Consideration for primary angioplasty: impact on the door-to-drug time in AMI patients ultimately treated with thrombolytic agent

The objective of this study was to determine if consideration for percutaneous transluminal coronary angioplasty (PTCA) delays administration of thrombolytic therapy in acute myocardial infarction (AMI) patients. Retrospective medical record review of patients ultimately diagnosed with AMI who presented to the ED with chest pain and ST segment elevation on the electrocardiogram; these patients also received acute reperfusion therapy (PTCA or thrombolytic agent). AMI was diagnosed by abnormal elevations in the creatinine phosphokinase MB fraction. The study period covered 2 years (July 1, 1994 to June 30, 1996) in a university hospital ED with an annual volume of 60,000 patient-visits. The use of reperfusion therapies, time intervals, and times of presentation were recorded. Patients were divided into two groups based on cardiac catheterization laboratory (CATH) availability: (group I, CATH currently in operation, Monday to Friday, 7 am to 7 pm and group II, CATH currently not in-operation, all other times). Fifty-two patients with AMI met entry criteria. Patients were treated with thrombolytic therapy in 25 cases; PTCA in 27 cases. Patients received thrombolytic agents within statistically equivalent time intervals regardless of the period of presentation; time to thrombolytic therapy for group I patients was 38 +/- 16 minutes compared with 36 +/- 26 minutes for group II patients (P =. 891). A trend toward significance was noted in the use of PTCA compared with thrombolytic agent; Group I patients were more often treated with PTCA (19) compared with group II patients (11, P =.067). Patients were more rapidly treated with PTCA during CATH operation; the mean time to PTCA for group I patients was 73.5 minutes compared with PTCA for group II patients with 107.8 minutes (P =.033). The consideration for PTCA did not significantly delay the administration of thrombolytic therapy at the study site institution. PTCA was initiated more rapidly in patients presenting with AMI during hours of CATH operation.     

Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: Impact on in-hospital times to thrombolysis in a rural community hospital

Because the benefits from thrombolytic therapy in acute myocardial infarction (AMI) are time dependent, multiple strategies have been devised to speed therapy. This study sought to determine whether hospital-based nurse and paramedic advanced life support (ALS) providers could be trained to independently evaluate (sight read) a prehospital 12-lead electrocardiogram (ECG) for the presence of AMI as part of a protocol designed to speed in-hospital administration of thrombolytic agents. Providers were required to determine on the basis of a protocol (1) whether or not AMI was present, and (2) whether or not thrombolytic therapy was indicated. Providers then radioed their impression to the emergency department (ED) and initiated a protocol to prepare identified candidates for thrombolysis. The final decision to initiate thrombolytic therapy was made by the ED physician after patient arrival at the hospital. One hundred fifty-five patients with chest pain were studied. Twenty-one (13.5%) were ultimately proven in-hospital to have AMI. Providers were able to recognize AMI in 17 of 21. Four of 21 did not meet ECG criteria for AMI on the field ECG, but were categorized as having a high index of suspicion for AMI by providers. There were no false-positive diagnoses. Fourteen patients (9%) received thrombolytic therapy. In-hospital times to administration of thrombolytic therapy decreased to an average of 22 ± 13.8 minutes in the studied group compared with a historical control group average of 51 ± 50 minutes. It is concluded that hospital-based paramedics and nurses can successfully be taught to evaluate (ie, sight read) a prehospital ECG for the presence of AMI with accuracy. A prehospital chest pain protocol using a field ECG can speed in-hospital administration of thrombolytic therapy to the extent that field administration of thrombolytic agents may not significantly improve times to administration of therapy when transport times are similar to those of this study.     

院外静脉溶栓救治急性心肌梗死

目的:使急性心肌梗死(AMI)患者得到良好的临床治疗效果,并探讨院外AMI患者溶栓治疗的可行性、安全性.方法:连续观察发病≤6小时的120例在院外给予静脉溶栓的AMI 患者,其中发病≤3小时内溶栓者91例,发病4～6小时溶栓者29例,对比两者的冠状动脉(冠脉)再通率;同时与同期住院治疗的120例AMI患者比较.结果:再通率:≤3小时溶栓者68.13%,4～6小时溶栓者58.33%,两者比较差异显著,P<0.005.确诊为AMI距接受溶栓时间:院外组为(0.54±0.58)小时, 院内组为(2.74±1.02)小时;2组比较P<0.000 1.院外AMI诊断准确率达98.4 %,无一例死亡.结论:急性心肌梗死院外静脉溶栓能减少不必要的耽搁时间,溶栓时间越早,冠脉再通率越高;院外溶栓治疗安全、可行.     

Effect of Continuous Quality Improvement Methods on Reducing Triage to Thrombolytic Interval for Acute Myocardial Infarction

Objectives: To assess the timeliness of thrombolytic therapy in the ED for selected patients with acute myocardial infarction (AMI) following continuous quality improvement (CQI) interventions.
Methods: A retrospective, historical comparison study was performed of triage-to-thrombolytic time intervals for AMI patients using chart review for data collection. Patients treated after implementation of the CQI process vs a historical control group were compared. The patients with AMI who had received thrombolytics during the one-year period prior to the CQI interventions and who had documentation of time intervals served as the control group. The patients treated during a four-month period, beginning about one and a half years following introduction of the CQI interventions, served as the intervention group. Interventions included: a triage protocol, CQI review, and staff feedback.
Results: The mean triage-to-thrombolytic interval was longer for the control group (72 ± 25 vs 40.0 ± 22 min; p < 0.0001). The mean triage-to-ECG interval also was longer for the control group (16.5 ± 8.9 vs 8.5 ± 7.5 min; p < 0.0001). Most (79%) of the study group received thrombolytic therapy within 60 minutes, and 39% within 30 minutes, whereas 39% of the control group received thrombolytic therapy within 60 minutes, and 3% within 30 minutes.
Conclusion: The implementation of CQI techniques, including 100% chart review, intensive systems analysis, and staff feedback, had a positive effect on the timeliness of thrombolytic therapy for the ED patients who had AMI. As a result, most (79%) of the patients received therapy within the 60-minute time window recommended currently by the American Heart Association.     

老年急性心肌梗死溶栓治疗相关因素分析

目的；分析影响老年急性心肌梗死（AMI）溶栓治疗的因素，提高溶栓使用率。方法：回顾性分析老年AMI患者313例，对其治疗状况进行全面分析研究。结果：313例老年AMI患者溶栓治疗81例，溶栓率为25．87％，未溶栓率为74．13％，未溶栓232例中，有52例（22．41％）适合于溶栓而未溶栓，未行溶栓治疗的原因：年龄＞70岁，占23．08％，来诊时间＞6h,占21．15％，无胸痛有精神症状改变占13．46％及其它原因等。结论：许多适合于溶栓治疗的患者未得到溶栓治疗，其主要原因是临床决策造成的。临床医生的正确决策可能提供更多的溶栓治疗的机会。     

急性心肌梗死溶栓治疗时间延误原因分析及对策

目的：为探讨AMI患者溶栓治疗前时间延误原因及对策。方法：采用自行设计的问卷对47例AMI患者进行溶栓治疗的调查，同时对100名急诊科和CCU护士对急性心肌梗死治疗的认知程度进行调查，结果：溶栓治疗的院外延误时间为165min（自身延误129min，交通延误36min），院内延误126min（急诊室78min，CCU延误48min）；47例患者中仅有7例（14．9％）对AMI和溶栓的知识有所了解。CCU护士对AMI溶栓认识程度显著好于急诊室护士。结论：加强AMI患者了AMI和溶栓知识的了解，以及对医护人员的培训，可减少病死率和致残率。     

Effects of EMS transportation on time to diagnosis and treatment of acute myocardial infarction in the emergency department

INTRODUCTION. Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography. PURPOSE. Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)? DESIGN. Retrospective, case-control study. POPULATION. The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992. METHODS. Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using "Student's" t-test and Yates corrected Chi-square. RESULTS. Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 +/-9.1 min. versus 20.8 +/-25.3 min.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 +/-31.5 min. versus 78.0 +/-63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups. CONCLUSION. Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions.(ABSTRACT TRUNCATED AT 250 WORDS)     

35例心肺复苏后急性心肌梗死患者静脉溶栓治疗的分析

目的：观察心肺复苏（ＣＰＲ）后急性心肌梗死（ＡＭＩ）患者静脉溶栓的疗效及存在的问题。方法：对３５例ＣＰＲ后ＡＭＩ患者（ＣＰＲ组）尿激酶静脉溶栓治疗情况进行回顾性分析,并与同期４２例无ＣＰＲＡＭＩ患者（对照组）静脉溶栓情况进行对比分析。结果：ＣＰＲ组发病至心脏停搏时间平均为（８４．０±３３．６）分钟,ＣＰＲ时间（７．７±３．０）分钟,平均溶栓时间为（９３．６±４８．８）分钟〔与对照组（１６３．１±６９．２）分钟比较,Ｐ＜０．００１〕;冠脉再通率为７４．３％（与对照组６６．７％比较,Ｐ＞０．０５）,ＣＰＲ组无一例发生胸内出血,但有８例（２２．９％）发生上消化道出血,其中１例严重出血（与对照组上消化道出血７．１％比较,Ｐ＜０．０５）。结论：对ＣＲＰ成功后无创ＡＭＩ患者迅速进行静脉溶栓治疗不仅安全有效,而且可适当扩大溶栓治疗的“时间窗”;ＣＰＲ后需注意预防机体应激性反应,尤其是上消化道出血的发生。     

Thrombolytic therapy in acute myocardial infarction at the pre-hospital stage

Mobile teams of the Leningrad Emergency Station came to use prehospital thrombolytic therapy (TT) for acute myocardial infarction (AMI) in 1986. The trial reported includes three groups of AMI patients: group I of 67 patients received avelysin in a dose of 0.5 mln FU, group II of 35 patients received celyase in a dose of 1 mln FU, group III consisted of 47 control subjects. The analysis of the treatment results showed that intravenous infusion of avelysin enabled myocardial reperfusion in 49.3% of cases while that of celyase in 5.7% (noninvasive data). High effectiveness of avelysin is inferred as well as safety of systemic TT at prehospital stage of AMI.     

临床护理路径在急性心肌梗死患者溶栓治疗中的应用

目的了解临床护理路径在急性心肌梗死患者溶栓治疗中的应用效果。方法将2005年1月-2006年12月收治的149例急性心肌梗死患者，采用匹配对照方法分为对照组72例、实验组77例，对照组入院后按常规的急救护理措施，实验组应用临床护理路径对患者进行急救护理，观察两组患者人院至溶栓治疗时间、治疗成功率、出血发生率等指标。结果实验组与对照组患者人院至溶栓治疗时间分别为（23±5．2）min与（66±12．3）min，两组比较，差异有统计学意义（P〈0．05）；实验组与对照组尿激酶溶栓成功率分别为62．3％与44．4％，两组比较，差异有统计学意义（P〈0．05）。结论临床护理路径在急性心肌梗死患者中的应用可缩短溶栓治疗时间，提高治疗成功率，同时也提高了工作效率及护理质量。     

Delays in thrombolytic therapy for acute myocardial infarction: association with mode of transportation to the hospital, age, sex, and race.

BACKGROUND: Although increased myocardial salvage and reduced mortality are associated with timely thrombolytic therapy for acute myocardial infarction, some patients still experience delays in treatment. OBJECTIVES: To examine treatment times in patients with acute myocardial infarction treated with thrombolytic therapy and to determine whether delays in treatment are associated with mode of transportation to the hospital, age, sex, or race. METHODS: Medical records of 176 patients with acute myocardial infarction treated with thrombolytic therapy at a community hospital were reviewed and analyzed retrospectively. RESULTS: Median times for the interval between arrival at the hospital and acquisition of a diagnostic electrocardiogram (door-to-electrocardiography time) and the interval between arrival and start of thrombolytic therapy (door-to-drug time) were 6 minutes and 34 minutes, respectively. However, 76.1% of the patients met the recommendation of the American College of Cardiology/American Heart Association of door-to-electrocardiography time of 10 minutes, and 47.2% met the recommendation of door-to-drug time of 30 minutes or less. Door-to-drug times did not differ significantly according to race or mode of transportation to the hospital. Door-to-electrocardiography and electrocardiography-to-drug times were significantly longer for older patients than for younger patients (P = .005 and P < .001, respectively), and electrocardiography-to-drug times were significantly longer for females than for males (P = .01). CONCLUSIONS: With increased emphasis on recognition and rapid treatment of patients with acute myocardial infarction at highest risk for delays in treatment, that is, women and the elderly, benefits of thrombolytic therapy might be maximized.     

Prehospital selection of patients for thrombolysis by paramedics

Method: Paramedics from rural Wales were trained in the acquisition and recognition of 12 lead ECGs, and also in the modified indications for thrombolytic therapy as defined by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Ninety six consecutive patients, with possible myocardial infarction, were included in the study. The paramedics made an independent decision regarding the eligibility of the patients for thrombolysis before hospital admission, noting the time that they could have administered the drug. These decisions were compared with the treatment subsequently received in hospital.

Results: No errors were made by the paramedics in case selection (specificity of 100% (95% CI 95.9% to 100%)). There was a potential reduction in call to needle time of 41.2 minutes (95% CI 25.7 minutes to 56.9 minutes, p=0.001).

Conclusions: It was concluded that the paramedic selection of patients for the prehospital administration of a thrombolytic is both feasible and safe.

     

再灌注性心律失常的临床特点与治疗

目的：探讨尿激酶静脉溶栓治疗急性心肌梗死（AMI）再通后发生再灌注性心律失常（RA）的特点。评价镁剂对RA的治疗。方法：将107例AMI住院患者全部地扩酶静脉溶栓治疗,然后将其分成A组（50例）和B组（57例）;B组在溶栓治疗前20分钟静脉注入镁剂。结果：两组溶栓患者根据临床判定标准判定再通69例,再通率为64．49％。溶栓前发生心律失常36例。A组31例再通患者中25例发生RA,B组38例再通患者中13例发生RA（P＜0．01）。结论：RA是AMI溶栓治疗成功后的重要并发症,表现为各种类型,尤以室性RA为主。镁剂对治疗RA有重要作用。     

不同方法治疗急性心肌梗死患者血清CK、CK-MB水平及疗效比较

目的 探讨急性心肌梗死溶栓治疗与普通治疗后血清心肌酶学指标的变化情况.方法 检测并分析接受溶栓治疗(实验组)或普通治疗(对照组)急性心肌梗死患者血清肌酸激酶(CK)、肌酸激酶同工酶MB(CK-MB)水平.结果 实验组与对照组治疗前血清CK、CK-MB检测结果差异无统计学意义(P＞0.05),治疗12 h后检测结果差异有...     

Serial Electrocardiograms for Chest Pain Patients with Initial Nondiagnostic Electrocardiograms: Implications for Thrombolytic Therapy

Objectives: To determine the proportion of acute myocardial infarction (AMI) patients without ST–segment elevation who subsequently develop ST–segment elevation during their hospital courses; and to compare demographics and presenting features of AMI patient subgroups: those with initial ST–segment elevation, those with in–hospital ST–segment elevation, and those with no ST–segment elevation. Methods: A retrospective cohort analysis of admitted chest pain patients who had a hospital discharge diagnosis of AM1 was performed. Each chart was examined for initial ECG interpretation, serial ECG analysis, patient age, gender, cardiac risk factors, in-hospital survival, time between sequential ECGs, and number of ECGs performed within the first 48 hours of hospital admission. Results: Of the 114 charts reviewed, 20 patients had ECGs meeting thrombolytic criteria on arrival. Of the 94 AM1 patients who had nondiagnostic ECGs on arrival, 19 (20%) subsequently developed ECG changes meeting thrombolytic criteria. Seven patients developed these changes within eight hours of the initial ECG, four from eight to 12 hours after, two from 12 to 24 hours after, and six more than 24 hours after. Most patients who had documented AMIs did not develop ECG criteria for thrombolytic therapy during their hospitalizations. Male gender and smoking history were more commonly associated with late ST-segment elevation for those presenting with nondiagnostic ECGs. All the patients who had late diagnostic ECG changes survived to hospital discharge. Serial ECGs were performed more frequently in the group who had initially diagnostic ECGs and least frequently in the group who did not develop ST-segment elevation during their hospitalizations. Conclusions: Most patients with AM1 do not meet ECG criteria for the administration of thrombolytic therapy. A significant minority (20%) of the admitted chest pain patients with subsequently confirmed AMIs developed ECG criteria for thrombolytics during their hospitalizations. Further attention to such patients who have delayed ST-segment elevation is warranted. A standardized in-hospital serial ECG protocol should be considered to identify admitted patients who develop criteria for thrombolytic or other coronary revascularization therapy.     

急性心肌梗死溶栓治疗LPO和SOD的动态变化及临床意义

目的 :探讨急性心肌梗死 (AMI)患者尿激酶静脉溶栓前后氧自由基 (OFR)浓度的动态变化及其与再灌注损伤的关系。方法 :接受尿激酶静脉溶栓治疗的 38例AMI患者在溶栓前及溶栓后 2、 6、 12、 2 4h分别取血测定血清中脂质过氧化物 (LPO)、过氧化物歧化酶(SOD) ,依间接指标及溶栓后 90min冠状动脉造影结果 ,将患者分为再通组 ( 2 7例 )和未通组( 11例 ) ,比较两组患者血中上述指标的动态变化 ,并设正常对照组。结果 :AMI患者溶栓前血清LPO、SOD浓度均明显高于对照组 ,溶栓后再通组LPO浓度较溶栓前明显升高 ,SOD则于溶栓早期显著降低 ,6h后逐渐回升至溶栓前水平 ,未通组于溶栓前后无明显变化。结论 :AMI后OFR活性增高 ,早期溶栓再灌注加剧OFR代谢紊乱并导致心肌再灌注损伤 ,溶栓后LPO的异常增高可望成为临床判断血管再通的新指标     

Prehospital thrombolytic treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex

In cooperation with a group of general practitioners (GP), we investigated the possible risk and benefit of prehospital initiation of thrombolytic therapy in acute myocardial infarction (AMI) with anisoylated plasminogen streptokinase activator complex (APSAC) at the patient's home. During a 14-month period, 58 patients with suspected AMI were evaluated by their GP using a protocol with strict inclusion and exclusion criteria. The GP alerted a special mobile intervention team which administered APSAC at home in 13 of the 19 patients. Coronary reperfusion was achieved in ten of these 13 patients. Apart from short and easily treated episodes of bradycardia and/or hypotension after the injection of the thrombolytic drug in four of 13 patients, no major adverse events were noted in the early treatment period. The estimated time gain by treating the patient at home instead of starting the treatment in the coronary care unit was 46 +/- 14 min. Therefore, at-home initiation of thrombolytic treatment seems feasible, fast, and safe.     

急性心肌梗死溶栓治疗血浆GMP-140的动态变化及临床意义

目的：探讨急性心肌梗死（AMI）患者尿激酶溶栓治疗前后血小板活性的动态变化及其与血管早期再通的关系。方法：接受尿激酶静脉溶栓治疗的38例AMI患者在溶栓前及溶栓后2h、6h、12h、24h分别取血测定血浆中α-颗粒膜蛋白（GMP-140），依溶栓前临床间接指标及溶栓后90min冠状动脉造影结果，将患者分为再通组（27例）和未通组（11例），比较两组患者血中GMP-140的动态变化，并设正常对照组。结果：AMI患者溶栓前血浆GMP-140浓度明显高于正常对照组。溶栓后再通组与未通纷呈不同浓度的动态变化，溶栓未通组，GMP-140升高；溶栓再通组，则GMP-140降低，两组溶栓后6h、12h、24h血浆GMP－140浓度差异显著（P＜0．001）。结论：AMI后血小板高度活化，血浆GMP-140与AMI的血栓形成、溶解及再通密切相关，其在溶栓后的迅速下降可望作为临床判断血管再通的新指标。     

Initiation of thrombolytic therapy for patients with acute myocardial infarction by emergency physicians: The Hong Kong experience

Abstract Objectives: To compare door-to-needle time and complications for eligible acute myocardial infarction patients receiving thrombolytic therapy in the emergency department and in the coronary care unit. Methods: A prospective study was performed involving all patients with acute myocardial infarction who received thrombolytic therapy either in the emergency department or the coronary care unit during the period January 1995 to March 1996. Patients’ time interval between registration in ED and receiving thrombolytic therapy (door-to-needle time) was the main audit parameter. Other emergency department information collected included inappropriate administration of thrombolytic therapy and the occurrence and management of complications of thrombolytic therapy. Results: In the United Christian Hospital, Hong Kong, 148 patients with acute myocardial infarction received thrombolysis. Sixty-eight cases (group A) received thrombolysis in the emergency department and 80 cases underwent thrombolysis in the coronary care unit. The 80 cases in the coronary care unit included 47 cases (group B) whose diagnosis of acute myocardial infarction and eligibility for thrombolysis were established in the emergency department, and 33 cases (group C) in which there were difficulties in diagnosis or exclusion of contraindications for thrombolysis. The mean door-to-needle times were 31.3 min in group A (95% CI, 27.6–35.1), 54 min in group B (95% CI, 47.8–60.2) and 171.8 min in group C (95% CI, 121.8–211.8). Inappropriate use of thrombolysis in the emergency department occurred in 2.9% of all cases. The most common complication of thrombolysis in the emergency department was hypotension (4.4%). All cases were successfully managed in the emergency department. There was one case of anaphylaxis during streptokinase infusion that required resuscitation in the emergency department. There were no deaths of patients receiving thrombolysis in the emergency department. Conclusion The initial experience of a regional hospital in Hong Kong supports the view that initiation of thrombolytic therapy in the emergency department can achieve a more favourable door-to-needle time without compromising the care of acute myocardial infarction patients.     

System thrombolytic therapy in acute myocardial infarction in the elderly

The paper presents a retrospective cohort study of the records of 430 patients with myocardial infarction aged 60 to 91. Group I (main group) consisted of 234 patients who received system thrombolytic therapy (TLT); group II (controls) consisted of 196 patients who received conventional therapy. Hospital and long-term lethality, the course of the disease, and the complications of thrombolysis were evaluated. The study found no effect of TLT itself on the end points; there were differences between subgroups with effective and non-effective thrombolysis. Thus, comparison of these variables in patients aged 60 to 74 showed a decrease in the hospital lethality in the main group: 6.6% vs. 20.6% in the control group (p = 0.00072), and an increase in five-year survival (p = 0.0057). Cardiac arrhythmias (CA) and chronic heart failure were much less frequent in group I. Transient hypotension occurred in 36% of patients on thrombolytic therapy; reperfusion-related CA were noted in 25% of patients receiving thrombolysis. There were no cases of serious hemorrhage or cerebral strokes. None of the complications resulted in a lethal outcome. The study demonstrates that TLT is not contra-indicated in the elderly with myocardial infarction; complications are, as a rule, insignificant and easily reversible. When reperfusion is successful, thrombolysis lowers early and long-term lethality and improves the course of the disease in this very complex category of patients.