Prehospital versus hospital fibrinolytic therapy using automated versus cardiologist electrocardiographic diagnosis of myocardial infarction: abortion of myocardial infarction and unjustified fibrinolytic therapy

Abstract

Background This study investigated the incidence of abortion of myocardial infarction and of unjustified fibrinolysis by using automated versus cardiologist-assisted diagnosis of acute ST-elevation myocardial infarction. The results of prehospital diagnosis and treatment (2 cities in the Netherlands) were compared with those of inhospital treatment. Unjustified fibrinolysis must be differentiated from justified thrombolysis resulting in aborted myocardial infarction. Both have the absence of a significant rise in cardiac enzymes in common. In aborted myocardial infarction, this is a result of timely reperfusion; in unjustified thrombolysis, this is the result of an incorrect diagnosis. Methods In the city of Rotterdam, 118 patients were treated before hospitalization for myocardial infarction, diagnosed through the use of a mobile computer electrocardiogram; in the city of Nijmegen, 132 patients were treated before hospitalization with the use of transtelephonic transmission of the electrocardiogram to the coronary care unit and judged by a cardiologist. Their data were compared with those of 269 patients treated inhospital in the city of Arnhem, using the same electrocardiographic criteria. Abortion of myocardial infarction was diagnosed as the absence of a significant rise in cardiac enzymes and the presence of resolution of chest pain and 50% of ST-segment deviation within 2 hours after onset of therapy. Lacking these, the diagnosis of unjustified fibrinolytic therapy was made. Results Unjustified treatment occurred in 8 (3.2%) prehospital-treated patients (4 in Rotterdam and 4 in Nijmegen). Of the inhospital–treated patients in Arnhem, 5 (1.9%) were treated unjustifiably ( P = .49). Aborted myocardial infarction occurred in 15.3% and 18.2% in Rotterdam and Nijmegen, respectively, against 4.5% in inhospital treatment in Arnhem ( P < .001). Conclusions Abortion of myocardial infarction is associated with prehospital thrombolysis. Unjustified fibrinolysis for acute myocardial infarction occurs in prehospital fibrinolysis as frequently as in the inhospital setting. The use of different electrocardiographic methods for diagnosing acute myocardial infarction does not appear to make any difference.