Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department

doi:10.1016/S0002-9149(99)80108-8

The American Journal of Cardiology

Volume 76, Issue 5, 15 August 1995, Pages 396-398

https://doi.org/10.1016/S0002-9149(99)80108-8 Get rights and content

Abstract

Because time to treatment in AMI is a critical factor in long-term outcome, it is important that complex trials designed to improve reperfusion therapy do not delay the time to treatment. Participation in the TIMI 5 trial did not significantly prolong our door-to-needle time. These results indicate that, if done carefully, complex, labor-intensive studies can be performed within a reasonable time limit. Care should be taken to design protocols incorporating easy drug preparation, informed consent by the ED, and efficiency of trial initiation.

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Cited by (12)

Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion
2006, Journal of Emergency Medicine
ST elevation (STE) in anterior precordial leads, in association with upwardly convex morphology (M) or straightM, is associated with anterior acute myocardial infarction (aAMI). Upwardly concaveM is characteristic of pseudoinfarction patterns such as early repolarization. A retrospective review was done of diagnostic electrocardiograms (EKG) of consecutive patients presenting to our Emergency Department (ED) who underwent emergent primary percutaneous intervention (PCI) and had proven left anterior descending (LAD) occlusion. If all leads from V2–V6 were upwardly concave, the EKG was classified as concaveM. If one lead was convex, the EKG had convexM. If no leads were convex and at least one was straight, it had straightM. Non-concaveM was defined as either convexM or straightM. Borderline STE was defined if the EKG did not have 2 consecutive leads with ≥ 2 mm of STE. “Subtle,” as opposed to “diagnostic,” morphology was defined as concaveM without terminal QRS distortion. Data were analyzed with descriptive statistics. There were 37 patients identified who met the inclusion criteria and whose records were available for review. ConcaveM was found in 16 of 37 (43%), 4 with terminal QRS distortion. Measurements resulted in a classification of borderline STE in 15 of 37 (41%) (9 of whom had subtle morphology) for Rater 1 and 12 of 37 (32%) (7 of whom had subtle morphology) for Rater 2, while 19% to 24% had both “subtle” morphology and borderline ST elevation. ConcaveM, as compared with convexM or terminal QRS distortion, was associated with a shorter duration of symptoms (p < 0.05). It is concluded that concave morphology cannot be used to exclude STEMI with LAD occlusion. Many patients with LAD occlusion have borderline ST elevation with subtle morphology. Concave morphology is associated with a shorter duration of symptoms.
The delay in transfer between the emergency department and the critical care unit for patients with an acute cardiac event - in hospital factors
2001, Australian Critical Care
The Lyell McEwin Health Service (LMHS) is a major public hospital located in the northern suburbs of Adelaide, a region where the death rate from ischaemic heart disease (IHD) is higher than the expected death rate in the population. A retrospective case note study conducted at this hospital investigated the duration that patients with unstable angina pectoris (UA) or acute myocardial infarction (AMI) spent in the emergency department (ED) before admission to the critical care unit (CCU) and the factors that contributed to delays of greater than 70 minutes. All patients admitted to the LMHS over an 18 month period with a discharge diagnosis related group (DRG) for AMI and UA were included in the study. A total of 667 case notes were examined; 403 of these cases met the inclusion criteria for the study.
The mean duration between arrival in the ED and subsequent admission to the CCU was found to be 161 minutes. DRG was a major factor in the length of time spent in the ED. The mean duration for patients with AMI was 124 minutes, whilst for UA the duration was 190 minutes (difference = 66 minutes, p<0.001). Other factors that were signifiant were gender (female = mean duration 29 minutes > males, p=0.015), and mode of transport to the ED (arrival by ambulance mean duration 30 minutes < private transport, p=0.017).
Recommendations arising from this study included that a system be established to enable the rapid assessment of all patients suspected of suffering AMI and UA, inclusive of their expeditious transfer to the CCU. In addition, a staff development programme was proposed to ensure medical and nursing staff become aware of a bias in this hospital toward transferring male patients in a shorter timeframe than females with the same DRG.
Acute myocardial infarction: Clinical characteristics, management and outcome in a Metropolitan Veterans Affairs Medical Center Teaching Hospital
1997, Journal of the American College of Cardiology
Objectives. The influence of race and age on thrombolytic therapy, invasive cardiac procedures and outcomes was assessed in a Veterans Affairs teaching hospital. The influence of Q wave evolution on the use of invasive cardiac procedures and outcome was also assessed.
Background. It is not well known how early revascularization procedures for acute myocardial infarction are delivered or influence survival in a Veterans Affairs patient population.
Methods. From October 1993 to October 1995, all patients with myocardial infarction were identified by elevated creatine kinase, MB fraction (CK-MB) and one of the following: chest pain or shortness of breath during the preceding 24 h or electrocardiographic (ECG) abnormalities.
Results. Racial groups were similar in terms of age, time to ECG, peak CK and length of hospital stay. Mortality increased with age (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.33 to 2.81). A trend toward increased mortality occurred for race other than Caucasian. Patients meeting ECG criteria were given thrombolytic agents in 49% of cases, but age, comorbidity count and Hispanic race decreased the probability of thrombolytic use. Cardiac catheterization was performed more often after thrombolytic agents (OR 1.85, 95% CI 0.97 to 3.54), but less often in African-Americans (OR 0.59, 95% CI 0.35 to 1.02), older patients (OR 0.39, 95% CI 0.24 to 0.64) or patients with heart failure (OR 0.30, 95% CI 0.17 to 0.52). Patients evolving non–Q wave infarctions were older and had increased comorbidity counts and trends toward increased mortality. Angioplasty was chosen less for patients ≥65 years old (p = 0.02); angioplasty and coronary artery bypass graft surgery were performed less in patients ≥70 years old (p = 0.02). Patients treated invasively had lower mortality rates than those treated medically (p < 0.02).
Conclusions. The use of thrombolytic agents and invasive treatment plans declined with age, and mortality increased with age. Trends toward increased mortality occurred with non–Q wave infarctions and race other than Caucasian.
(J Am Coll Cardiol 1997;29:915–25)
© 1997 by the American College of Cardiology
Assessment of initiation time of thrombolytic therapy in patients with ST-segment elevation myocardial imfarction in Hamad General Hospital
2008, Qatar Medical Journal
Consent for intravenous thrombolysis in acute stroke: Review and future directions
2007, Archives of Neurology
Emergency department thrombolysis improves door to needle times
2004, Emergency Medicine Journal

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¹: Ms. Boisjolie's address is: Hennepin County Medical Center, Cardiology Division, 701 Park Avenue, Minneapolis, Minnesota 55415.

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Brief reportImpact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction

Lancet

Myocardial reperfusion, limitation of infarct size, reduction of left ventricular dysfunction, and improved survival: should the paradigm be expanded?

Circulation

Brief report
Impact of a thrombolysis research trial on time to treatment for acute myocardial infarction in the emergency department