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December 8, 1989, Vol 262, No. 22 >
ARTICLE | December 8, 1989

An Analysis of Time Delays Preceding Thrombolysis for Acute Myocardial Infarction FREE

Scott W. Sharkey, MD; Douglas D. Brunette, MD; Ernest Ruiz, MD; William T. Hession, MD; Douglas G. Wysham, MD; Irvin F. Goldenberg, MD; Morrison Hodges, MD
[+] Author Affiliations

Reprint requests to the Division of Cardiology, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415 (Dr Sharkey).


JAMA. 1989;262(22):3171-3174. doi:10.1001/jama.1989.03430220094037
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References

For a patient to derive maximal benefit from intravenous thrombolytic therapy for acute myocardial infarction, early treatment is essential. As part of the Thrombolysis in Myocardial Infarction II trial, this study investigated the time delays that preceded treatment of 236 consecutive patients with intravenous tissue-plasminogen activator (TPA) during acute myocardial infarction. The average ( ± SD) time from the onset of symptoms to treatment with TPA was 153 54 minutes. After arrival in the emergency department, patients waited an average of 19.9 ± 17.8 minutes for the initial electrocardiogram. Following the diagnosis of acute myocardial infarction by electrocardiogram, an additional 70 ± 40 minutes elapsed before thrombolytic therapy began. The interval between the initial electrocardiogram and initiation of treatment with TPA was less when the drug was first administered in the emergency department (46.8 ± 23.4 minutes) rather than after transfer to the coronary care unit (82.1 ±34.7 minutes). In-hospital delays at the two academic and two private hospitals accounted for more than half of the total time from the onset of symptoms to initiation of thrombolytic therapy. We conclude that significant in-hospital delays are likely to occur before a patient receives thrombolytic therapy for acute myocardial infarction. Various factors conspire to create these delays, but a well-organized team approach to treatment will help to minimize delays in the implementation of this new form of therapy.

(JAMA. 1989;262:3171-3174)

REFERENCES

1 +
Topol EJ, Bates ER, Walton JA, et al.  Community hospital administration of intravenous tissue-plasminogen activator in acute myocardial infarction: improved timing, thrombolytic efficacy, and ventricular function . J Am Coll Cardiol. 1987;; 10:1173-1177.
2 +
Taylor GJ, Mikell FL, Moses WH, et al.  Intravenous versus intracoronary streptokinase therapy for acute myocardial infarction in community hospitals . Am J Cardiol. 1984;;54:256-260.
3 +
Loscalzo J, Braunwald E.  Tissue-plasminogen activator . N Engl J Med. 1988;;319:925-931.
4 +
Sherry S.  Appraisal of various thrombolytic agents in the treatment of acute myocardial infarction . Am J Med. 1987;;83( (suppl 2A) ):31-45.
5 +
Sheehan FH, Mathey DG, Schofer J, Dodge HT, Bolson EL.  Factors that determine recovery of left ventricular function after thrombolysis in patients with acute myocardial infarction . Circulation. 1985;;71:1121-1128.
6 +
Serruys PW, Simoons ML, Suryapranata H, et al.  Preservation of global and regional left ventricular function after early thrombolysis in acute myocardial infarction . J Am Coll Cardiol. 1986;;7:729-742.
7 +
Mathey DG, Schofer J, Sheehan FH, Becher H, Tilsner V, Dodge HT.  Intravenous urokinase in acute myocardial infarction . Am J Cardiol. 1985;;55:878-882.
8 +
Ritchie JL, Cerquiera M, Maynard C, Davis K, Kennedy JW.  Ventricular function and infarct size: the Western Washington Intravenous Streptokinase in Myocardial Infarction Trial . J Am Coll Cardiol . 1988;;11:689-697.
9 +
Vermeer F, Simoons ML, Bar FW, et al.  Which patients benefit most from early thrombolytic therapy with intracoronary streptokinase ? Circulation. 1986;;74:1379-1389.
10 +
Schwarz F, Schuler G, Katus H, et al.  Intracoronary thrombolysis in acute myocardial infarction: duration of ischemia as a major determinant of late results after recanalization . Am J Cardiol. 1982;;50:933-937.
11 +
Mathey DG, Sheehan FH, Schofer J, Dodge HT.  Time from onset of symptoms to thrombolytic therapy: a major determinant of myocardial salvage in patients with acute transmural infarction . J Am Coll Cardiol. 1985;;6:518-525.
12 +
 Gruppo Italiano per lo Studio della Streptochinasi nell' Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet. 1986;;1:397-402.
13 +
Schroder R, Neuhaus KL, Leizorovicz A, Linderer T, Tebbe U, the ISAM Study Group.  A prospective placebo-controlled double-blind multi-center trial of intravenous streptokinase in acute myocardial infarction (ISAM): long-term mortality and morbidity . J Am Coll Cardiol. 1987;;9:197-203.
14 +
ISIS-2 Collaborative Group.  Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;;2:349-360.
15 +
Vogel J, Coughlin B, Setty R, Avolio R, McFadden RB.  Intravenous streptokinase in acute myocardial infarction at the community hospital: a six-year experience . Am J Cardiol. 1988;;62( (suppl) ): 25K-27K.
16 +
Passamani E, Hodges M, Herman M, et al.  The Thrombolysis in Myocardial Infarction (TIMI) Phase II Pilot Study: tissue-plasminogen activator followed by percutaneous transluminal coronary angioplasty . J Am Coll Cardiol. 1987;;10( (suppl) ): 51B-64B.
17 +
TIMI Operations Committee, Braunwald E, Knatterud GL, Passamani E, Robertson TL.  Announcement of protocol change in Thrombolysis in Myocardial Infarction trial . J Am Coll Cardiol. 1987;;9:467.
18 +
Kennedy JW, Atkins JM, Goldstein S, Jaffe AS, et al.  Recent changes in management of acute myocardial infarction: implications for emergency care physicians . J Am Coll Cardiol. 1988;;11:446-449.
19 +
Herlitz J, Hartford M, Holmberg S, Blohm M, Luepker R, Karlson BW.  Effects of a media campaign on delay time and ambulance use in acute chest pain . Circulation. 1988;;78( (suppl II) ):II-188.
20 +
Fine DG, Weiss AT, Sapoznikov D, et al.  Importance of early initiation of intravenous streptokinase therapy for acute myocardial infarction . Am J Cardiol. 1986;;58:411-417.
21 +
Weaver WD, Martin JS, Litwin PE, et al.  Prehospital thrombolytic therapy: preliminary report on feasibility . Circulation. 1988;;78( (suppl II) ):II-111. Abstract.
22 +
Koren G, Weiss AT, Hasin AT, et al.  Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase . N Engl J Med. 1985;;313:1384-1389.
23 +
Mark DB, Hlatky MA, O'Connor CM, et al.  Administration of thrombolytic therapy in the community hospital: established principles and unresolved issues . J Am Coll Cardiol . 1988;;12( (suppl) ):32A-43A.
24 +
Tjoe S, Luria MH.  Delays in reaching the cardiac care unit: an analysis . Chest. 1972;;61:617-621.
25 +
Schroeder JS, Lamb IH, Hu M.  The prehospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation, and emergency room periods . Am J Med. 1978;;64:742-748.

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1 +
Topol EJ, Bates ER, Walton JA, et al.  Community hospital administration of intravenous tissue-plasminogen activator in acute myocardial infarction: improved timing, thrombolytic efficacy, and ventricular function . J Am Coll Cardiol. 1987;; 10:1173-1177.
2 +
Taylor GJ, Mikell FL, Moses WH, et al.  Intravenous versus intracoronary streptokinase therapy for acute myocardial infarction in community hospitals . Am J Cardiol. 1984;;54:256-260.
3 +
Loscalzo J, Braunwald E.  Tissue-plasminogen activator . N Engl J Med. 1988;;319:925-931.
4 +
Sherry S.  Appraisal of various thrombolytic agents in the treatment of acute myocardial infarction . Am J Med. 1987;;83( (suppl 2A) ):31-45.
5 +
Sheehan FH, Mathey DG, Schofer J, Dodge HT, Bolson EL.  Factors that determine recovery of left ventricular function after thrombolysis in patients with acute myocardial infarction . Circulation. 1985;;71:1121-1128.
6 +
Serruys PW, Simoons ML, Suryapranata H, et al.  Preservation of global and regional left ventricular function after early thrombolysis in acute myocardial infarction . J Am Coll Cardiol. 1986;;7:729-742.
7 +
Mathey DG, Schofer J, Sheehan FH, Becher H, Tilsner V, Dodge HT.  Intravenous urokinase in acute myocardial infarction . Am J Cardiol. 1985;;55:878-882.
8 +
Ritchie JL, Cerquiera M, Maynard C, Davis K, Kennedy JW.  Ventricular function and infarct size: the Western Washington Intravenous Streptokinase in Myocardial Infarction Trial . J Am Coll Cardiol . 1988;;11:689-697.
9 +
Vermeer F, Simoons ML, Bar FW, et al.  Which patients benefit most from early thrombolytic therapy with intracoronary streptokinase ? Circulation. 1986;;74:1379-1389.
10 +
Schwarz F, Schuler G, Katus H, et al.  Intracoronary thrombolysis in acute myocardial infarction: duration of ischemia as a major determinant of late results after recanalization . Am J Cardiol. 1982;;50:933-937.
11 +
Mathey DG, Sheehan FH, Schofer J, Dodge HT.  Time from onset of symptoms to thrombolytic therapy: a major determinant of myocardial salvage in patients with acute transmural infarction . J Am Coll Cardiol. 1985;;6:518-525.
12 +
 Gruppo Italiano per lo Studio della Streptochinasi nell' Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet. 1986;;1:397-402.
13 +
Schroder R, Neuhaus KL, Leizorovicz A, Linderer T, Tebbe U, the ISAM Study Group.  A prospective placebo-controlled double-blind multi-center trial of intravenous streptokinase in acute myocardial infarction (ISAM): long-term mortality and morbidity . J Am Coll Cardiol. 1987;;9:197-203.
14 +
ISIS-2 Collaborative Group.  Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;;2:349-360.
15 +
Vogel J, Coughlin B, Setty R, Avolio R, McFadden RB.  Intravenous streptokinase in acute myocardial infarction at the community hospital: a six-year experience . Am J Cardiol. 1988;;62( (suppl) ): 25K-27K.
16 +
Passamani E, Hodges M, Herman M, et al.  The Thrombolysis in Myocardial Infarction (TIMI) Phase II Pilot Study: tissue-plasminogen activator followed by percutaneous transluminal coronary angioplasty . J Am Coll Cardiol. 1987;;10( (suppl) ): 51B-64B.
17 +
TIMI Operations Committee, Braunwald E, Knatterud GL, Passamani E, Robertson TL.  Announcement of protocol change in Thrombolysis in Myocardial Infarction trial . J Am Coll Cardiol. 1987;;9:467.
18 +
Kennedy JW, Atkins JM, Goldstein S, Jaffe AS, et al.  Recent changes in management of acute myocardial infarction: implications for emergency care physicians . J Am Coll Cardiol. 1988;;11:446-449.
19 +
Herlitz J, Hartford M, Holmberg S, Blohm M, Luepker R, Karlson BW.  Effects of a media campaign on delay time and ambulance use in acute chest pain . Circulation. 1988;;78( (suppl II) ):II-188.
20 +
Fine DG, Weiss AT, Sapoznikov D, et al.  Importance of early initiation of intravenous streptokinase therapy for acute myocardial infarction . Am J Cardiol. 1986;;58:411-417.
21 +
Weaver WD, Martin JS, Litwin PE, et al.  Prehospital thrombolytic therapy: preliminary report on feasibility . Circulation. 1988;;78( (suppl II) ):II-111. Abstract.
22 +
Koren G, Weiss AT, Hasin AT, et al.  Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase . N Engl J Med. 1985;;313:1384-1389.
23 +
Mark DB, Hlatky MA, O'Connor CM, et al.  Administration of thrombolytic therapy in the community hospital: established principles and unresolved issues . J Am Coll Cardiol . 1988;;12( (suppl) ):32A-43A.
24 +
Tjoe S, Luria MH.  Delays in reaching the cardiac care unit: an analysis . Chest. 1972;;61:617-621.
25 +
Schroeder JS, Lamb IH, Hu M.  The prehospital course of patients with chest pain: analysis of the prodromal, symptomatic, decision-making, transportation, and emergency room periods . Am J Med. 1978;;64:742-748.

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