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; Theodore L. Schreiber, MD
▪ 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.
Cragg DR, Friedman HZ, Bonema JD, Jaiyesimi IA, Ramos RG, Timmis GC, et al. Outcome of Patients with Acute Myocardial Infarction Who Are Ineligible for Thrombolytic Therapy. Ann Intern Med. ;115:173–177. doi: 10.7326/0003-4819-115-3-173
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Published: Ann Intern Med. 1991;115(3):173-177.
Acute Coronary Syndromes, Cardiology, Coronary Heart Disease, Emergency Medicine.
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