Ketley D, Woods K L
Department of Pharmacy, Leicester Royal Infirmary.
Br Heart J. 1995 Sep;74(3):224-8. doi: 10.1136/hrt.74.3.224.
To identify and rank the factors that currently limit the use of thrombolytic treatment in patients admitted to hospital with acute myocardial infarction.
Weighted sampling study with retrospective data retrieval from clinical records.
All hospitals within the Trent region providing acute general medical services.
Random sample of 420 patients admitted during February-April 1993 who had acute myocardial infarction as the main discharge diagnosis.
Treatment odds ratios (and 95% confidence intervals (CI)) for the use of thrombolysis in patient groups defined by relevant clinical characteristics.
The patient population was older and less likely to have ST segment elevation on the initial electrocardiogram than patients entered into the randomised trials of thrombolysis. Thrombolytic treatment was given to 49% of patients (SE 2.4%). After controlling for negative associations with a history of stroke (treatment odds ratio 0.18 (95% CI 0.04 to 0.53)) and peptic ulcer (odds ratio 0.52 (95% CI 0.26 to 1.01)) use of thrombolysis decreased with increasing patient age. This was particularly noticeable for those aged > 74 years (odds ratio 0.17 (95% CI 0.05 to 0.51)) relative to those aged < 65 years. Thrombolysis was less likely to be used in patients with ST depression (odds ratio 0.22 (95% CI 0.11 to 0.41)) or bundle branch block (odds ratio 0.18 (95% CI 0.07 to 0.44)) than in those with ST elevation on the initial electrocardiogram. Delay from symptom onset to admission was more than 12 h in 15% of patients.
The patient population admitted to hospital with acute myocardial infarction differs in several respects from the samples that have been included in the trials of thrombolysis. The main factors limiting wider use of thrombolysis are diagnostic uncertainty at admission and delayed presentation. Perceived clinical contraindications to treatment are of lesser importance. There is evident reluctance to use thrombolytic treatment in older patients, who were substantially under-represented in the clinical trials.
识别并对目前限制急性心肌梗死住院患者使用溶栓治疗的因素进行排序。
采用加权抽样研究，从临床记录中回顾性检索数据。
特伦特地区提供急性综合医疗服务的所有医院。
1993年2月至4月期间入院的420例患者的随机样本，这些患者以急性心肌梗死作为主要出院诊断。
根据相关临床特征定义的患者组中使用溶栓治疗的治疗优势比（及95%置信区间（CI））。
与参加溶栓随机试验的患者相比，该患者群体年龄更大，初始心电图出现ST段抬高的可能性更小。49%的患者接受了溶栓治疗（标准误2.4%）。在控制了与中风病史（治疗优势比0.18（95%CI 0.04至0.53））和消化性溃疡（优势比0.52（95%CI 0.26至1.01））的负相关后，溶栓治疗的使用随着患者年龄的增加而减少。相对于65岁以下的患者，74岁以上患者尤其明显（优势比0.17（95%CI 0.05至0.51））。与初始心电图出现ST段抬高的患者相比，ST段压低（优势比0.22（95%CI 0.11至0.41））或束支传导阻滞（优势比0.18（95%CI 0.07至0.44））的患者使用溶栓治疗的可能性较小。15%的患者从症状发作到入院的延迟超过12小时。
急性心肌梗死住院患者群体在几个方面与溶栓试验中纳入的样本不同。限制更广泛使用溶栓治疗的主要因素是入院时诊断不确定和就诊延迟。治疗的明显临床禁忌证的重要性较低。在老年患者中明显不愿使用溶栓治疗，而老年患者在临床试验中的代表性严重不足。
