Recent guidelines have acknowledged that thrombolysis decreases mortality from acute myocardial infarction (AMI) independently of age. The purpose of this study was to determine the age-related rates of thrombolytic administration and in-hospital mortality and the variables related to the use of thrombolytic therapy for patients with AMI.
A prospective cohort analysis involved a registry of 44 acute care Quebec hospitals that enrolled 3741 patients with AMI between January 1995 and May 1996. The main outcomes of interest were crude and adjusted age-related in-hospital mortality rates and rates of use of thrombolytic therapy.
In-hospital mortality rates increased dramatically with age from 2.1% in patients with AMI who were less than 55 years of age to 26.3% in those who were 85 years of age or older. Overall, 35.8% of the patients received thrombolysis. There was a pronounced inverse gradient in the use of thrombolysis with age, ranging from 46.2% in the youngest age group ( or = 85 years). After adjustment for potential confounders, the older patients remained significantly less likely to receive thrombolytic therapy. Compared with patients who were less than 55 years of age, the odds ratio of receiving thrombolytic therapy was 0.68 (95% confidence interval [CI] 0.52-0.89) for patients aged 65-74 years, 0.48 (95% CI 0.35-0.65) for patients aged 75-84 years and 0.13 (95% CI 0.06-0.26) for patients aged 85 years or more. Other variables related to thrombolytic therapy were diabetes (odds ratio [OR] 0.77, 95% CI 0.59-1.00), cerebrovascular disease (OR 0.46, 95% CI 0.30-0.72), angina (OR 0.73, 95% CI 0.56-0.95), typical chest pain (OR 2.56, 95% CI 1.88-3.47); ST elevation (OR 8.93, 95% CI 7.24-11.00), Q wave MI (OR 5.26, 95% CI 4.20-6.60) and increased length of time between onset of symptoms and arrival at hospital.
Age is an important independent predictor of in-hospital mortality and lower thrombolytic use following AMI. Other studies are required to further evaluate the appropriateness of thrombolytic therapy for elderly patients.
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Age-related differences in patients with an acute coronary syndrome (ACS) have not been well characterized in prior observational studies that often included only certain age groups or subjects with myocardial infarction (MI).
We stratified 4627 patients admitted with an ACS across 9 provinces between 1999 and 2001 enrolled in the Canadian ACS Registry into 3 age groups ( or = 75 years) to evaluate differences in clinical characteristics, management, and 1-year outcome.
Older patients more frequently had previous angina, MI, or heart failure and were less likely to have positive cardiac markers, ST elevation, and Q-wave MI or to receive thrombolytics, beta-blockers, and cholesterol-lowering and antiplatelet agents in hospital, at discharge, and at 1 year. In multivariable analyses controlling for patient factors, every decade increase in age was independently associated with reduced use of coronary angiography (odds ratio [OR] 0.79, 95% CI 0.74-0.84, P
We sought to identify the Canadian population with potential access to intravenous tissue plasminogen activator within 3 hours of onset of acute ischemic stroke.
Assuming that 60 minutes is needed for stroke recognition, emergency room evaluation, and administration of tissue plasminogen activator, 120 minutes remain for transport, using a 3-hour treatment window. Ambulance databases were analyzed for transport times of 60, 90, and 120 minutes and were found to correspond to transport distances of 32, 64, and 105 kilometers (20, 40, and 65 miles), respectively. Using Geographical Information System (GIS) software, these radii were overlaid on thematic maps of Canadian hospitals identified as having a third- or fourth-generation CT and with a neurologist and an emergency physician on staff. Analysis was then performed on complete Canadian census data from 1991 and the interim 1996 census count.
67.3%, 78.2%, and 85.3% of the total Canadian population were within 32, 64, and 105 kilometers, respectively, of an identified hospital. For individuals >/=65 years of age, 64.4%, 77.0%, and 85.7% were within the respective radii. Complete analysis by age, ethnic origin, and gender are detailed.
In the model described, a substantial percentage of the Canadian population has geographic access to a hospital potentially capable of delivering intravenous thrombolysis for acute ischemic stroke. GIS analysis can identify both population groups and rural areas with limited access to thrombolytic stroke treatment. A coordinated emergency medical service response for stroke is advocated to maximize coverage, as a 60-minute delay in emergency room arrival eliminated 5.1 million people from potential treatment.
Most patients with symptomatic acute myocardial infarction (AMI), the leading cause of death in western industrialized nations, use the emergency department (ED) as their point of entry. Yet, one identified barrier to early recognition of patients with AMI is ED overcrowding. In this paper, the author presents a quality improvement model that applies Lean Six Sigma guidelines to the clinical setting.
Treatment of acute myocardial infarction (AMI) has changed dramatically during the 1990s, and the patients are older. Our aim was to characterize current clinical course, medication and invasive treatment in elderly patients with AMI, compare treatment between sexes and also with data from 1994.
The study population included all patients aged > or = 75 years (n = 197, 68% female), who were admitted from January 1997 to December 1998 to our hospital because of AMI.
Sixty-six percent of both sexes had non-Q AMI. Peak creatine kinase (CK)-MB fraction values were significantly higher in men (p = 0.035). Thrombolysis was performed on 16% and coronary angiography, coronary angioplasty/cardiac surgery on 8% of patients each. In-hospital mortality was high (25%). Cholesterol-lowering agents were used for only 8% of patients. During hospitalization, 15% of patients had an infection requiring intravenous antibiotics. Multivariate analysis revealed that infection increased in-hospital mortality 2.90-fold (95% CI: 1.23-6.82) and congestive heart failure (CHF) 2.25-fold (95% CI: 1.02-4.97). Post-discharge mortality was 10% during the median follow-up of 12 months; 75% of deaths were due to re-infarction. Compared with the year 1994, the use of beta-blockers (84 vs. 70%, p = 0.010) and angiotensin-converting enzyme inhibitors (43 vs. 31%, p = 0.062) had increased, and digitalis (27 vs. 43%, p = 0.0065) and calcium antagonists (13 vs. 26%, p = 0.0086) had decreased.
Treatment and hospital course of AMI in these elderly patients did not differ between sexes. Although drug treatments have become more evidence-based during the end of 1990s, in-hospital mortality was still high and more effective prevention, effective treatment of infections and CHF may be important for improving prognosis.
The aim of this study was to compare electrocardiogram (ECG)-12 dynamics depending on the methods of facilitated and primary angioplasty in patients with acute coronary syndrome. The ECG changes in 81 patients - 73 patients with acute myocardial infarction and 8 patients with unstable angina pectoris - were studied.
The ECG analysis before reperfusion therapy and after angioplasty included: dynamics of summary elevation (Sigma ST+) and depression (Sigma ST-) of ST segment and changes of summary value of R waves (Sigma R) in 12 leads. The results were estimated with consideration for the length of the period from the beginning of pain syndrome till treatment and topics of the infraction-related artery.
According to our data, there was no difference between facilitated and primary transluminal coronary angioplasty in their effect on focal myocardial variation dynamics and the size of peri-infarction zone.
A reliable decrease in elevation and depression of ST segment was observed in reperfusion therapy not later than 6 hours after the beginning of pain syndrome. When reperfusion therapy is begun later, dynamics of summary values of ST segment elevation and depression before and after treatment are not reliable.
The authors reorganized the emergency room (ER) by moving CT to the ER and streamlining triage by prenotification by emergency medical services (EMS), which reduced in-hospital delays and enhanced access to stroke thrombolysis. CT delay dropped from 1 hour 3 minutes +/- 14 minutes in 1999 to 7 +/- 2 minutes in 2004 (p
OBJECTIVES: To explore factors associated with delay time prior to hospital admission and in hospital amongst acute myocardial infarction (AMI) patients with particular emphasis on the delay time to the administration of thrombolytic therapy. METHODS: During a 6-year period we prospectively computerized pre-hospital and in-hospital time intervals for AMI patients admitted to the coronary care unit (CCU) direct from the emergency department (ED) or via paramedics, at Sahlgrenska Hospital, Göteborg, Sweden. RESULTS: Pre-hospital delay: independent predictors of a prolonged delay were increased age (P = 0.0007), female sex (P = 0.02) and a history of hypertension (P = 0.03). For AMI patients who received thrombolytic treatment and the only independent predictor of a prolonged delay was increased age (P = 0.005). In-hospital delay: for all AMI patients independent predictors of a prolonged delay were prolonged pre-hospital delay (P