Evaluation of timeliness, appropriateness, and efficacy/toxicity of thrombolytic therapy for myocardial infarction

Context

The American College of Cardiology/American Heart Association (ACC/AHA) has established guidelines for the use of thrombolytic therapy in acute myocardial infarction (AMI).  Compliance with these guidelines at our institution is unknown.

Objectives

The objective of this study was to evaluate the timeliness and appropriateness of thrombolytic therapy for AMI and to characterize its efficacy and toxicity.

Setting

Emergency Department (ED) of a large Canadian community hospital.

Design

Retrospective chart review between September 1, 1998 and August 31, 1999.  Subjects were patients who received thrombolytic therapy for AMI.

Main Outcome Measures

Five endpoints were examined: timeliness, measured by door-to-needle time (DTNT), door-to-data time, data-to-decision time, and decision-to-drug time; appropriateness of thrombolysis and of choice of thrombolytic agent as per the ACC/AHA guidelines; efficacy, defined as the absence of death, need for urgent revascularization, and extension of infarct or reinfarction following thrombolytic therapy; and toxicity, the occurrence of an allergic reaction, hypotension, major bleed, or minor bleed.

Results

Sixty-four patients were included. The median DTNT was 43 minutes. The recommended DTNT of <30 minutes was achieved in 28% of patients. The median door-to-data time was 8 minutes, which is within the recommended interval of 10 minutes. The decision time was not documented in charts. The data-to-drug time was found to be 30 minutes. Thrombolytics were indicated in all cases. The ratio of use of tissue plasminogen activator (t-PA) to streptokinase (SK) was 53:47. SK was chosen appropriately in all cases. SK could have been used in 15% of patients treated with t-PA. Thrombolytic therapy was efficacious in 87% of patients. There were no allergic reactions. Hypotension occurred in 5 patients treated with each t-PA and SK. Minor bleeds occurred in 7 and 4 patients and major bleeds in 2 and 1 patients treated with t-PA and SK respectively.

Conclusions

The appropriateness and particularly the timeliness of thrombolysis for AMI in the ED at this hospital needs to be improved.

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