Use of the Electrocardiograph-Based Thrombolytic Predictive Instrument To Assist Thrombolytic and Reperfusion Therapy for Acute Myocardial Infarction - Use of the Electrocardiograph-Based Thrombolytic Predictive Instrument To Assist Thrombolytic and Reperfusion Therapy for Acute Myocardial Infarction
Does an electrocardiograph-based Thrombolytic Predictive Instrument (TPI) improve the use of thrombolytic and overall reperfusion therapy?
Patients Enrolled: 1197
Patients presenting to the emergency department at 28 hospitals in US with AMI and ST-segment elevation on an electrocardiogram (ECG) were randomly assigned to TPI or control group. The TPI automatically printed on the ECG provides an estimate of the risk of death and hemorrhage with and without thrombolysis. Information used to derive this risk included age, gender, history of hypertension, history of diabetes, blood pressure, time since onset of ischemic symptoms as well as electrocardiographic data that included ST-T wave changes and Q waves along with their location. Clinical effectiveness was assessed by the percentages of patients receiving thrombolytic therapy, thrombolytic therapy within 1 hour of initial ECG, and overall reperfusion (thrombolytic therapy or primary PCI).
43% of 2,875 patients with AMI had ST-segment elevation. Of these, 1197 were randomly assigned to the two study groups (587 to the TPI group and 610 to the control group). Neither the overall use of thrombolytic therapy (60.5% in controls vs 62.1% in TPI patients; [P = 0.2]), nor the use of these agents within one hour (52.5% of controls and 53.3% of TPI patients [P > 0.2] nor the over all rate of reperfusion (67.6% of controls and 70.3% of TPI patients [P = 0.2]) differed between the two groups. The overall use of thrombolytic therapy and any reperfusion strategy increased in patients with inferior AMI and among women in the TPI group, but not among those with anterior AMI or in men. The use of thrombolytic therapy or reperfusion therapy, including administration of thrombolytic therapy within one hour increased in patients who required physician consultation by telephone in the TPI group.
Among patients with ST segment elevation MI, the availability of a TPI was not associated with any significant impact on the utilization or delivery of reperfusion therapy within the first hour after patient arrival. The number of patients with ST elevation AMI that were ideal (with appropriate indication [including within the time window for reperfusion] and without any contraindications to reperfusion therapy was not provided. In absence of this information, it is difficult to ascertain the true impact of the TPI tool from the current study. Further, the current tool does not incorporate any contraindications to reperfusion strategy, a factor equally important in the algorithm for the use of any reperfusion strategy.
Selker HP, Beshansky JR, Griffith JL, for the TPI Trial Investigators. Use of the Electrocardiograph-Based Thrombolytic Predictive Instrument To Assist Thrombolytic and Reperfusion Therapy for Acute Myocardial Infarction: A Multicenter, Randomized, Controlled, Clinical Effectiveness Trial. Ann Intern Med 2002; 137:87-95.
Keywords: Thrombolytic Therapy, Blood Pressure, Emergency Service, Hospital, Fibrinolytic Agents, Electrocardiography, Hypertension, Diabetes Mellitus
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