One thousand heart attacks in Grampian: the place of cardiopulmonary resuscitation in general practice.

The outcome of 1011 heart attacks in patients under the care of general practitioners who practised cardiopulmonary resuscitation and were equipped with defibrillators is reported. The 28 day mortality was 36% (367 patients), and 59% of deaths occurred outside hospital. The general practitioner was the first medical contact in 92% of heart attacks and was equipped with a defibrillator in 80% of such calls. Fifty six patients had a cardiac arrest in the presence of a general practitioner, and resuscitation was attempted in 47 cases, representing 5% of all calls for heart attacks. Twenty one (45%) resuscitated patients reached hospital alive, and 13 (28%) survived to leave hospital. The opportunities for cardiopulmonary resuscitation in general practice occur sufficiently often to warrant training and equipping general practitioners for advanced life support. The results of resuscitation by general practitioners working alone compare favourably with those of mobile coronary care units based in hospitals.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

Early identification of patients at low risk of death after myocardial infarction and potentially suitable for early hospital discharge.

OBJECTIVES--To find (a) whether data available shortly after admission for acute myocardial infarction can provide a reliable prognostic indicator of survival at 28 days, and (b) whether such an indicator might be used to identify patients at low risk of death and suitable for early discharge. DESIGN--Retrospective analysis of data collected on patients admitted to a coronary care unit for acute myocardial infarction. A validation sample was selected at random from these patients. SETTING--Coronary care units in Perth, Western Australia. SUBJECTS--6746 patients aged under 65 and resident in the Perth Statistical Division who during 1984-92 were admitted to a coronary care unit with symptoms of myocardial infarction. MAIN OUTCOME MEASURES--Sensitivity and specificity of several models for predicting survival at 28 days after myocardial infarction, and detailed performance characteristics of a particular model. RESULTS--Patients with a pulse rate of 100 beats/min or less, aged 60 or under, and with symptoms typical of myocardial infarction, no past history of myocardial infarction or diabetes, and no significant Q wave in the admission electrocardiogram had a very high chance of survival at 28 days (99.2%). These patients made up one third of all patients studied. CONCLUSION--The prognostic index identifies patients very soon after admission who are at low risk of death and potentially eligible for early discharge from hospital or the coronary care unit. Computing the index does not need complex cardiac investigations.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Value of Routine Cardiac Monitoring in the Management of Acute Myocardial Infarction outside a Coronary Care Unit

In a coronary care unit patients and electrocardiographic monitors are under almost continuous observation by trained personnel. This paper suggests that in a general medical ward without this facility routine cardiac monitoring with E.C.G. oscilloscopes is unlikely to lower the overall mortality from acute myocardial infarction. A mortality of 25% for acute myocardial infarction was the same for a hospital without a coronary care unit where monitoring was routinely performed and for two neighbouring hospitals which did not routinely use monitoring during the period of analysis.The need to train personnel in the recognition of E.C.G. monitor tracings and the difficulties associated with monitor alarm systems are emphasized.     

Sudden Death in Hospital after Discharge from Coronary Care Unit

In a group of 339 patients with acute myocardial infarction treated in a coronary care unit, 273 left the unit while improving and were expected to leave hospital alive; 23 had a cardiac arrest or died suddenly while still in hospital—17 died immediately or after temporary resuscitation and six were resuscitated to leave hospital alive. Ventricular fibrillation was found in 13 of the 20 patients attended by the cardiac arrest team. The incidents were scattered from the 4th to the 24th day after the onset of infarction. Risk factors in these “late sudden death” patients were compared with the 250 patients who left the unit while improving and did not die or suffer cardiac arrest. The patients susceptible to late sudden death were characterized early in their hospital course by the findings of severe, predominantly anterior infarction, left ventricular failure, persistent sinus tachycardia, and frequent ventricular arrhythmias. It is suggested that such patients be chosen for prolonged observation in a second-stage coronary care unit.     

Immunoscintigraphy for detecting acute myocardial infarction without electrocardiographic changes.

OBJECTIVE--To establish whether immunoscintigraphy with antibody to myosin may detect acute myocardial infarction without electrocardiographic changes. DESIGN--Prospective study of patients with suspected acute myocardial infarction or unstable angina with cardiac imaging with 111indium myosin antibody, estimation of cardiac enzyme concentrations, electrocardiography, 201thallium imaging, and radionuclide ventriculography. SETTING--Coronary care unit in a district general hospital. PATIENTS--119 Consecutive patients with suspected acute myocardial infarction or unstable angina. Patients with cardiomyopathy, myocarditis, valvular heart disease, myocardial infarction or cardiac surgery in the previous two weeks or with left bundle branch block and women of childbearing age were excluded. RESULTS--Of 75 patients with suspected acute myocardial infarction, seven had no diagnostic electrocardiographic changes despite normal conduction patterns. Immunoscintigraphy with myosin antibody disclosed necrosis in all seven patients, which was localised in regions supplied by diseased coronary arteries in all but one. Six patients had abnormal images on 201thallium imaging, and all seven had abnormal wall motion at the site of antibody uptake. One patient with minimal left main stem and right coronary artery atheroma had uptake of antibody at two discrete sites. CONCLUSIONS--Immunoscintigraphy with antibody to myosin confirms myocardial infarction in the absence of electrocardiographic changes and discloses the site of infarction.     

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.     

Myocardial infarction: a comparison between home and hospital care for patients.

To compare the results of home and hospital treatment in men aged under 70 years who had suffered acute myocardial infarction within 48 hours 1895 patients were considered for study in four centres in south-west England. Four-hundred-and-fifty patients were randomly allocated to receive care either at home by their family doctor or in hospital, initially in an intensive care unit. The randomised treatment groups were similar in age, history of cardiovascular disease, and incidence of hypotension when first examined. They were followed up for up to a year after onset. The mortality rate at 28 days was 12% for the random home group and 14% for the random hospital group; the corresponding figures at 330 days were 20% and 27%. On average, older patients and those without initial hypotension fared rather better under home care. The patients who underwent randomisation were similar to those whose place of care was not randomised, except that the non-randomised group contained a higher proportion of initially hypotensive patients, whose prognosis was poor wherever treated. These results confirm and extend our preliminary findings. Home care is a proper form of treatment for many patients with acute myocardial infarction, particularly those over 60 years and those with an uncomplicated attack seen by general practitioners.     

Mobile Intensive Care in Myocardial Infarction

In the first six months of its existence a mobile intensive care unit was used to admit 95 patients with definite or probable myocardial infarction to the local district hospital. Though the area served was a rural one, with a radius of about 25 miles from the hospital, the average interval between receiving a call and starting intensive care was less than 30 minutes. Five patients with ventricular fibrillation were successfully resuscitated by the mobile team outside hospital. The mobile unit has made it possible to admit many more patients with myocardial infarction to hospital than before, and we believe its cost and use of skilled staff are justified by the results. The unit reduces the delay between the onset of symptoms and initiation of intensive care and thus diminishes the risk of primary ventricular fibrillation, which is maximal soon after the onset of symptoms. Since mobile intensive care removes the risk of transport it allows concentration of cases of acute myocardial infarction in the larger hospitals.     

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.     

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.     

Late Ventricular Dysrhythmias after Myocardial Infarction

Serious ventricular dysrhythmias occurred in hospital after discharge from a coronary intensive care unit in 11 out of 142 patients with myocardial infarction. Previous rhythm changes, hypotension, and left ventricular failure were common findings; only one of these patients had an uneventful previous course. Four patients were resuscitated and left hospital; six were resuscitated but died at varying periods up to eight days after the event; one patient could not be resuscitated. Recent coronary occlusion or further myocardial infarction was demonstrated in 7 of these 11 patients and presumably accounted for the dysrhythmia.     

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.     

The post-infarction nurse practitioner project

Objectives To confirm the feasibility of nurse practitioner interventionin non-high-risk patients with recent myocardial infarction (MI). Design Observational study. Setting Acute coronary care unit in a teaching hospital. Methods We performed an open-label feasibility study to identify non-high-risk MI patients and evaluate the outcome of a new nurse practitioner intervention programme. The initial pilot phase served to identify the non-high-risk population. In the subsequent confirmation phase, 500 consecutive non-high-risk post-MI patients with preserved LV function without heart failure were included to receive nurse practitioner management. The nurse practitioner intervention started on transfer from the coronary care unit to the cardiology ward and continued thereafter for up to 30 days. Main outcome measures Time to first event analysis of death from all causes or repeat myocardial infarction. Results 500 Patients without signs of heart failure or depressed LV function were identified as nonhigh- risk and eligible for inclusion in the nurse practitioner intervention programme. In the implementation phase, none of the patients died and 0.9% developed a repeat myocardial infarction after 30 days of follow-up. Compared with the pilot phase, patients in the implementation phase spent fewer days in hospital (mean 11.1 versus 6.2 days; p<0.001). Conclusion It is feasible to identify non-high-risk post-MI patients, who can be managed adequately by a nurse practitioner. Embedding experienced nurse practitioners within critical care pathways may result in significant decreases in length of hospital stay. (Neth Heart J 2009;17:61-7.)     

Study of patients' psychological attitudes to a coronary care unit

Seventy-four consecutive male patients aged 38 to 63 years were admitted to a coronary care unit with their first myocardial infarction. Their attitude to the unit was studied by interview and personality tests. Only six patients found the unit anxiety-provoking. Dependency feelings were found to occur frequently, both after transfer from the unit to the general wards and after discharge from hospital. It is suggested that the weaning process from the unit should be gradual and that at least one follow-up outpatient appointment should be arranged, as well as good liaison between the family doctor and the hospital.     

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.     

Evolution of emergency cardiac care in Canada.

Acute myocardial infarction is the most common cause of death in Canada. Most deaths occur within the first 2 hours of the onset of symptoms, before the person seeks or is able to obtain medical aid, and are due to arrhythmias rather than massive myocardial damage. Effective electrical and drug treatment of arrhythmias has reduced the hospital mortality but not the community mortality. If mortality from acute myocardial infarction and other causes of sudden unexpected death is to be reduced substantially a major reorganization of emergency medical services is needed so that the benefits of the modern coronary care unit can be provided to the patient as rapidly as possible. Public education in basic life support procedures to sustain life until advanced life support aid arrives is the first step towards the development of a more effective system of emergency cardiac care.     

Trial of early nifedipine in acute myocardial infarction: the Trent study.

Over 30 months 9292 consecutive patients admitted to nine coronary care units with suspected myocardial infarction were considered for admission to a randomised double blind study comparing the effect on mortality of nifedipine 10 mg four times a day with that of placebo. Among the 4801 patients excluded from the study the overall one month fatality rate was 18.2% and the one month fatality rate in those with definite myocardial infarction 26.8%. A total of 4491 patients fulfilled the entry criteria and were randomly allocated to nifedipine or placebo immediately after assessment in the coronary care unit. Roughly 64% of patients in both treatment groups sustained an acute myocardial infarction. The overall one month fatality rates were 6.3% in the placebo treated group and 6.7% in the nifedipine treated group. Most of the deaths occurred in patients with an in hospital diagnosis of myocardial infarction, and their one month fatality rates were 9.3% for the placebo group and 10.2% for the nifedipine group. These differences were not statistically significant. Subgroup analysis also did not suggest any particular group of patients with suspected acute myocardial infarction who might benefit from early nifedipine treatment in the dose studied.     

Likelihood of Treatment in a Coronary Care Unit for a First-Time Myocardial Infarction in Relation to Sex,Country of Birth and Socioeconomic Position in Sweden

Objective

To examine the relationship between sex, country of birth, level of education as an indicator of socioeconomic position, and the likelihood of treatment in a coronary care unit (CCU) for a first-time myocardial infarction.

Design

Nationwide register based study.

Setting

Sweden.

Patients

199 906 patients (114 387 men and 85,519 women) of all ages who were admitted to hospital for first-time myocardial infarction between 2001 and 2009.

Main outcome measures

Admission to a coronary care unit due to myocardial infarction.

Results

Despite the observed increasing access to coronary care units over time, the proportion of women treated in a coronary care unit was 13% less than for men. As compared with men, the multivariable adjusted odds ratio among women was 0.80 (95% confidence interval 0.77 to 0.82). This lower proportion of women treated in a CCU varied by age and year of diagnosis and country of birth. Overall, there was no evidence of a difference in likelihood of treatment in a coronary care unit between Sweden-born and foreign-born patients. As compared with patients with high education, the adjusted odds ratio among patients with a low level of education was 0.93 (95% confidence interval 0.89 to 0.96).

Conclusions

Foreign-born and Sweden-born first-time myocardial infarction patients had equal opportunity of being treated in a coronary care unit in Sweden; this is in contrast to the situation in many other countries with large immigrant populations. However, the apparent lower rate of coronary care unit admission after first-time myocardial infarction among women and patients with low socioeconomic position warrants further investigation.