Rule S, Brooksby P, Sanderson J
Taunton & Somerset Hospital, Musgrove Park, UK.
Postgrad Med J. 1993 Mar;69(809):190-3. doi: 10.1136/pgmj.69.809.190.
The early administration of thrombolytic agents significantly reduces mortality following a myocardial infarct and ideally they could be given by general practitioners when the patient is first seen. However, the diagnosis of myocardial infarction in the early stages can be very difficult especially if an electrocardiogram is not available. This may limit the use of thrombolytic drugs by general practitioners. We assessed the accuracy of diagnosis in general practice by asking general practitioners referring patients with chest pain, the likelihood that the event was due to a myocardial infarction and if they would use thrombolysis if it were available. Diagnostic accuracy and appropriate use of thrombolysis was analysed retrospectively, comparing the general practitioner with the admitting hospital doctor. One hundred consecutive patients were studied. The general practitioners accurately diagnosed myocardial infarctions in approximately 45% of cases and would have given thrombolysis inappropriately on 67% of occasions mainly because the final diagnosis in most of these patients was unstable angina rather than infarction. The hospital doctors administered streptokinase inappropriately to 33% of the patients and four had complications during treatment. Of those patients receiving thrombolysis, the average time delay from the general practitioner referring the patient to hospital to the patient being treated was 107 minutes. This study confirms that the diagnosis of myocardial infarction in the early stages is difficult and that thrombolytic therapy may be given inappropriately (mainly to patients with unstable angina). We conclude that until the accuracy of diagnosis of myocardial infarction can be improved in general practice it would seem inappropriate for thrombolysis to be given in the community at the moment.
早期给予溶栓药物可显著降低心肌梗死后的死亡率，理想情况下，全科医生在首次接诊患者时即可给予此类药物。然而，早期心肌梗死的诊断可能非常困难，尤其是在无法进行心电图检查的情况下。这可能会限制全科医生使用溶栓药物。我们通过询问转诊胸痛患者的全科医生，评估了其诊断的准确性、事件由心肌梗死引起的可能性以及若有溶栓药物是否会使用，以此来评估全科医疗中的诊断准确性。对诊断准确性和溶栓药物的合理使用进行了回顾性分析，将全科医生与收住入院的医生进行比较。共研究了连续的100例患者。全科医生在约45%的病例中准确诊断出心肌梗死，并且在67%的情况下会不恰当地给予溶栓治疗，主要原因是这些患者中的大多数最终诊断为不稳定型心绞痛而非心肌梗死。医院医生对33%的患者不恰当地使用了链激酶，且有4例患者在治疗期间出现并发症。在接受溶栓治疗的患者中，从全科医生将患者转诊至医院到患者接受治疗的平均延迟时间为107分钟。本研究证实，早期心肌梗死的诊断困难，且溶栓治疗可能使用不当（主要针对不稳定型心绞痛患者）。我们得出结论，在全科医疗中，除非心肌梗死的诊断准确性能够提高，否则目前在社区进行溶栓治疗似乎并不合适。
