Influences on general practitioners' use of pre-hospital thrombolysis: a qualitative study

BACKGROUND: The aim of the study was to determine factors influencing general practitioners' (GPs') decisions to provide pre-hospital thrombolysis for acute myocardial infarction. METHODS: Semi-structured, face-to-face interviews were carried out with 21 GPs in Grampian (10 rural; 11 urban). RESULTS: The GPs believed that thrombolysis has an important role in the management of acute myocardial infarction, but urban practitioners were not convinced that time savings could be made by GP provision. Practical issues such as taking an electrocardiogram, ascertaining contra-indications in patients, maintaining skills, equipment, and workload were barriers preventing the provision of pre-hospital thrombolysis. There was a sense that primary care needed to feel that it is initiating change rather than having change thrust upon it. CONCLUSION: Decision-making processes in primary care are complex, even when the evidence supporting change is strong. Health service planners wishing to implement successful change need to consider other issues such as practical matters, support structures, current morale and practitioner perceptions of control.     

院前急救护理干预对急性心肌梗死患者的应用效果

目的探讨院前急救护理干预对急性心肌梗死患者的临床应用效果。方法入选2009年3月至2013年3月我中心急救组分布据点的80例急性心肌梗死患者作为研究对象,根据送院方式分为院前急救护理干预组（观察组,我中心急救车送入医院）40例和对照组（家属直接送入医院）40例,通过对我中心院前急救组分布据点院前急救后预后情况跟踪随访对比两组患者的血管再通率、死亡率、抢救时间和住院时间、护理质量满意度。结果两组患者血管再通率组间差异有统计学意义,P〈0．05;观察组死亡率明显低于对照组。但差异无统计学意义,P〉0．05;对比两组溶栓时间和抢救时间,组间差异有统计学意义,P〈0．05：两组护理质量满意度差异有统计学意义,P〈0．05。结论院前急救护理干预可以明显提高患者的临床疗效及护理质量满意度．有效提高血管再通率,降低死亡率和减少抢救时间,值得临床推广应用。     

Integrating partner professionals. The Early Explorers project: Peers Early Education Partnership and the health visiting service

Background A range of voluntary sector organizations are involved in the delivery of services to children, particularly within the Early Year's sector and children's centres. Peers Early Education Partnership (PEEP) Early Explorers project is one example of the way in which explicit partnerships are being forged across statutory and voluntary sectors with the aim of improving outcomes for children and families. This paper reports an exploration of stakeholder views and experiences of two Early Explorer clinics located in areas of high deprivation. Methods Semi‐structured interviews were conducted with a purposive sample of stakeholders (n= 25) from children's centres, PEEP, the health visiting service and service users. Data were fully transcribed and analysed using a thematic approach. Results The data suggest that the two key groups of stakeholders providing Early Explorer clinics (i.e. health visitors and PEEP practitioners) had quite different objectives in terms of their early goals for the clinic, but that despite these differences good progress was achieved in terms of working together effectively. All stakeholders including service users referred to the presence of PEEP as having improved the quality of the clinic environment, and participating mothers identified a wide range of benefits from the enhanced service. However, somewhat restricted views about the role of practitioners within the clinics were identified by users, and the findings suggest that although the early goals for the clinic had been exceeded, these may have been limited in terms of true ‘partnership’ working. Conclusions Early Explorer clinics appeared to have enhanced the service provided within traditional child health clinics and to have provided practitioners with access to hard‐to‐reach families and parents with access to services that are consistent with the broader policy aims of improving parent–infant interaction. However, questions remain as to whether the benefit of ‘partnership’ working was fully realized.     

An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction

BACKGROUND: The aim of the study was to audit the impact of cardiac nurse practitioner led thrombolysis as a method of reducing call to needle times for acute myocardial infarction (AMI) in a single district hospital. METHODS: This was a prospectively planned, observational study, comparing time delay between arrival at hospital and the administration of thrombolysis ('door to needle' time) in patients presenting with AMI in a district general hospital serving a population of 270000. The 6 months before and 6 months after initiation of the scheme were compared. RESULTS: There were 151 consecutive patients (undergoing 163 thrombolysis episodes). The median door to needle time fell from 60 min (range 42-110 min) to 30 min (range 20-61 min) (p<0.01). In those patients eligible for immediate thrombolysis the number of cases treated within 30 min of arrival rose from 10/58 (17 per cent) to 48/64 (75 per cent) (p<0.01). The proportion of cases where there was an initial delay as a result of non-diagnostic ECG or possible contra-indication to therapy remained constant, 20/78 (25 per cent) cases before and 21/85 (25 per cent) cases after initiation of the scheme. The number of cases of inappropriate thrombolysis fell from 73 per cent to 30 per cent. CONCLUSION: The provision of i.v. thrombolysis by cardiac nurse practitioners is safe and should be considered as a method for achieving acceptable door to needle times in the management of acute myocardial infarction.     

The relation between socioeconomic status and short-term mortality after acute myocardial infarction persists in the elderly: results from a nationwide study

We assessed whether the previously observed relationship between socioeconomic status (SES) and short-term mortality (pre-hospital mortality and 28-day case-fatality) after a first acute myocardial infarction (AMI) in persons <75?years, are also observed in the elderly (i.e. ≥75?years), and whether these relationships vary by sex. A nationwide register based cohort study was conducted. Between January 1st 1998 and December 31st 2007, 76,351 first AMI patients were identified, of whom 60,498 (79.2?%) were hospitalized. Logistic regression analyses were performed to measure SES differences in pre-hospital mortality after a first AMI and 28-day case-fatality after a first AMI hospitalization. All analyses were stratified by sex and age group (<55, 55-64, 65-74, 75-84, ≥85), and adjusted for age, ethnic origin, marital status, and degree of urbanization. There was an inverse relation between SES and pre-hospital mortality in both sexes. There was also an inverse relation between SES and 28-day case-fatality after hospitalization, but only in men. Compared to elderly men with the highest SES, elderly men with the lowest SES had a higher pre-hospital mortality in both 75-84?year-olds (OR?=?1.26; 95?% CI 1.09-1.47) and ≥85?year-olds (OR?=?1.26; 1.00-1.58), and a higher 28-day case-fatality in both 75-84?year-olds (OR?=?1.26; 1.06-1.50) and ≥85?year-olds (OR?=?1.36; 0.99-1.85). Compared to elderly women with the highest SES, elderly women with the lowest SES had a higher pre-hospital mortality in ≥85?year-olds (OR?=?1.20; 0.99-1.46). To conclude, in men there are SES inequalities in both pre-hospital mortality and case-fatality after a first AMI, in women these SES inequalities are only shown in pre-hospital mortality. The inequalities persist in the elderly (≥75?years of age). Clinicians and policymakers need to be more vigilant on the population with a low SES background, including the elderly.     

院前疑诊急性冠状动脉综合症患者病因及死因分析

目的：了解院前疑诊急性冠状动脉综合症（ACS）患者病因及死因,以提高医疗防治水平.方法：2004年1月～2005年10月,因疑诊ACS由我院120出车接诊患者,回顾性分析接诊记录及住院病历.结果：院前疑诊ACS患者292例,ACS156例,其它心血管疾病88例,其它疾病48例.前8位病因是急性心肌梗死（AMI,29.5%）、不稳定性心绞痛（UA,24.0%）、高血压（7.2%）、心律失常（6.2%）、主动脉夹层（4.8%）、心力衰竭（4.1%）、气胸（3.8%）,未确诊者（4.1%）.总死亡30例,AMI12例,主动脉夹层9例,未确诊者5例,其它4例.结论：AMI是本地区疑诊ACS患者的首位病因,死亡例数最多;主动脉夹层发病率排第5位,但死亡率最高;应加强社区冠心病、高血压知识宣传与教育.     

ISIS 4: Clinical Controversy Regarding Magnesium Infusion, Thrombolytic Therapy, and Acute Myocardial Infarction

Magnesium (Mg) infusions over 24 hours were given to patients with suspected acute myocardial infarction (AMI) at least 2 hours after thrombolysis. Patients showed no benefit and even some increased risk in contrast to reduction in mortality obtained by Mg therapy in smaller trials. Results of all of the studies were pooled and statistically analyzed, according to a fixed-effects model that is inappropriate for studies of different protocols. The panel concluded that further study of Mg in AMI is not needed. This conclusion has been questioned.     

急性心肌梗死后合并心源性休克的相关危险因素分析

[目的]从急性心肌梗死(acute myocardial infarction,AMI)患者中筛选出心源性休克(cardiogenic shock,CS)的相关危险因素,为临床医生和预防医学工作者提供参考依据。[方法]以1994～2004年中山大学和昆明医学院两所附属医院的2173例ST段抬高型AMI患者为研究对象,以是否发生CS为应变量,以患者的病史、性别、年龄、家族史、生活习惯和入院时的体检指标、治疗情况等指标为自变量,建立logistic回归模型,从而筛选出与CS密切相关的有价值的临床指标。[结果]年龄、性别、体重指数、心功能分级、心梗部位、外周动脉疾病、既往心梗病史、心血管病家族史,以及不接受溶栓治疗是与CS相关的9项危险因素。有心血管病家族史者发生CS的风险比无心血管病家族史者升高约43倍。未接受溶栓以及溶栓不成功者发生CS的可能性比溶栓成功者高15倍。在溶栓成功者中,41%的人在症状发作后6h内接受溶栓治疗;而在溶栓不成功者中,56%的人在症状发作超过12h才开始溶栓。[结论]AMI症状发作后早期接受溶栓治疗能大大减少CS的发生,早期溶栓治疗可作为中国老年人群CS第三级预防的一个有效手段。     

急性心肌梗死患者溶栓治疗后心电图早期T波倒置、BNP变化对左室重构的意义

目的观察急性心肌梗死患者接受静脉溶栓治疗后心电图T波倒置、血浆中BNP的水平变化与左室重构之间的关系,探讨T波倒置、BNP对左室重构的预测价值。方法首次急性心肌梗死患者共54例,溶栓治疗后持续24h监测心电图,A组(溶栓治疗后24小时出现T波倒置,n=38)与B组(溶栓治疗后24小时T波仍直立,n=16)于治疗前及治疗后第7天,采用电化学发光法对血浆BNP水平进行检测,并随访复查急性心肌梗死后2~3天及第3个月超声心动图。结果溶栓治疗后BNP水平,A组明显小于B组;A组内治疗前后BNP比较,治疗后明显减小;B组治疗后BNP水平明显增加。A组患者溶栓治疗后2~3天及3个月时LVEDD比较,差异无显著性;B组患者溶栓治疗后3个月时LVEDD明显增大,B组左室重构发生率明显高于A组。结论急性心肌梗死患者溶栓治疗后心电图早期T波倒置和BNP水平降低对于预测左室重构有重要意义。     

80岁以上高龄老人急性心肌梗死溶栓治疗的临床探讨

目的 探讨80岁以上高龄老人ST段抬高的急性心肌梗死(AMI)静脉溶栓治疗的疗效和安全性。方法 使用尿激酶(UK)静脉溶栓治疗80岁以上的AMI患9例。观察疗效及随访资料。结果 间接指标表明9例80岁以上的高龄老人AMI静脉溶栓成功，梗死相关血管(IRA)再通。结论 80岁以上的高龄老人AMI在无绝对禁忌证时，采用个体化给药进行静脉溶栓是相对安全、有效的。     

An Australian comparison of specialist care of acute myocardial infarction.

OBJECTIVE: To determine whether patients hospitalized with acute myocardial infarction (AMI) in an Australian setting receive better pharmacological care if managed by cardiologists than by non-cardiologists. DESIGN: Retrospective chart review of patients hospitalized between 1 January 1997 and 30 June 1998, undertaken by abstractors blind to study objectives. SETTING: One tertiary and two community hospitals in south-east Queensland, Australia, in which all patients admitted with AMI were cared for by cardiologists and general physicians, respectively. STUDY PARTICIPANTS: Two cohorts of consecutive patients satisfying diagnostic criteria for AMI: 184 in the tertiary hospital and 207 in the community hospitals. MAIN OUTCOME MEASURES: Frequency of use, in highly eligible patients, of thrombolysis, beta-blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, lipid-lowering agents, nitrates, and calcium antagonists. Cohorts were compared for differences in prognostic factors or illness severity. RESULTS: In community hospital patients, there was greater use of thrombolysis [100% versus 83% in the tertiary hospital; difference 17%, 95% confidence interval (CI) 11-26%; P < 0.001] and of ACE inhibitors (84% versus 66%; difference 18%, 95% CI 3-34%; P = 0.02), and lower median length of stay (6.0 days versus 7.0 days; P = 0.001) compared with tertiary hospital patients. Frequency of use of other drugs, and adjusted rates of death and re-infarction were the same for both cohorts. CONCLUSIONS: With respect to pharmacological management of patients hospitalized with AMI, cardiologists and general physicians appear to provide care of similar quality and achieve equivalent outcomes. Further studies are required to confirm the generalizability of these results to Australian practice as a whole.     

Concentrating stroke care provision in the Czech Republic: The establishment of Stroke Centres in 2011 has led to improved outcomes

This article describes policy processes that have led to the re-organisation of stroke care in the Czech Republic since 2011, which has been part of a broader process of care concentration in several medical fields. Currently, stroke care is provided by 13 Comprehensive and 32 Primary Stroke Centres. The paper explains factors that supported the reform implementation, reviews implications, and discusses future challenges.Mandatory reporting of quality indicators, the introduction of a benchmarking system, integration with pre-hospital emergency care, and the introduction of countrywide patient triage have supported more timely treatment for stroke patients and better quality of care. Data from the Stroke Care Quality Indicators of the Czech Stroke Society show positive trends in many areas: the number of patients treated with intravenous thrombolysis quadrupled in eight years, with 26.4 % of all acute stroke patients receiving thrombolysis in 2018. Czech Republic now ranks third in Europe in the number of thrombolysis per population and second in the number of mechanical thrombectomies per population. The Czech experience provides an example of positive outcomes of concentrated stroke care, while highlighting the importance of proper implementation processes. In particular, it is essential to involve stakeholders and to provide reputational incentives through continuous benchmarking.     

炎性细胞因子在急性心肌梗死溶栓治疗中的变化及预后影响研究

目的 探讨炎性细胞因子C反应蛋白(CRP)、白细胞介素(IL)-6、肿瘤坏死因子(TNF)-α及白细胞(WBC)计数在急性心肌梗死(AMI)溶栓治疗与未溶栓治疗中的差异,及其与预后的相关性.方法 将229例AMI患者按是否接受静脉溶栓治疗分为溶栓组(131例)及未溶栓组(98例),分别于入院即刻、入院后6h、入院后24h抽血测定心肌肌钙蛋白I(cTnI)、肌酸激酶(CK)、肌酸激酶同工酶-MB(CK-MB),于入院次日晨抽血测定CRP、IL-6、TNF-α、WBC计数.随访6个月,比较两组患者预后的差异.结果 溶栓组失访27例.溶栓组6个月内死亡1例,病死率为1.0％(1/104),未溶栓组死亡6例,病死率为6.1％(6/98),两组6个月内病死率比较差异有统计学意义(P＜0.05).溶栓组CK、CK-MB峰提前,差异有统计学意义(P＜0.05).溶栓组TNF-α、IL-6水平较未溶栓组升高,与未溶栓组比较,差异有统计学意义(P＜0.05),两组CRP、WBC计数水平比较差异无统计学意义(P＞ 0.05).溶栓组中再通104例,再通率为79.4％( 104/131),再通患者TNF-α、IL-6水平显著高于未通患者,差异有统计学意义(P＜0.05).结论 溶栓患者TNF-α、IL-6水平升高可能与再灌注损伤相关,亦提示为心肌坏死本身的炎性反应,检测CRP、IL-6、TNF-α、WBC计数对AMI患者预后的判断有临床意义,抗炎、抗氧化治疗对改善AMI预后有重要意义.     

Audit of thrombolysis initiated in an accident and emergency department.

Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment.     

早期尿激酶静脉溶栓治疗急性心肌梗死68例临床观察

目的探讨早期激酶静脉溶栓治疗急性心肌梗死的临床疗效及安全性。方法将68例AMI患者采用早期使用尿激酶溶栓治疗静脉再通溶栓治疗,并与68例AMI患者的常规治疗作对照。观察溶栓治疗患者的再通情况及其溶栓后24小时内T波倒置对判定冠脉再通的意义。结果尿激酶观察组与对照组的冠脉再通率分别为66.2%和16.2%,两组再通率差异有统计学意义(P<0.05),发病至开始溶栓时间越短,再通率越高。结论早期尿激酶溶栓治疗可提高急性心肌梗死疗效,降低死亡率。ST-T改变和T波倒置具有判断闭塞冠脉的临床价值。     

早期尿激酶静脉溶栓治疗急性心肌梗死68例临床观察

目的探讨早期激酶静脉溶栓治疗急性心肌梗死的临床疗效及安全性。方法将68例AMI患者采用早期使用尿激酶溶栓治疗静脉再通溶栓治疗,并与68例AMI患者的常规治疗作对照。观察溶栓治疗患者的再通情况及其溶栓后24小时内T波倒置对判定冠脉再通的意义。结果尿激酶观察组与对照组的冠脉再通率分别为66．2％和16．2％,两组再通率差异有统计学意义（P〈0．05）,发病至开始溶栓时间越短,再通率越高。结论早期尿激酶溶栓治疗可提高急性心肌梗死疗效,降低死亡率。ST-T改变和T波倒置具有判断闭塞冠脉的临床价值。     

Sex differences in risk factors, treatment and mortality after acute myocardial infarction: an observational study

BACKGROUND: Coronary heart disease is the major cause of death of postmenopausal women in industrialised countries. Although acute myocardial infarction (AMI) affects men in greater numbers, the short-term outcomes for women are worse. In the longer term, studies suggest that mortality risk for women is lower or similar to that of men. However, length of follow up and adjustment for confounding factors have varied and more importantly, the association between treatment and outcomes has not been examined. STUDY OBJECTIVE: To investigate the association between sex differences in risk factors and hospital treatment and mortality after AMI. DESIGN: A prospective observational study collecting demographic and clinical data on cases of AMI admitted to hospitals in Yorkshire. The main outcome measures were mortality status at discharge from hospital and two years later. SETTING: All district and university hospitals accepting emergency admissions in the former Yorkshire National Health Service (NHS) region of northern England. PARTICIPANTS: 3684 consecutive patients with a possible diagnosis of AMI admitted to hospitals in Yorkshire between 1 September and 30 November 1995. MAIN RESULTS: AMI was confirmed by the attending consultant for 2196 admissions (2153 people, 850 women and 1303 men). Women were older and less likely than men to be smokers or have a history of ischaemic heart disease. Crude inhospital mortality was higher for women (30% versus 19% for men, crude odds ratio of death before discharge for women 1.78, 95% confidence intervals 1.46, 2.18, p=0.00). This difference persisted after adjustment for age, risk factors and comorbidities (adjusted OR 1.29, 95% CI 1.04, 1.63, p=0.02), but was not significant when treatment was taken into account. Women were less likely to be given thrombolysis (37% versus 46%, p<0.01) and aspirin (83% versus 90%, p<0.01), discharged with beta blockers (33% versus 47%, p<0.01) and aspirin (82% versus 88% p<0.01) or be scheduled for angiography, exercise testing or revascularisation. Adjustment for age removed much of the disparity in treatment. Crude mortality rate at two years was higher for women (OR 1.81, 95%CI 1.41, 2.31, p=0.00). Age, existing risk factors and acute treatment accounted for most of this difference, with treatment on discharge having little additional influence. CONCLUSIONS: Patients admitted to hospital with AMI should be offered optimal treatment irrespective of age or sex. Women have a worse prognosis after AMI and under-treatment of older people with aspirin and thrombolysis may be contributing to this.