H Dalton BS MCPRc. D Chappel MA Ms. R Climie mB Bs. St Helier Hospital, Carshalton,. Surrey SM5 1AA. Keywords: thrombolysis; myocardial infarction.
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Journal of the Royal Society of Medicine Volume 82 July 1989
Thrombolysis for acute myocardial infarction in a District General Hospital
H Dalton BS MCPRc Surrey SM5 1AA
D Chappel MA Ms
St Helier Hospital, Carshalton,
R Climie mB Bs
Keywords: thrombolysis; myocardial infarction
Summary We report our experience in establishing thrombolysis as a routine part ofthe management ofpatients with acute myocardial infarction in our hospital; with particular reference to the effectiveness of the policy, safety and delays in administration. Introduction The use of thrombolytic therapy in acute myocardial infarction is now well established. A number of studies have demonstrated a marked improvement in mortality when intravenous streptokinase is given within four hours",2, and more especially within one and a half hours3 of the onset of pain.
STREPTOKINASE GIVEN IN THE CASUALTY DEPARTMENT
LII
STREPTOKINASE GIVEN IN THE CORONARY CARE UNIT
15
u)
10
: A
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Patients, methods and results In November 1986 the protocol for the use of intravenous streptokinase in acute myocardial infarction was first introduced at St Helier Hospital (a District General Hospital in South West London serving a population of 310 000). The protocol called for all patients presenting within 6 h of the onset of pain and acute ECG changes, suggestive of acute myocardial infarction, being considered for therapy. The exclusion criteria used in the GISSI Study' were applied. Absolute contraindications to treatment with streptokinase were recent or current bleeding; cerebrovascular accident within the previous two months; a surgical procedure or trauma within the previous 10 days; invasive procedures (e.g. percutaneous biopsy, subclavian puncture) within the previous 10 days; uncontrolled hypertension (systolic > 200 mmHg, diastolic > 110 mmHg); previous treatment with streptokinase; any other life-threatening condition concomitant with myocardial infarction. Relative contraindications included recent external cardiac massage, known haemostatic disorders, pregnancy and haemorrhagic diabetic retinopathy. Between November 1986 and April 1988, 370 patients with subsequently proven acute myocardial infarction were admitted to the coronary care unit; of these, 57 (15%) received intravenous streptokinase. Of these 57 patients, data was available on 51 (mean age 58 years; range 38-78 years). Ten patients (20%) were referrals from the general practitioner; 41 patients (80%) presented direct to the casualty department. No major complications (such as haemmorhage or life-threatening reperfusion arrhythmias) occurred with streptokinase. Three patients had streptokinase discontinued because of an apparent allergic reaction with hypotension and/or rash: they all recovered rapidly.
0-30
31-60
61-90
91-120 121-150 151-180 181-210 > 210
TIME TO ADMINISTRATION OF STREPTOKINASE (MINUTES)
Figure 1. Time to administration of streptokinase in acute myocardial infarction after arrival in the casualty department
In retrospect, following careful review of the casenotes, five patients received streptokinase inappropriately; two because of presenting too late and three because no myocardial infarction was threatened, but no complications occurred. Initially, streptokinase was only given in the coronary care unit. On review, the mean time to administration from the patient's arrival in the casualty department was considered too long (at 141 min, range 45-614 min). From February 1988 onwards it was agreed that streptokinase should be given in casualty. This produced an important reduction in the mean time to administration of streptokinase from arrival in hospital (61 min; range 30-105 min). (Figure 1). In the first four months of 1987 only 13% of patients with acute myocardial infarction received streptokinase. For the equivalent period in 1988 this figure was 25%.
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Discussion The Royal Our experience shows that 18 months after introducing Society of thrombolysis, only a small percentage of patients Medicine
Journal of the Royal Society of Medicine Volume 82 July 1989
presenting with acute myocardial infarction received this important therapy. Such treatment has proved to be safe and was rarely given inappropriately. We have demonstrated an important reduction in the time taken to administer streptokinase, when this is given in the casualty department rather than the coronary care unit. Patients with chest pain in casualty should receive high priority to keep any delays in receiving thrombolysis to a minimum. Twenty per cent of our patients were referred by their GPs. The lack of major problems with streptokinase therapy suggests that it could be possible for GPs to initiate treatment before transfer of the patient to hospital. This would clearly minimize any potential delays, but before being considered on a routine basis, the problems of accurate diagnosis and management of complications (outside the hospital setting) should be carefully assessed. Potential delays in transfer ofthe patient by ambulance to hospital are greatest in rural areas. However, problems can occur in urban districts (e.g. inner London in the 'rush hour'). In these settings it is not uncommon for it to take over half an hour to get the patient to hospital: such delays in the initiation of thrombolytic therapy could have serious consequences. It is in this area that we believe efforts could most usefully be made to improve thrombolytic delivery times. General practitioners could be trained to recognize acute myocardial infarction both clinically and electrocardiographically. They should also
appreciate when the administration of streptokinase is inappropriate (e.g. active peptic ulcer, recent surgery, etc.). Amnbulance staff could also be trained to supervise this form oftherapy. It would be necessary for them to be competent in the interpretation of ECG's, basic life-support and administration and supervision of intravenous treatment. They would need to know the potential side effects of streptokinase and the correct course of action to take if any were to occur during the (long) journey to hospital. Acknowledgments: We wish to thank Dr C Pumphrey for his help and encouragement. Also the consultants at St Helier Hospital for use of their patient's records. References 1 Gruppo Italiano per lo studio della Streptochinasi nell'infarto miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;i:397-401 2 Second International Study of Iifarct Survival (ISIS-2) Steering Committee. Intravenous streptokinase given within 0-4 hours onset of myocardial infarction reduced mortality in ISIS-2. Lancet 1987;i:502 3 Koren G, Weiss A, Hasin Y, et aL Prevention of myocardial damage in acute myocardial ischaemia by early treatment with intravenous streptokinase. NEngl J Med 1985;313:1384-9
(Accepted 28 December 1988. Correspondence to Dr HDalton, 57 Woodbourne Avenue, Streatham, London SW16 1 UX)
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