Gibler W Brian, Armstrong Paul W, Ohman E Magnus, Weaver W Douglas, Stebbins Amanda L, Gore Joel M, Newby L Kristin, Califf Robert M, Topol Eric J
Department of Emergency Medicine, University of Cincinnati, Cincinnati OH, USA.
Ann Emerg Med. 2002 Feb;39(2):123-30. doi: 10.1067/mem.2002.121402.
Early treatment with fibrinolytic therapy substantially decreases mortality in acute myocardial infarction (AMI). We examined delays to hospital arrival and treatment in 2 large, multinational, randomized trials of fibrinolytic therapy: Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-I) and Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO-III).
We evaluated delays to hospital arrival, time from arrival to treatment, and total time to treatment in the 27,849 US patients with AMI enrolled in GUSTO-I or GUSTO-III. Time intervals were defined prospectively for total time to treatment and symptom onset to hospital arrival as 0 to 2 hours (early), 2 to 4 hours, or more than 4 hours (late). Time to fibrinolytic therapy once in hospital was prospectively defined as 0 to 1 hour (early) or more than 1 hour (late). Socioeconomic data were also obtained from patients enrolled in the GUSTO-III trial.
In GUSTO-III, as in GUSTO-I, patients who arrived at the hospital later were older (64 years versus 60 years; P =.001) and more often female (35% versus 27%; P =.001), black (6% versus 4%; P =.02), and diabetic (25% versus 16%; P =.001). These groups also received treatment later once in hospital, as did patients with hypertension (48% versus 42%; P =.001), previous angina (46% versus 36%; P =.001), and previous infarction (21% versus 16%; P =.001). Higher levels of education, professional occupations, and private health insurance were associated with significantly earlier arrival and treatment. Although in hospital time to treatment has decreased (66 minutes to 48 minutes; P <.0001), time to arrival has not changed over the past 7 years, averaging 84 minutes.
Certain groups of patients with AMI, including the elderly, women, diabetic patients, and minorities, exhibit delays to hospital arrival and treatment in the emergency setting. Patients with higher educational levels, professional occupations, and private health insurance arrive at the hospital sooner and receive treatment more quickly. Patients and health care providers must be educated regarding high-risk populations for delay to maximize benefit from fibrinolytic therapy.
溶栓治疗早期干预可显著降低急性心肌梗死（AMI）的死亡率。我们在两项大型跨国溶栓治疗随机试验中，即“冠状动脉闭塞性疾病链激酶和组织型纤溶酶原激活剂的全球应用（GUSTO - I）”和“开放闭塞冠状动脉策略的全球应用（GUSTO - III）”，研究了患者到达医院及接受治疗的延迟情况。
我们评估了参与GUSTO - I或GUSTO - III试验的27849例美国AMI患者到达医院的延迟时间、从到达医院到接受治疗的时间以及总的治疗延迟时间。对于总的治疗延迟时间和从症状发作到到达医院的时间间隔，前瞻性地定义为0至2小时（早期）、2至4小时或超过4小时（晚期）。在医院内开始溶栓治疗的时间前瞻性地定义为0至1小时（早期）或超过1小时（晚期）。还从参与GUSTO - III试验的患者中获取了社会经济数据。
在GUSTO - III试验中，与GUSTO - I试验情况相同，较晚到达医院的患者年龄更大（64岁对60岁；P = 0.001），女性比例更高（35%对27%；P = 0.001），黑人比例更高（6%对4%；P = 0.02），糖尿病患者比例更高（25%对16%；P = 0.001）。这些患者群体在医院内接受治疗的时间也较晚，高血压患者（48%对42%；P = 0.001）、既往有心绞痛患者（46%对36%；P = 0.001）和既往有心肌梗死患者（21%对16%；P = 0.001）也是如此。较高的教育水平、职业以及私人医疗保险与更早到达医院和接受治疗显著相关。尽管在医院内的治疗时间有所减少（从66分钟降至48分钟；P < 0.0001），但在过去7年中，到达医院的时间并未改变，平均为84分钟。
某些AMI患者群体，包括老年人、女性、糖尿病患者和少数族裔，在紧急情况下到达医院和接受治疗存在延迟。教育水平较高、职业较好以及拥有私人医疗保险的患者到达医院更早且接受治疗更快。必须对患者和医疗服务提供者进行教育，使其了解存在延迟风险的高危人群，以便最大程度地从溶栓治疗中获益。
