Recommendations for ensuring early thrombolytic therapy for acute
myocardial infarction
The Heart and Stroke Foundation of Canada, the Canadian Cardiovascular Society
and the Canadian Association of Emergency Physicians, for the Emergency Cardiac Care
Coalition
Canadian Medical Association Journal 1996; 154: 483-487
This article, prepared by Dr. Michael Shuster, chair of the ECC Coalition and a practising
emergency physician at the Mineral Springs Hospital, Banff, Alta., and Dr. Garth Dickinson,
president of the Canadian Association of Emergency Physicians, an emergency physician at the
Ottawa General Hospital and an assistant professor in the Division of Emergency Medicine at the
University of Ottawa, Ottawa, Ont., was adapted from an earlier report released in 1995 by the
Heart and Stroke Foundation of Canada for the ECC Coalition.
Paper reprints of the full text may be obtained from: Heart and Stroke Foundation of Canada, 200-160 George St., Ottawa ON K1N 9M2; fax 613 241-3278
© 1996 Canadian Medical Association
See related editorial: Initiating thrombolytic therapy for acute myocardial infarction: Whose job is it anyway?
Abstract
Objective: To recommend practical steps to ensure early thrombolytic therapy and thereby reduce
mortality and morbidity associated with acute myocardial infarction (AMI).
Options: Various factors were considered that influence time to thrombolysis related to patients,
independent practitioners and health care systems.
Outcomes: Reduction in morbidity and mortality associated with AMI.
Evidence: Early initiation of thrombolytic therapy reduces morbidity and mortality associated with
AMI. The ECC Coalition analysed the factors that might impede early implementation of
thrombolytic therapy.
Values: Published data were reviewed, and recommendations were based on consensus opinion of
the Emergency Cardiac Care (ECC) Coalition. The ECC Coalition comprises 20 professional,
nongovernment and government organizations and has a mandate to improve emergency cardiac
care services through collaboration.
Benefits, harms and costs: Early thrombolytic therapy reduces morbidity and mortality associated
with AMI. Implementation of the recommendations will result in reduced time to thrombolytic
therapy, streamlining of current practices and enhanced cooperation among health care
professionals to expedite care. Depending on existing practices, implementation may require
protocol development, and public and professional education. Although costs are associated with
educating the public and health care professionals, they are outweighed by the financial and social
benefits of reduced morbidity and mortality.
Recommendations: Early recognition of AMI symptoms by the public and health care
professionals, early access to the emergency medical services system and early action by
emergency care providers in administering thrombolytic therapy (within 30 minutes after the
patient's arrival at the emergency department).
Validation: No similar consensus statements or practice guidelines for thrombolytic therapy in
Canada are available for comparison.
Sponsors: The development of these recommendations was funded by the Heart and Stroke
Foundation of Canada. The recommendations are endorsed by the Heart and Stroke Foundation
of Canada, the Canadian Cardiovascular Society, the Canadian Association of Emergency
Physicians and the representatives of the member organizations of the ECC Coalition.
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Large randomized controlled trials have clearly shown that morbidity and mortality associated
with acute myocardial infarction (AMI) can be reduced by the early initiation of thrombolytic
therapy.[1-4] In one study the rate of death 21 days after AMI was reduced by 47% when
thrombolytic therapy was started within 1 hour after the onset of pain.[5] In another trial the infarct
size was reduced by more than 50% when thrombolytic therapy was begun within 70 minutes
after the onset of pain.[6] Other studies have also shown that the sooner the treatment is initiated,
the greater the benefit.[7-9]
The Emergency Cardiac Care Coalition (ECC Coalition), comprising representatives from 20
professional, nongovernment and government organizations, believes that thrombolytic therapy
can, and should, be administered to a patient with AMI within 30 minutes of arrival at hospital.[1]
In 1993 the ECC Coalition recognized that, in Canada, thrombolytic therapy was not reliably
provided at the earliest possible moment. In the face of increasing evidence that earlier treatment
improves the outcome of patients with AMI, the ECC Coalition met to identify steps to eliminate
or minimize delay at every stage between the onset of symptoms and treatment. The
recommendations in this statement reflect the shared professional opinion of all of the ECC
Coalition member groups.
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The ECC Coalition strongly supports coordinated efforts to minimize the time to thrombolytic
therapy for AMI by eliminating unnecessary delays. All hospitals and communities should
critically examine their current programs and practices in light of the following recommendations.
Awareness: early access to medical care
It is vital that anyone who experiences symptoms of AMI or cardiac arrest be assisted as quickly
as possible. For this to occur, a cardiac emergency must be recognized and the emergency medical
services (EMS) system activated. Delay may involve lack of recognition of the symptoms by the
affected person or a bystander.[10,11] Further delay may be encountered if a universal access
number (911) or a tiered response by the EMS system is not available in the area.[12,13]
Therefore, the ECC Coalition recommends the following:
- Programs should be instituted in every community to educate the public on the symptoms
of AMI and the actions to take in the event of AMI.[9-11,14] One such program is the Heart and
Stroke Foundation of Ontario's Heart Steps (Appendix 1).
- Professional organizations should take an active role in ensuring that their members are
aware of the importance of reducing the time to thrombolytic therapy by eliminating unnecessary
delays.
- Family physicians and other health care providers should play a key role in educating their
patients on the symptoms of AMI and the actions to take.13
- Family physicians and other health care providers should ensure that the families of
patients at high risk for AMI know the symptoms of AMI and the actions to take.
Emergency medical services
and prehospital care
EMS systems play a key role in prehospital care and the transportation of AMI patients. Rapid
administration of state-of-the-art treatment by EMS personnel is essential for improving chances
of survival.[1]
The ECC Coalition recommends the following:
- Ambulance personnel, first responders, and nurses or rural physicians who arrange
transport for patients should alert the receiving hospital of any patient who may be suffering
AMI.[1,9]
- EMS personnel should establish a protocol for identifying people who may be
experiencing AMI,[1,15] determining the suitability for thrombolytic therapy[6] (Appendices 2 and 3)
and communicating this information to the receiving facility.
- Ambulance services should consider the use of field electrocardiograms to help identify
people who may be suffering AMI.[1,12,15-18]
- EMS systems with advanced life support capability should monitor closely the developing
body of evidence on prehospital thrombolytic therapy. EMS systems in communities where
transportation time may be prolonged should assess their need and ability to provide prehospital
thrombolytic therapy in light of the current evidence[8,16,18] and the overall provision of care.
Hospital care
A goal of emergency departments should be to administer thrombolytic therapy to all eligible
patients within 30 minutes after their arrival at the emergency department.[1] Identification of the
causes of delays in assessment and treatment in the emergency department and implementation of
steps to minimize those delays will improve patient outcome.
The ECC Coalition recommends the following:
- All emergency departments should be ready and able to provide thrombolytic
therapy.[9,16,19]
- Thrombolytic drugs should be readily available on a 24-hour basis.
- The hospital should work with local EMS services to identify AMI patients before they
arrive at the emergency department.[1]
- The emergency department should develop a plan
to minimize the delay in delivering thrombolytic
therapy.[9,20]
- The nurse(s) and physician(s) and other members of the health care team who provide care
in the coronary/critical care unit or the emergency department should cooperate to develop a plan
for the diagnosis, treatment and delivery of care to patients with suspected AMI (Appendix
3).[1,9,19] The plan should (a) be appropriate to the hospital and take into account all of the
hospital's resources, (b) be specific and delineate the responsibilities of team members during the
first hours of care, (c) specify the equipment and supplies needed and their location, the tests
required and other details relevant to the provision of care, and (d) ensure that thrombolytic
therapy is initiated within 30 minutes after the patient's arrival at the emergency department.[13]
- An ongoing evaluation and audit protocol should be implemented and reviewed regularly
to ensure that objectives are met.[16]
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There is substantial evidence that early initiation of thrombolytic therapy can greatly reduce
morbidity and mortality associated with AMI.[1-9,19] By addressing every area in which delays
may occur, the ECC Coalition recommends ways in which early initiation of thrombolytic therapy
can be achieved.
Implementation of these recommendations will require change of practices, development of EMS
and hospital protocols, and education of health care professionals and the public for the early
recognition of AMI symptoms, early access to the EMS system and early action by emergency
care providers. The costs of implementing these recommendations depend on existing practices
and protocols and the level of public awareness in the community.
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These recommendations have been endorsed by all of the member groups of the ECC Coalition. It
is the coalition's belief that no other set of comprehensive recommendations on early thrombolytic
therapy has been developed for use in Canada. For this reason an exacting comparative analysis
against similar guidelines was not undertaken.
The development of the statement was funded by the Heart and Stroke Foundation of Canada.
These recommendations are endorsed by the Heart and Stroke Foundation of Canada, the
Canadian Cardiovascular Society, the Canadian Association of Emergency Physicians and the
representatives of the member organizations of the Emergency Cardiac Care Coalition.
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- National Heart Attack Alert Program Coordinating Committee, 60 Minutes to Treatment
Working Group: Emergency department: rapid identification and treatment of patients with acute
myocardial infarction. Ann Emerg Med 1994; 23: 311-329
- The GUSTO Investigators: An international randomized trial comparing four thrombolytic
strategies for acute myocardial infarction. N Engl J Med 1993; 329: 673-682
- Fibrinolytic Therapy Trialists' Collaborative Group: Indications for fibrinolytic therapy in
suspected acute myocardial infarction: collaborative overview of early mortality and major
morbidity results from all randomized trials of more than 1000 patients. Lancet 1994; 343:
311-322
- Emergency Cardiac Care Committee and Subcommittees, American Heart Association:
Guidelines for cardiopulmonary resuscitation and emergency cardiac care. III: Adult advanced
cardiac life support. JAMA 1992; 268: 2199-2241
- 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
- Weaver WD, Cerqueira M, Hallstrom AP et al: Prehospital-initiated vs hospital-initiated
thrombolytic therapy: the Myocardial Infarction Triage and Intervention Trial. JAMA 1993; 270:
1211-1216
- LATE Study Group: Late Assessment of Thrombolytic Efficacy (LATE) study with
alteplase 6-24 hours after onset of acute myocardial infarction. Lancet 1993; 342: 759-766
- Rawles JS: Halving of mortality at 1 year by domiciliary thrombolysis in the Grampian
Region Early Anistreplase Trial (GREAT). J Am Coll Cardiol 1994; 23: 1-5
- Sharkey SW, Brunette DD, Ruiz E et al: An analysis of time delays preceding
thrombolysis for acute myocardial infarction. JAMA 1989; 262: 3171-3174
- Leitch JW, Birbara T, Freedman B et al: Factors influencing the time from onset of chest
pain to arrival at hospital. Med J Aust 1989; 150: 6-10
- Wielgosz ATJ, Nolan RP, Earp JA et al: Reasons for patients' delay in response to
symptoms of acute myocardial infarction. CMAJ 1988; 139: 853-857
- Kerciakes DJ, Gibler WB, Martin LH et al: Cincinnati Heart Project Study Group.
Relative importance of emergency medical system transport and the prehospital electrocardiogram
on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report
from the Cincinnati Heart Project. Am Heart J 1992; 123 (4 pt 1): 835-840
- Birkhead JS, for the Joint Audit Committee of the British Cardiac Society and a
Cardiology Committee of Royal College of Physicians of London: Time delays in provision of
thrombolytic treatment in six district hospitals. BMJ 1992; 305: 445-448
- Cooper RS, Simmons B, Castaner A et al: Survival rates and prehospital delay during
myocardial infarction among black persons. Am J Cardiol 1986; 57: 208-211
- Kereiakes DJ, Weaver WD, Anderson JL et al: Time delays in the diagnosis and treatment
of acute myocardial infarction: a tale of eight cities. Report from the Prehospital Study Group and
the Cincinnati Heart Project. Am Heart J 1990; 120: 773-780
- Moses HW, Bartolozzi JJ, Koester DL et al: Reducing delay in the emergency room in
administration of thrombolytic therapy for myocardial infarction associated with ST elevation. Am
J Cardiol 1991; 68: 251-253
- Grim P, Feldman T, Martin M et al: Cellular telephone transmission of 12-lead
electrocardiograms from ambulance to hospital. Am J Cardiol 1987; 60: 715-720
- Weaver WD, Eisenberg MS, Martin JS et al: Myocardial infarction triage and intervention
project - phase I: Patient characteristics and feasibility of prehospital initiation of thrombolytic
therapy. J Am Coll Cardiol 1990; 15: 925-931
- Gonzalez ER, Jones LA, Ornato JP et al (Virginia Thrombolytic Study Group): Hospital
delays and problems with thrombolytic administration in patients receiving thrombolytic therapy: a
multicenter prospective assessment. Ann Emerg Med 1992; 21: 1215-1221
- Kline EM, Smith DD, Martin JS et al: In-hospital treatment delays in patients treated with
thrombolytic therapy: a report of the GUSTO Time to Treatment Substudy. [abstract] Circulation
1992; 86 (4 suppl 1): I-702
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The Emergency Cardiac Care (ECC) Coalition comprises the Canadian Association of Critical
Care Nurses, the Canadian Association of Emergency Physicians, the Canadian Association of
Fire Chiefs, the Canadian Cardiovascular Society, the Canadian Council of Cardiovascular
Nurses, the Canadian Medical Association, the Canadian Nurses Association, the Canadian Red
Cross Society, the Canadian Ski Patrol System, the Canadian Society of Ambulance Personnel,
the Canadian Society of Respiratory Therapists, the College of Family Physicians of Canada,
Health Canada, the Heart and Stroke Foundation of Canada, the Régie régionale
de la Santé et Services sociaux de l'Estrie, the Ottawa-Carleton Public Health Unit, the
Royal Canadian Mounted Police Training and Development Branch, St. John Ambulance, the
ACT Foundation of Canada and Urgences Santé.
Disclaimer
This guideline is for reference and education only and is not intended to be a substitute for the advice of an appropriate health care professional or for independent research and judgement. The CMA relies on the source of the CPG to provide updates and to notify us if the guideline becomes outdated. The CMA assumes no responsibility or liability arising from any outdated information or from any error in or omission from the guideline or from the use of any information contained in it.
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