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Sir,—Two recent papers in Heartshowed that direct admission of patients with acute myocardial infarction to the coronary care unit (CCU) by ambulance staff reduced time delays in administering thrombolytic treatment.1 2The approach is novel; however, because it involves training a large number of ambulance personnel in reading ECGs as well as evolving a system for admitting suitable patients directly to CCUs, it will consume resources. Moreover, the position of the CCU within many hospitals may not allow easy access by ambulance.
It is possible to reduce delays by simpler methods. Transferring patients from the accident and emergency department to the CCU takes time that might explain the delay between the two groups observed in these studies.1 2 Data from Edinburgh3showed that administering thrombolytic treatment in the accident and emergency department significantly reduced delays. Therefore, the simple step of giving thrombolytics in the accident and emergency department might achieve the same results as direct admission to CCU by trained ambulance personnel. A study comparing the delays between thrombolysis provided in the accident and emergency department and thrombolysis provided after direct CCU admission is advisable before the policy of direct admission to CCU by trained ambulance personnel is widely adopted.
There are other factors that may influence the timing of thrombolytic treatment. Our data4 show that the delay in administering thrombolytics in accident and emergency depended on the method of administration: for infusions (streptokinase or alteplase) it was a mean (SD) of 49.5 (43.82) minutes but for a bolus (anistreplase) it was 16.5 (16.46) minutes. Therefore, greater use of thrombolytic agents that can be given by bolus may be particularly important.