title: Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy.
abstract: OBJECTIVE
  To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history.
  
  
  METHODS
  Retrospective chart review.
  
  
  METHODS
  A large community-based hospital.
  
  
  METHODS
  All patients with acute myocardial infarction hospitalized during a 27-month period.
  
  
  METHODS
  Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy.
  
  
  RESULTS
  The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria.
  
  
  CONCLUSIONS
  Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.
authors.affiliation: William Beaumont Hospital, Royal Oak, Michigan.
authors.forename: D R
authors.initials: DR
authors.lastname: Cragg
authors.forename: H Z
authors.initials: HZ
authors.lastname: Friedman
authors.forename: J D
authors.initials: JD
authors.lastname: Bonema
authors.forename: I A
authors.initials: IA
authors.lastname: Jaiyesimi
authors.forename: R G
authors.initials: RG
authors.lastname: Ramos
authors.forename: G C
authors.initials: GC
authors.lastname: Timmis
authors.forename: W W
authors.initials: WW
authors.lastname: O'Neill
authors.forename: T L
authors.initials: TL
authors.lastname: Schreiber
mesh_terms: D000367:Age Factors; D000368:Aged; D002561:Cerebrovascular Disorders / Q000150:complications; D004562:Electrocardiography; D004608:Eligibility Determination; D005260:Female; D006470:Hemorrhage; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality*; D012307:Risk Factors; D013223:Statistics as Topic; D015912:Thrombolytic Therapy; D013997:Time Factors