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Outcome of Patients with Acute Myocardial Infarction Who Are Ineligible for Thrombolytic Therapy

David R. Cragg, MD; Harold Z. Friedman, MD; John D. Bonema, MD; Ishmael A. Jaiyesimi, MD; Renato G. Ramos, MD; Gerald C. Timmis, MD; William W. O'Neill, MD; and Theodore L. Schreiber, MD
[+] Article, Author, and Disclosure Information

Requests for Reprints: David R. Cragg, MD, Division of Cardiology, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073-6769.

Current Author Addresses: Drs. Cragg, Friedman, Bonema, Jaiyesimi, Ramos, Timmis, O'Neill, and Schreiber: Division of Cardiology, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073-6769.

© 1991 American College of PhysiciansAmerican College of Physicians

Ann Intern Med. 1991;115(3):173-177. doi:10.7326/0003-4819-115-3-173
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Objective: To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history.

Design: Retrospective chart review.

Setting: A large community-based hospital.

Patients: All patients with acute myocardial infarction hospitalized during a 27-month period.

Measurements: Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy.

Main Results: The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P < 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P < 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, > 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (> 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria.

Conclusions: Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.





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