研究,证明入院前溶栓比入院后效果好。对冠脉内输注rt-PA（50mg）和2次静脉推注小剂量rt-PA治疗急性心肌梗死的效果也进行了探索。     

Acute Myocardial Infarction: Home and Hospital Treatment

This is a preliminary report of a co-operative study of 1,203 episodes of acute myocardial infarction in men under 70 years in four centres in the south west of England. The mortality at 28 days was 15%. A comparison is made between home care by the family doctor and hospital treatment initially in an intensive care unit: 343 cases were allocated at random. The randomized groups do not differ significantly in composition with respect to age; past history of angina, infarction, or hypertension; or hypotension when first examined. The mortality rates of the random groups are similar for home and hospital treatment. The group sent electively to hospital contained a higher proportion of initially hypotensive patients whose prognosis was bad wherever treated; those who were not hypotensive fared rather worse in hospital.For some patients with acute myocardial infarction seen by their general practitioner home care is ethically justified, and the need for general admission to hospital should be reconsidered.     

Analysis of Sex Differences in Preadmission Management of ST-Segment Elevation (STEMI) Myocardial Infarction

BackgroundMany reports suggest gender disparity in cardiac care as a contributor to the increased mortality among women with heart disease.ObjectiveWe sought to identify gender differences in the management of Myocardial Infarction (MI) Alert–activated ST-segment elevation myocardial infarction (STEMI) patients that may have resulted from prehospital initiation.MethodsA retrospective database was created for MI Alert STEMI patients who presented to the emergency department (ED) of an academic community hospital with 74,000 annual visits from April 2000 through December 2008. Included were patients meeting criteria for an MI Alert (an institutional clinical practice guideline designed to expedite cardiac catheterization for STEMI patients). Data points (before and after initiation of a prehospital alert protocol) were compared and used as markers of therapy: time to ECG, receiving β-blockers, and time to the catheterization laboratory (cath lab). Differences in categorical variables by patient sex were assessed using the χ² test. Medians were estimated as the measure of central tendency. Quantile regression models were used to assess differences in median times between subgroups.ResultsA total of 1231 MI Alert charts were identified and analyzed. The majority of the study population were male (70%), arrived at the ED via ambulance (60.1%), and were taking a β-blocker (67.8%) or aspirin (91.6%) at the time of the ED admission. Female patients were more likely than male patients to arrive at the ED via ambulance (65.9% vs 57.6%, respectively; P = 0.014). The median age of female patients was 68 years, whereas male patients were significantly younger (median age, 59 years; P < 0.001). The proportion of patients currently taking a β-blocker or low-dose aspirin did not vary by gender. Overall, 78.2% of the MI Alert patients arriving at the ED were MI2 (alert initiated by ED physician), and this did not vary by gender (P = 0.33). A total of 1064 MI Alert patients went to the cath lab: 766 male patients (88.9%) and 298 female patients (80.8%). Overall, the median time to cath lab arrival was 79 minutes for men and 81 minutes for women (P = 0.38). Overall, the median time to cath lab arrival significantly decreased from MI1 to MI3, (P_trend < 0.001). For prehospital-initiated alerts (MI3), the median time to cath lab arrival was the same for men and women (64 minutes; P = 1.0). For hospital-initiated alerts, time to cath lab arrival was 82 minutes for male patients and 84 minutes for female patients (P = 0.38). Prehospital activation of the process decreased the time to the cath lab by 19 minutes (P < 0.001; 95% CI, 13.2–24.8).ConclusionNo significant gender differences were apparent in the STEMI patients analyzed, whether the MI Alert was initiated in the ED or prehospital initiated. Initiating prehospital-based alerts significantly decreased the time to the cath lab.     

Magnitude of benefit from earlier thrombolytic treatment in acute myocardial infarction: new evidence from Grampian region early anistreplase trial (GREAT)

OBJECTIVE--To generalise from the results of the Grampian region early anistreplase trial (GREAT) and to express the benefit of earlier thrombolysis in terms of lives saved per hour of earlier treatment. DESIGN--Multivariate analysis of a randomised double blind trial. SETTING--29 rural practices in Grampian region and teaching hospitals in Aberdeen. SUBJECTS--311 patients with suspected acute myocardial infarction and without contraindications to thrombolysis who were seen by their general practitioners within four hours of the start of symptoms. INTERVENTIONS--Anisterplase 30 units given intravenously, either by general practitioners before hospitalisation or later in hospital. MAIN OUTCOME MEASURE--Death within 30 months of entry into trial. RESULTS--Death within 30 months was positively related to age (P < 0.0001) and to delay between start of symptoms and thrombolytic treatment (P = 0.0004). However, the probability of dying rose exponentially with earlier presentation, so death within 30 months was negatively related to the logarithm of the time of randomisation (P = 0.0163). In patients presenting two hours after start of symptoms each hour''s delay in receiving thrombolysis led to the loss of 21 lives per 1000 within 30 days (95% confidence interval 1 to 94 lives per 1000) (P = 0.03) and 69 lives per 1000 within 30 months (16 to 141 lives per 1000) (P = 0.0004). CONCLUSIONS--The magnitude of the benefit from earlier thrombolysis is such that giving thrombolytic treatment to patients with acute myocardial infarction should be accorded the same degree of urgency as the treatment of cardiac arrest.     

Bringing the hospital to the patient: first treatment of stroke patients at the emergency site

Background

Early treatment with rt-PA is critical for favorable outcome of acute stroke. However, only a very small proportion of stroke patients receive this treatment, as most arrive at hospital too late to be eligible for rt-PA therapy.

Methods and Findings

We developed a “Mobile Stroke Unit”, consisting of an ambulance equipped with computed tomography, a point-of-care laboratory system for complete stroke laboratory work-up, and telemedicine capabilities for contact with hospital experts, to achieve delivery of etiology-specific and guideline-adherent stroke treatment at the site of the emergency, well before arrival at the hospital. In a departure from current practice, stroke patients could be differentially treated according to their ischemic or hemorrhagic etiology even in the prehospital phase of stroke management. Immediate diagnosis of cerebral ischemia and exclusion of thrombolysis contraindications enabled us to perform prehospital rt-PA thrombolysis as bridging to later intra-arterial recanalization in one patient. In a complementary patient with cerebral hemorrhage, prehospital diagnosis allowed immediate initiation of hemorrhage-specific blood pressure management and telemedicine consultation regarding surgery. Call-to-therapy-decision times were 35 minutes.

Conclusion

This preliminary study proves the feasibility of guideline-adherent, etiology-specific and causal treatment of acute stroke directly at the emergency site.