Thrombolytic therapy: time to treatment
CMAJ 1997;157:250-1
See response by: J.L. Cox, C.D. Naylor, P.W. Armstrong
To conclude that the time to thrombolytic therapy for patients with an acute myocardial infarction (AMI) was slower in Canada than in other countries was correct at the time of the GUSTO-I trial; but to state that door-to-needle time is unacceptably long in Canadian hospitals now is untrue and discredits the advances achieved by those in emergency medicine in this country ("Time to treatment with thrombolytic therapy: determinants and effect on short-term nonfatal outcomes of acute myocardial infarction" CMAJ 1997;156:497-505, by Dr. Jafna L. Cox and colleagues [abstract / résumé]).
The GUSTO-I trial compared the effects of 4 thrombolytic strategies on mortality.1 After subsequent analysis of this data, the researchers claimed, in 1994, that the choice of thrombolytic therapy was less important to survival than time to treatment.2,3 The GUSTO-I data are old (1990 to 1993), and the study is representative of a different era when the administration of thrombolytics was under the guidance and control of internists or cardiologists.
Since then, the responsibility for the immediate assessment and treatment of patients with an AMI in the emergency department has essentially been assumed by emergency physicians; across Canada, they have achieved great reductions in the time to thrombolysis.
In 1993, long before the recommendation by the Emergency Cardiac Care Coalition that emergency physicians treat patients with a clear diagnosis of AMI within 30 minutes,4 we designed a quality-improvement project to decrease door-to-needle time. We decreased the median elapsed time from admission to thrombolysis for all patients with an AMI from 62 to 40 minutes.5
Since then, emergency physicians across this country have achieved spectacular improvements. Centenary Health Centre in Scarborough, Ont., has reduced times to 29 minutes,6 and the average time at the Hamilton Civic Hospitals is 21 minutes, according to information from those hospitals. Concern is now voiced that further reductions may be achieved only with a rising cost of physician error and patient complications.
The picture of thrombolytic treatment represented in the article by Cox and colleagues no longer exists. Are Canadian physicians up to the challenge? Yes. This question has been clearly answered both in emergency medicine literature, and in practice in emergency departments across this country.
Ken Markel, MD
Department of Emergency Medicine
Chair
Quality Improvement Committee
Richmond Hospital
Richmond, BC
References
- The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329:673-82.
- Ridker PM, O'Donnell CJ, Marder VJ, Hennekens CH. A response to "Holding GUSTO up to the light." Ann Intern Med 1994;120:882-4.
- Farkouh ME, Lang JD, Sackett DL. Thrombolytic agents: the science of the art of choosing the better treatment. Ann Intern Med 1994;120:886-8.
- The Heart and Stroke Foundation of Canada, the Canadian Cardiovascular Society and the Canadian Association of Emergency Physicians, for the Emergency Cardiac Care Coalition. Recommendations for ensuring early thrombolytic therapy for acute myocardial infarction. CMAJ 1996;154:483-7.
- Markel KN, Marion SA. CQI: improving the time to thrombolytic therapy for patients with acute myocardial infarction in the emergency department. J Emerg Med 1996;14:685-9.
- Heart-felt change: improving the care of acute myocardial infarction patients. Informed 1996;2(2):11-12.
 |
Send a letter to the editor responding to this letter
Envoyez une lettre à la rédaction au sujet de cette lettre |
Letters