title: Persistence of delays in presentation and treatment for patients with acute myocardial infarction: The GUSTO-I and GUSTO-III experience.
abstract: OBJECTIVE
  Early treatment with fibrinolytic therapy substantially decreases mortality in acute myocardial infarction (AMI). We examined delays to hospital arrival and treatment in 2 large, multinational, randomized trials of fibrinolytic therapy: Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III).
  
  
  METHODS
  We evaluated delays to hospital arrival, time from arrival to treatment, and total time to treatment in the 27,849 US patients with AMI enrolled in GUSTO-I or GUSTO-III. Time intervals were defined prospectively for total time to treatment and symptom onset to hospital arrival as 0 to 2 hours (early), 2 to 4 hours, or more than 4 hours (late). Time to fibrinolytic therapy once in hospital was prospectively defined as 0 to 1 hour (early) or more than 1 hour (late). Socioeconomic data were also obtained from patients enrolled in the GUSTO-III trial.
  
  
  RESULTS
  In GUSTO-III, as in GUSTO-I, patients who arrived at the hospital later were older (64 years versus 60 years; P =.001) and more often female (35% versus 27%; P =.001), black (6% versus 4%; P =.02), and diabetic (25% versus 16%; P =.001). These groups also received treatment later once in hospital, as did patients with hypertension (48% versus 42%; P =.001), previous angina (46% versus 36%; P =.001), and previous infarction (21% versus 16%; P =.001). Higher levels of education, professional occupations, and private health insurance were associated with significantly earlier arrival and treatment. Although in hospital time to treatment has decreased (66 minutes to 48 minutes; P <.0001), time to arrival has not changed over the past 7 years, averaging 84 minutes.
  
  
  CONCLUSIONS
  Certain groups of patients with AMI, including the elderly, women, diabetic patients, and minorities, exhibit delays to hospital arrival and treatment in the emergency setting. Patients with higher educational levels, professional occupations, and private health insurance arrive at the hospital sooner and receive treatment more quickly. Patients and health care providers must be educated regarding high-risk populations for delay to maximize benefit from fibrinolytic therapy.
authors.affiliation: Department of Emergency Medicine, University of Cincinnati, Cincinnati OH, USA. brian.gibler@uc.edu
authors.forename: W Brian
authors.initials: WB
authors.lastname: Gibler
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: W Douglas
authors.initials: WD
authors.lastname: Weaver
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Stebbins
authors.forename: Joel M
authors.initials: JM
authors.lastname: Gore
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Topol
mesh_terms: D017677:Age Distribution; D000368:Aged; D004635:Emergency Medicine; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006304:Health Status; D006801:Humans; D007348:Insurance, Health; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic; D017678:Sex Distribution; D012923:Social Class; D013300:Streptokinase / Q000627:therapeutic use*; D013997:Time Factors; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D013300:Streptokinase