Thrombolytic therapy guided by a decision analysis model: are there potential benefits for patient management?

Although thrombolytic therapy improves the outcome of myocardial infarction, it is associated with increased risks of stroke and bleeding; these risks may outweigh the benefits of therapy. The risks and benefits of thrombolysis, for any individual clinical situation, can be explicitly estimated by means of decision analysis.

The aim of this study was to compare the actual use of thrombolytic agents for suspected acute myocardial infarction (AMI) with the management preferred by a decision analysis model.

Admission data prospectively obtained in 262 consecutive patients admitted to a rural community hospital's coronary care unit with suspected AMI, as well as clinical decisions and outcomes, were reviewed and analyzed.

Seventeen deaths from AMI and no major strokes were observed, compared with 18.30 deaths and 0.85 major strokes predicted by a decision analysis model. Forty-seven of 84 patients with confirmed AMI and 3 of 178 without AMI were given a thrombolytic agent, compared with 65 patients with and 7 without AMI who had decision analysis-guided therapy. Decision analysis-guided therapy could have saved 3.7 additional lives and gained 29.6 life years, but produced 0.4 extra strokes. Changing the quality adjustment for stroke or heart failure would not have altered the treatment preferred by decision analysis in any of the 262 cases studied. Some patients were predicted to benefit considerably from thrombolysis with little extra risk of stroke and vice versa: all cases must, therefore, be assessed individually.

A decision analysis model can guide thrombolytic therapy by promptly defining its risks and benefits.