• National service Framwork
• coronary heart disease

The benefits of early thrombolysis in acute myocardial infarction are well known.¹ In March 2000 the National Service Framework for coronary heart disease established a target of 60 minutes between the patient’s call for help and the delivery of thrombolysis.² Emphasis is placed upon improved ambulance response and more efficient delivery of in hospital or prehospital thrombolysis, but hardly any attention is paid to the “decision time”: the minutes that elapse between symptom onset and a call for professional help.

We routinely audit all patients thrombolysed in our inner city emergency department. Times of pain onset and call for help are recorded when available. Between February 2000 and January 2001 complete data are available for 94 of the 127 patients thrombolysed. Sixty two (66%) of these patients had experienced symptoms for more than half an hour before calling for help. The median decision time was 60 minutes. Twenty per cent of patients called their general practitioner rather than an ambulance.

From June 2001 to June 2002 we also recorded whether each patient thrombolysed was known to have previous coronary heart disease. Complete data on 108 of the 123 patients thrombolysed revealed that 38 had known and 70 unknown coronary heart disease. The median decision times were 77 and 60 minutes respectively.

Our figures strongly support the view that overall “pain to needle” times are greatly undermined by prolonged decision times. For whatever reason, many patients remain reluctant to seek assistance, and comparison with previous audit suggests that very little has changed since 1993.³ It also seems that patients with known coronary heart disease are no more likely to seek early professional help.

We believe that there is a need for greater emphasis on patient education within the National Service Framework. Improvements in the “pain to needle” time, and thereby patient outcomes, are now most likely to be achieved through a reduction in decision times, but the best approach to this problem remains unclear. Previous media campaigns undertaken in Europe have led to significant reductions in the decision time, though the cost of this has often been an increase in the number of emergency department chest pain attendances, many of whom do not have significant cardiac disease.⁴ We suggest that an effective and contemporary public education strategy is urgently required, and that the effect of this intervention be evaluated as fully as possible. In the meantime we wish to reiterate the simple recommendation made by the National Service Framework and British Heart Foundation: patients with ischaemic heart disease should call an emergency ambulance if their angina is unrelieved after 15 minutes. In addition, any member of the public experiencing symptoms suggestive of myocardial infarction should call the ambulance service and not their general practitioner.