Initial therapy for acute myocardial infarction: socioeconomic implications and limitations

The optimal therapeutic approach for acute myocardial infarction (AMI) is still evolving; however, many would consider one of two basic options: "medical"-only thrombolysis or reperfusion, or an early (invasive), percutaneous coronary intervention (PCI). The decision about which is most appropriate depends (perhaps unfortunately) on more than just medical factors. That is, the choice for some patients is also limited by payor source and the technical capabilities at the site of the initial treatment. Practically speaking, a significant portion of the US population simply does not have the option of (at least, initial) PCI.

Kino Community Hospital in Tucson, AZ, serves primarily an indigent population in southern Arizona, near the border with Mexico. This facility does not have in-house capability for PCI. Therefore, shortly after the publication of the original Thrombolysis in Myocardial Infarction (TIMI) 14 study (June 1999), we implemented their combination reperfusion protocol for the initial therapy of eligible patients admitted to the hospital with AMI. This report documents our experience with this medical reperfusion regimen in 42 patients over a span of almost 3 years. A retrospective chart review was conducted to evaluate outcome in 42 patients with ST-segment elevation myocardial infarction given the TIMI-14 reperfusion regimen. Resolution of ST-segment changes occurred in 30 patients (71.4%) [complete resolution in 25 patients (59.5%) and incomplete resolution in 5 patients (1.9%)], with major bleeding complicating the therapy of only 1 patient (2.38%) [corrected]. After stabilization in our facility, 28 patients (66.6%) needed PCI.

This report summarizes the experience of a small county hospital where medical thrombolysis is the only immediate therapy available.