Coronary thrombolysis: still too little too late?

We reviewed the case records of 109 consecutive patients with a definite diagnosis of myocardial infarction, admitted through the accident and emergency department of an inner-city general hospital to identify delays in referral to hospital, admission to the coronary care unit, and start of thrombolysis. Of the 109 patients, only 28 (26%) received streptokinase (the only thrombolytic drug used at this hospital), and at least 47 (58%) of the remaining 81 who should have benefited from it did not. However, the proportion of patients given streptokinase improved significantly after publication of the Second International Study of Infarct Survival (ISIS 2) study results. The average delay from onset of symptoms to presentation at the accident department was over 3 hours, with a further 1 hour in-hospital delay before administration of streptokinase. This study revealed considerable underuse of thrombolytic therapy in cases where treatment was clearly indicated, but this picture improved substantially during the period of audit.