EDITOR, - In his assimilation of general practitioners' views on prehospital thrombolysis John Rawles fails to look in detail at the subgroup from whom we are most likely to gain an interesting insight - namely, those general practitioners who took part in the Grampian region early anistreplase trial.1 Only 25 of the 87 doctors who took part in the study (a study which he suggests shows that the efficacy of thrombolysis is doubled when it is given before admission to hospital) identified themselves as current users of thrombolysis. Why did the remaining doctors stop using this treatment?

Rawles's main conclusions are that general practitioners feel the need to be better educated and value the input of local cardiologists in establishing protocols and management guidelines. I would have thought that those general practitioners who took part in the Grampian study had been sufficiently well educated and supported by local cardiologists. Why, when these two barriers to use have been removed and the case for the effectiveness of the treatment has been well made, do large numbers of general practitioners feel unable to change their behaviour? Has it anything to do with the cost of the treatment? Given that the second international study of infarct survival suggests that aspirin is as effective as streptokinase, perhaps the role of general practice should be to ensure that this safer treatment is started as soon as possible.

It is disconcerting to find that 22% of the general practitioners who gave thrombolytic drugs felt confident of doing so without recourse to electrocardiography and that 45% were happy to give them despite having no access to a defibrillator. The users also reported, on average, over 50% more cases of suspected myocardial infarction than non-users (5.27 v 3.30). …