Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy
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D R Cragg1, H Z Friedman, J D Bonema
1William Beaumont Hospital, Royal Oak, Michigan.
Insights
Most acute myocardial infarction patients are ineligible for thrombolytic therapy due to contraindications. Ineligible patients face significantly higher mortality rates, highlighting a critical gap in reperfusion treatment for high-risk individuals.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Research
Background:
- Thrombolytic therapy is a cornerstone treatment for acute myocardial infarction (AMI).
- Patient eligibility for thrombolytic therapy is often limited by contraindications.
- Understanding the characteristics and outcomes of ineligible patients is crucial for improving AMI care.
Purpose of the Study:
- To determine the proportion of AMI patients ineligible for thrombolytic therapy.
- To analyze the natural history and outcomes of these ineligible patients.
Main Methods:
- Retrospective chart review of patients hospitalized with AMI.
- Analysis of data from a large community-based hospital over a 27-month period.
- Identification of reasons for exclusion from thrombolytic therapy and assessment of mortality.
Main Results:
- 78% of AMI patients did not receive reperfusion therapy, with 16% receiving protocol thrombolysis and 7% receiving non-protocol reperfusion due to contraindications.
- Ineligible patients were older, more likely women, and had more comorbidities (hypertension, previous MI, chronic angina).
- Mortality was fivefold higher in ineligible patients (19%) compared to protocol-treated patients (4%), with increased risk associated with advanced age, bleeding risk, ineligible ECG, and multiple exclusion criteria.
Conclusions:
- Thrombolytic therapy is underutilized in the US for AMI, primarily administered to low-risk patients.
- A significant majority of acute myocardial infarction patients are excluded from reperfusion therapies.
- The high mortality in ineligible patients underscores the need for alternative treatment strategies and further research.
Objective:
To determine what proportion of patients with acute myocardial infarction are not eligible for thrombolytic therapy and to assess their natural history.
Design:
Retrospective chart review.
Setting:
A large community-based hospital.
Patients:
All patients with acute myocardial infarction hospitalized during a 27-month period.
Measurements:
Of 1471 patients with acute myocardial infarction, 230 (16%) received thrombolytic therapy according to the protocol and an additional 97 (7%) received nonprotocol thrombolytic therapy, primary coronary balloon angioplasty, or both because of contraindications. The other 1144 patients (78%) did not receive reperfusion therapy.
Main Results:
The patients who did not receive thrombolytic therapy were older, more likely to be women, and more likely to have a history of hypertension, previous myocardial infarction, or chronic angina (all comparisons, P less than 0.002). An average of 1.9 reasons for exclusion were identified per patient among the ineligible patients. Mortality was fivefold higher among ineligible patients (19%; Cl, 16% to 21%) than among protocol-treated patients (4%; Cl, 1% to 6%) (P less than 0.001). In-hospital mortality rates for excluded patients were 28% (Cl, 23% to 32%) in elderly patients (age, greater than 76 years; n = 396); 29% (Cl, 23% to 35%) in patients with stroke or bleeding risk (n = 209); 17% (Cl, 14% to 20%) in patients with delayed presentation (greater than 4 hours after the onset of chest pain; [n = 599]); 14% (Cl, 11% to 16%) in patients with an ineligible electrocardiogram (ECG) (n = 673); and 26% (Cl, 21% to 32%) in patients with a miscellaneous reason for exclusion (n = 243). Independent predictors of increased mortality were: age greater than 76 years, stroke or other bleeding risk, ineligible ECG, or the presence of two or more exclusion criteria.
Conclusions:
Thrombolytic therapy is currently used in the United States for only a minority of patients with acute myocardial infarction: those who have low-risk prognostic characteristics.
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