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PubMed2000

Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study.

BACKGROUND: Duration of prehospital delay in patients with acute myocardial infarction (AMI) is receiving increasing attention given the time-dependent benefits associated with prompt use of coronary reperfusion strategies. OBJECTIVE: To examine trends (1986-1997) in time to hospital presentation and factors associated with prolonged delay in a community-wide study of patients with AMI. METHODS: Longitudinal study of 3837 residents of the Worcester, Mass, metropolitan area hospitalized with AMI in 7 one-year periods between 1986 and 1997 in whom information about prehospital delay was available. RESULTS: The mean, median, and distribution of delay times exhibited either inconsistent or no changes over time. In 1986, the mean and median prehospital delay times were 4.1 and 2.2 hours, respectively; these times were 4.3 and 2.0 hours, respectively, in patients hospitalized in 1997. Overall, with no significant differences noted over time, approximately 44% of patients with AMI presented to area-wide hospitals in less than 2 hours after the onset of acute coronary symptoms. Increasing age, history of angina or diabetes, onset of symptoms in the afternoon or evening, and hospitalization in the most recent study year (1997) were significantly associated with delays of more than 2 hours in seeking hospital care after controlling for a variety of factors that might affect delay. CONCLUSIONS: The results of this population-based study suggest that a large proportion of patients with AMI continue to exhibit prolonged delay. The characteristics of many of these individuals can be identified in advance for targeted educational efforts. Arch Intern Med. 2000;160:3217-3223.

Aged↗
PubMed1987

Therapeutic trends in the management of patients with acute myocardial infarction (1975-1984): the Worcester Heart Attack Study.

As part of an ongoing community-wide study of time trends in the incidence and case-fatality rates of patients hospitalized with acute myocardial infarction (MI) in all 16 Worcester, Massachusetts, metropolitan hospitals during the years 1975, 1978, 1981, and 1984, changes over time in the therapeutic management of 3263 patients with validated acute myocardial infarction were examined. Beta-blocker (21%, 1975; 52%, 1984) and nitrate (56%, 1975; 93%, 1984) therapy use increased dramatically over time. Use of antiplatelet agents was inconsistent over time, while use of digoxin remained stable, being used in approximately 40% of all patients over the four periods studied. Use of antiarrhythmic medications other than lidocaine decreased consistently over time (31%, 1975; 22%, 1984). Lidocaine use increased between 1975 (31%) and 1978 (52%) and then leveled off to being used in approximately 45% of hospitalized patients with acute MI in 1981 and 1984. A variety of demographic (e.g., age, sex, teaching hospital) and clinical characteristics (e.g., MI order, MI type, MI location, peak CPK findings, occurrence of acute clinical complications) were also associated with the use of these therapies for the combined study periods. The results of this population-based study suggest considerable changes over time in the therapeutic management of patients hospitalized with acute myocardial infarction and of numerous patient demographic and clinical factors associated with their use.

Adrenergic beta-Antagonists↗
PubMed1994

Temporal trends and factors associated with extent of delay to hospital arrival in patients with acute myocardial infarction: the Worcester Heart Attack Study.

Factors associated with delay to hospital arrival after the onset of symptoms suggestive of acute myocardial infarction (AMI) were examined in the late 1960s and 1970s, but recent data concerning these characteristics are limited. The purpose of the present study was to examine overall and temporal distributions of the extent of patients' delay from the time of onset of AMI symptoms to hospital arrival and factors associated with delay in seeking medical care from a multihospital, population-based perspective. Review of medical records was undertaken of patients hospitalized with a discharge diagnosis of AMI in 16 teaching and community hospitals in Worcester, Mass. in 1986, 1988, and 1990. The study sample comprised 1279 patients hospitalized with validated AMI in whom data concerning extent of patient delay from onset of symptoms suggestive of AMI to hospital arrival were available. The average delay between onset of symptoms suggestive of AMI and arrival at local emergency departments did not change significantly with time (average of 4.1 hours in 1986, 4.0 hours in 1988, and 4.6 hours in 1990). The median delay was 2.0 hours during each of these years. Fifty percent of patients with AMI went to area-wide emergency departments within 2 hours of the onset of acute symptoms, 22% between 2 and 4 hours, and 28% delayed > 4 hours. Results of a multivariable regression analysis showed that older age, history of diabetes, type of medical insurance coverage and previous AMI were significantly associated with delays in hospital arrival of > 2 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

Very early thrombolytic therapy in suspected acute myocardial infarction. The Thrombolysis Early in Acute Heart Attack Trial Study Group.

Three hundred fifty-two patients with suspected acute myocardial infarction (AMI) were randomized to placebo (175) or tissue-type plasminogen activator (rt-PA) (177). Patients were eligible if evaluated within 165 minutes from onset of chest pain and if age was less than 75 years. Electrocardiographic criteria were not required. A mobile coronary care unit with a cardiologist present was used to initiate treatment at home in 29% of the patients. Primary endpoints were infarct size (serum lactate dehydrogenase isoenzyme activity), left ventricular function (radioangiography) and exercise capacity at 30 days. AMI was diagnosed in 59% of all randomized patients. The incidence was similar in the 2 groups (placebo, 108, rt-PA, 101). Among all randomized patients, rt-PA was associated with significantly decreased infarct size and an increased ejection fraction. Among rt-PA-treated patients there were significantly fewer Q-wave infarctions. No difference in exercise capacity could be detected. No benefit was found in subgroups of patients without ST-segment elevation on the initial electrocardiogram. There were 18 (10.3%) and 11 (6.2%) deaths (p = 0.23) within 30 days in the placebo and rt-PA groups, respectively. Adverse reactions were similar in both groups with no excess of complications in the home-treated group. Very early treatment with rt-PA in patients with a strong suspicion of AMI and ST-segment elevation limits infarct size and improves left ventricular function. The infarct pattern is shifted from Q-wave to non-Q-wave infarcts by rt-PA. The study suggests that thrombolysis can be given before hospital admission without additional risk. Furthermore, electrocardiographic records are useful for selection of patients.

Coronary Care Units↗
PubMed1984

Comparisons between different syndromes of heart attack--a multivariate analysis.

A register of acute coronary events in Auckland, New Zealand enabled characterization of cases of the following different coronary syndromes: definite myocardial infarction (MI) (divided to Type I with typical ECG findings and Type II with new symmetrical T wave inversion only), nonhypotensive definite infarction with and without ventricular fibrillation, possible myocardial infarction and sudden death. Comparisons between these syndromes were analyzed. ECG type II (as compared to ECG type I) definite infarction was a more chronic, repeated syndrome, with more myocardial fibrosis in fatal cases, and more previous prolonged anginal pain without documented infarction. Cases of possible (as compared to definite) myocardial infarction were also more likely to report previous prolonged aningal pain, to use beta blockers, furosemide and less likely to die within 30 days. They consumed significantly more alcohol and were more likely to be female, than cases of definite infarction. Patients with nonhypotensive definite infarction complicated by ventricular fibrillation had higher acute phase pulse rates and more pallor and sweating than similar patients not experiencing ventricular fibrillation. Some possible explanations for the above findings were discussed.

Analysis of Variance↗