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Heart Disease

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Elderly heart attack patients who have multiple health problems may not receive prompt clot-busting treatment

Elderly heart attack patients with multiple health problems, who are most in need of thrombolytic (clot-busting) medication, do not receive it as promptly as other patients, according to a recent study supported in part by the Agency for Healthcare Research and Quality (HS07357). Ideally, heart attack victims should receive thrombolytic therapy within an hour of symptom onset in order to salvage the myocardium.

Previous studies have shown less damaged heart tissue and fewer deaths among those who are given timely thrombolytic therapy. The longer the delay in administering this therapy, the more likely a poor clinical outcome, explains lead author Thomas J. McLaughlin, Sc.D., of Harvard Medical School. Dr. McLaughlin, Stephen B. Soumerai, Sc.D., also of Harvard, and their colleagues studied 776 patients arriving at 37 Minnesota hospitals who were admitted for diagnosed or suspected heart attack (acute myocardial infarction, AMI) and were treated with a thrombolytic agent.

They found that during 1992 and 1993 and 1995 and 1996, almost 40 percent of AMI patients who received thrombolytics were administered them 60 minutes or more after hospital arrival. As expected, the later time period (1995-1996) was associated with earlier administration of thrombolytic treatment, perhaps indicating a trend toward speedier use of thrombolytic agents. Delays in treatment were more likely for patients age 75 or older (odds ratio, OR 1.57; 1 is equal odds) and those with a greater burden of coexisting medical problems (OR 1.46). Use of emergency transport was strongly associated with receipt of thrombolytic treatment in less than an hour (OR 0.46), as was chest pain (OR 0.40).

The presence of chest pain presumably expedites AMI diagnosis. Also, initial patient assessment, including electrocardiography, can occur during emergency transport, saving assessment time in the emergency department. Further delay in use of thrombolytic agents for older, more impaired patients may be due to the complex clinical decisionmaking concerning these patients. For example, elderly people have a higher risk of bleeding, particularly intracranial hemorrhage, with thrombolytic treatment. Quality improvement efforts should be directed at accelerating the decision process for these vulnerable patients for whom expeditious treatment may be most beneficial, conclude the researchers.

See "Delayed thrombolytic treatment of older patients with acute myocardial infarction," by Dr. McLaughlin, Jerry H. Gurwitz, M.D., Donald J. Willison, Sc.D., and others, in the October 1999 Journal of the American Geriatrics Society 47(10), pp. 1222-1228.

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