Early versus late hospital arrival for acute myocardial infarction in the western Washington thrombolytic therapy trials

doi:10.1016/0002-9149(89)91038-2

The American Journal of Cardiology

Volume 63, Issue 18, 1 June 1989, Pages 1296-1300

https://doi.org/10.1016/0002-9149(89)91038-2 Get rights and content

Abstract

In the 3 Western Washington thrombolytic therapy trials, 54.9% of patients with acute myocardial infarction arrived at the hospital within 2 hours of symptom onset. These early arrivers were younger and more likely to be hypotensive and in cardiogenic shock than were patients arriving later. There were decreases in the time from symptom onset to hospital arrival (p = 0.0002) and in the time from hospital arrival to institution of thrombolytic therapy (p <0.0001) in the 8 hospitals that participated in both the Western Washington intravenous streptokinase and tissue plasminogen activator trials from 1983 to 1988. For those patients receiving thrombolysis, early arrival was associated with increased survival (p = 0.031) after adjustment by Cox regression analysis for important clinical predictors of long-term survival. These covariates included pulmonary edema, anterior wall acute myocardial infarction, hypotension and absence of chest pain at hospital arrival. Reductions in barriers to timely administration of thrombolytic therapy can be achieved and can result in improved survival.

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Citation Excerpt :
The first few hours are of utmost importance for limiting infarction size and to prevent cardiac death in patients with acute myocardial infarction (AMI) [1–3].
Time is crucial when an acute myocardial infarction (AMI) occurs, but patients often wait before seeking medical care.
To investigate and compare patients' and relatives' knowledge of AMI, attitudes toward seeking medical care, and intended behaviour if AMI-symptoms occur.
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Both patients and relatives appeared to act more appropriate to someone else's chest pain than to their own. Patients did not have better knowledge of AMI-symptoms than relatives. Women would more often contact someone else before seeking medical care. A greater percentage of elderly (65–75 years), compared to younger individuals, reported that they would call for an ambulance if chest pain occurred.
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One reason could be that these patients had a larger amount of jeopardized myocardium and thus greater pain that urged them to seek medical care sooner compared with patients with less myocardial involvement. In accordance with this reasoning, patients with poor left ventricular function and a resulting higher mortality risk have been shown to have a tendency to seek help soon after symptom onset.17,18 Another possibility is that these patients, for whatever reason, presented sooner and that the degree of ST↑ reflected an earlier stage of MI.
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There was no gender difference in the report of chest pain (χ²(1) = 3.78, p = .052), or in prehospital delay time (median = 96.5 minutes). Thrombolysis was administered in 158 males (68.4%) and 50 females (50.0%) without reported contraindication. Females (median = 27 minutes) had a significantly longer interval between diagnostic electrocardiogram (ECG) and administration of a thrombolytic than males (median = 22, U = 3,056). No contraindication was indicated for not administering a thrombolytic (i.e., too late, risk of bleed) in approximately 40% of females. In accordance with clinical practice guidelines, thrombolysis was more often administered in participants with a shorter time interval between symptom onset and hospital arrival. For females, thrombolysis was more often administered in younger participants (Kruskal Wallis = 5.88).
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Ischemic heart disease is the major cause of death, disability and lost productivity in the developed countries of the world. The evolution of cardiac care units has improved patient survival from myocardial infarctions, but requires a high-tech, very expensive treatment facility. Chest pain centers, located in emergency departments, present an efficient alternative to triage patients with chest pain, providing prompt and accurate diagnosis, risk evaluation and appropriate treatments. Hospitals benefit from this cost-effective approach as resources are used more efficiently, and patients benefit from a supportive treatment facility that focuses on early intervention. Early recognition of prodromal unstable angina symptoms and intercession with newly developed treatment can help move the cardiologist toward a more proactive role that minimizes or avoids myocardial infarctions rather than reacting to the acute event.
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View full text

Early versus late hospital arrival for acute myocardial infarction in the western Washington thrombolytic therapy trials

Abstract

JACC

Am J Cardiol

Am J Cardiol

JACC

Am Heart J

Am J Med

JAMA

Circulation

Effectiveness of intravenous thrombolytic therapy in acute myocardial infarction

Lancet

A prospective trial of intravenous streptokinase in acute myocardial infarction (ISAM): mortality, morbidity, and infarct size at 21 days

N Engl J Med

Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected myocardial infarction: ISIS-2

Lancet

Western Washington Randomized Trial of Intracoronary Streptokinase in Acute Myocardial Infarction

N Engl J Med