The earliest thrombolytic treatment of acute myocardial infarction: ambulance or emergency department?
Because the effectiveness of thrombolytic therapy is inversely related to the time interval before it is given, prehospital thrombolytic administration has been proposed and implemented to shorten the time between acute myocardial infarction (AMI) symptom onset and definitive therapy. Regardless of how effective these prehospital approaches prove to be, they have the potential to shorten the time to thrombolytic therapy in only a minority of the affected U.S. population because only approximately half of AMI patients are transported by the Emergency Medical Services (EMS) system. Preliminary efforts to shorten patient delay in response to AMI symptoms and to increase the number of patients who use the paramedic system have met with limited success. Other potential problems relating to prehospital thrombolytic administration include the high cost of electrocardiographic and communication equipment per ambulance, field drug stock cost and breakage, and additional medicolegal risks for physicians and prehospital providers. The medicolegal risk can be estimated by setting up a clinical decision analysis model. If prehospital treatment were to become standard care in the United States, half of the 1.5 million AMI patients per year (750,000) who are transported by paramedics would be candidates for prehospital treatment. Assuming a 30% treatment rate (225,000), a 5% major bleed and a 1% stroke complication rate, then 11,250 major bleeds and 2,250 strokes would occur in field-treated AMI patients. If we assume that the absence of physician screening might increase the incidence of complications between 1% and 10%, then 113 to 1,125 extra bleeds and 23 to 225 extra strokes would result from prehospital treatment compared with treatment in the emergency department (ED).(ABSTRACT TRUNCATED AT 250 WORDS)
Division of Cardiology, Medical College of Virginia, Richmond 23298.
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JP
Ornato
D000552:Ambulances / Q000592:standards*; D003661:Decision Support Techniques; D004634:Emergency Medical Technicians; D004636:Emergency Service, Hospital / Q000592:standards*; D005069:Evaluation Studies as Topic; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy*; D012307:Risk Factors; D015912:Thrombolytic Therapy / Q000592:standards; D013997:Time Factors; D014481:United States
D005343:Fibrinolytic Agents