The magnitude of the benefit from preCCU thrombolysis in acute myocardial infarction: a long term follow up.
OBJECTIVE
Our aim was to determine the relationship among the time saved by administration of thrombolytic therapy in prehospital versus hospital setting and long term mortality; number, duration of hospitalizations and their causes.


BACKGROUND
There is much theoretic, experimental and trial evidence to indicate that in acute myocardial infarction the earlier the thrombolytic therapy is given, the greater its efficacy. However, the clinical importance of this gain time in long term is still uncertain.


METHODS
280 patients with suspected acute myocardial infarction in perspective, controlled study with two parallel groups of consecutive patients without contraindication for thrombolysis, who were seen by general emergency physicians before hospitalization (Gr.1) or later in hospital by the attending cardiologist (Gr.2). The main outcomes measured was mortality rate at 5 years, causes, number and duration of new hospitalizations.


RESULTS
The median pain to needle time was 90' (25 degrees percentile:67'; 75 degrees percentile:165') in Gr.1 vs 165' in Gr.2 (25 degrees percentile:110'; 75 degrees percentile:225'). The median time difference was 75' (P<0.001). The 35th day total mortality rate was 7.5% and 10.6% (p:n.s.) in Gr.1 vs Gr.2 respectively, 8.6% (Gr.1) vs 19.7% (Gr.2) (P<0.015) at 1 year, and 19.2% (Gr.1) vs 47.2% (Gr.2) (P<0.015) at 5 years. The percentage of patients with a number of new hospitalizations greater than 1 during 5 years was not significantly different in Gr.1 vs Gr.2 (44.1% vs 48.35, p:n.s.). The total duration of hospitalization was 479 days in Gr.1 vs 1431 days in Gr.2 (P<0.001). The 75 Gr.1 patients alive at the end of 5 years follow up had a mean hospital stay of 3.86+/-5.92 days vs 8.05+/-16.60 days (P<0.036) of the 94 Gr.2 patients alive after 5 years. The total and mean stay for recurrence of acute MI was significantly different in Gr.1 vs Gr.2 (90 vs 425 days: P<0.001; and 13+/-6.2 days vs 25+/-5.4: P<0.003 respectively). Cardiac failure led to the 1.16% in Gr.1 vs 9.43% of new admission (P<0.028) for a total of 57 vs 243 days in Gr.1 and Gr.2 respectively (P<0.001). Cumulative mortality rate for any cause at 5 years was 19.2% and 47.2% in prehospital and in hospital treated patients (P<0.015), obtaining diverging survival curves.


CONCLUSIONS
The magnitude of the benefit from earlier thrombolysis is such that giving thrombolytic treatment earlier is the main problem to reduce the time from onset of symptoms to reperfusion, to salvage myocardial muscle and obtain diverging survival curves.
Department of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy.
S
S
Coccolini
G
G
Berti
A
A
Maresta
D016255:Anistreplase / Q000627:therapeutic use; D004632:Emergency Medical Services; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D007902:Length of Stay; D008297:Male; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D012008:Recurrence; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome
D005343:Fibrinolytic Agents; D016255:Anistreplase