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Re: Minutes matter - Hours matter more!

Dear Editor

Leah et al’s interesting paper describes a 10.5-minute time saving based on preparation of thrombolytic therapy for acute myocardial infarction (AMI). They go on to demonstrate an improvement in performance against the door to needle standard.[1]

While no cost – benefit examination is made, the authors make reference to Boersma’s work to illustrate the benefits of early thrombolysis.[2] Perhaps more useful is work by Morrison et al which presents a linear model suggesting a mortality benefit of 2 lives per 100 patients treated per hour of earlier thrombolysis delivery.[3] Using this model the authors would need to treat 300 patients to save a life.

Studies have shown pre-hospital thrombolysis to be feasible, safe and effective. Impressive call-to-needle time savings of 240 minutes were demonstrated by the GREAT study based in rural North East Scotland.[4] Similarly benefits in the urban environment have been described.[5]

Our point is simply that if we are to invest in expensive bolus thrombolytics, we should perhaps also develop systems to allow their administration in the pre-hospital setting.

References

(1) V Leah, C Clark, K Doyle, and T J Coats. Does a single bolus thrombolytic reduce door to needle time in a district general hospital? Emerg Med J 2004 21: 162-164.

(2) Boersma E, Maas ACP, Deckers JW, Simoons ML. Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour. Lancet 1996; 348: 771-75.

(3) Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ. Mortality and prehospital thrombolysis for acute myocardial infarction. A meta-analysis. JAMA 2000; 283: 2686-92.2.

(4) GREAT Group. Feasibility, safety and efficacy of domiciliary thrombolysis by General Practitioners: Grampian region Anistriplase trial: BMJ 1992; 305: 548 – 553.