Delay in calling for help for chest pain

EDITOR—We agree with the central message of Rawles et al's article, that for patients with acute myocardial infarction the first medical attendant has the ideal opportunity to provide early thrombolysis.1 Rawles et al show the massive reduction in call to needle times achieved when thrombolysis is given by the general practitioner who first attends the patient.

We audited the provision of thrombolysis in Sheffield between 1996 and 1997, and there are striking differences between our results and those of Rawles et al. The policy of Sheffield District Health Authority is to encourage patients with chest pain to call an ambulance; general practitioners are encouraged to facilitate immediate transfer to hospital and not to delay this until after visiting the patient.

Rawles et al found that 32% of patients in urban areas with acute myocardial infarction called an ambulance rather than their general practitioner. In Sheffield, 80.3% of patients called an ambulance, with a median interval between onset of pain and ambulance call of 79.5 minutes; this increased to 156.5 minutes for patients receiving a prior visit from their general practitioner.

The shortest door to needle times occurred in patients thrombolysed within the accident and emergency department (median 41.5 minutes, 58 patients); if patients were transferred to a coronary care unit before thrombolysis, the median door to needle time increased to 70 minutes (76 patients). Patients referred by their general practitioners directly to medical wards had the longest door to needle times (median 75.5 minutes, 13 patients).

The audit standard for call to needle time was achieved in 64% of our patients who called an ambulance, were taken to the accident and emergency department and were thrombolysed in the department by their first medical attendant. When patients were taken from the department to a coronary care unit before thrombolysis, the …