Professional Documents
Culture Documents
Maarten L Simoons, Eric Boersma, Coen van der Zwaan, Jaap W Deckers
downtown Amsterdam in 1978 and is still operational intarction with a duration of less than 12 h and with
at the Academic Medical C e n t r e 2 z Similar units were persistent ST-segment elevation or new bundle branch
10~11 . . . .
created in other hospitals in Netherlands. These early block. Different strategies may be chosen, Including
precoronary care units provided E C G arrhythmia percutaneous transluminal coronary angioplasty (PTCA),
monitoring, sequential measurements of myocardial with or without stenting, and intravenous administration
proteins (creatinine kinase [CK], CK-MB) and functional of alteplase (accelerated regimen), reteplase, strep-
assessment of myocardial perfusion, 13 although the latter tokinase, or other fibrinolytics. A rescue P T C A procedure
method may be too costly for routine use. Introduction may be offered to patients with apparent reperfusion after
of precoronary care units did reduce the proportion of intravenous thrombolysis, xl As in many other fields of
patients not at immediate risk who were nevertheless medicine, efficacy and costs of these different strategies
admitted to the more costly coronary care unit and are proportionally related, with high direct costs for the
facilitated early discharge of low-risk patients. 1~14 More most effective treatment regimen--direct PTCA. Since
recently, similar chest-pain units have been opened in the facilities are often limited, a physician has to choose the
USA) ~ most appropriate therapy within budgetary constraints.
The diagnosis of evolving myocardial infarction or Again, a systematic assessment of the expected benefit
of unstable angina is surrounded by uncertainty: a expressed as "life-years saved" by each mode of therapy
decision not to admit a given patient may, in retrospect, be as well as assessment of the risks of such therapy,
questioned. Yet, admission and clinical assessment of all particularly the risk of intracranial )aaemorrhage with
patients with vague, non-specific symptoms would be thrombolytic therapy, 22 may guide physicians in their
an unnecessary overkill. Simple algorithms may assist the choice of treatment for individual patients. 23'z4
general practitioner as well as the physician in a hospital
emergency department in such decisions. Key elements Management of ACS without persistent
for such decision are the history of a patient, the character ST-segment elevation
and duration of chest-pain, and, particularly, the ECG. Patients with ACS without persistent ST-segment
A unique approach has been developed in Rotterdam, elevation, or new bundle branch block, usually have severe
where the ambulances are equipped with computerised coronary artery stenosis without total occlusion.
diagnostic E C G systems. The E C G interpretation is Immediate thrombolytic therapy in such patients is not
provided on site to the general practitioners, who are beneficial and should be avoided. The appropriate therapy
encouraged to reconsider whether a particular patient includes aspirin, unfractionated or low-molecular-weight
should be admitted to hospital if symptoms have resolved heparin, nitrates, and B-blockers. Platelet glycoprotein
and the E C G is normal26 Of the first 121 patients who IIb/IIIa receptor blockers have been shown to reduce the
were initially considered for hospital admission, but in risk of progression to myocardial infarction or death in
whom that decision was reversed upon analysis of the these patients. 2s'26 Systematic risk assessment may help
E C G taken at home and provided by the ambulance to select the optimum regimen for each patient, and
system, ten (8%) had a small infarction based on to identify those in whom early revascularisation by
subsequent systematic analysis of myocardial enzymes. All P T C A or bypass surgery may be offered. Useful models
recovered uneventfully. It was decided that the small risk for risk assessment have been developed from the
of a false-negative diagnosis was acceptable ~6 and the G U S T O IIb and P U R S U I T databases. 2~,2~ Risk factors
limited risk of early discharge from a precoronary care associated with development of myocardial infarction
unit. ~ 4 or death include advanced age, biochemical markers of
myocardial necrosis at enrolment, a recent history of
Prehospital thrombolytic therapy severe angina (Canadian Cardiac Society Class III or IV),
Equipment for E C G diagnosis, in addition to E C G and ST-segment depression on the E C G at presentation.
arrhythmia monitoring, was introduced for early In the larger trials, measurement of CK-MB or total C K
recognition of myocardial infarction in order to enable was recorded as a marker of myocardial necrosis at
immediate prehospital reperfusi0n therapy. 1~,~ The enrolment. Other smaller studies, however, indicate that
benefits of such early prehospital fibrinolytic therapy measurement of cardiac troponin T or troponin I has
have been established, and are of similar magnitude a higher predictive value for the identification of patients
to the benefits of direct percutaneous transluminal at low risk of new life-threatening events. 29 In patients
coronary angioplasty compared with inhospital at high risk of such events, for example, with a risk greater
fibrinolysis--about 20 additional survivors of 1000 than 5% in 30 days, angiography and coronary
treated. ~9~2More widespread use of prehospital diagnosis revascularisation should be considered, z~ Patients at very
and treatment of myocardial infarction should be low risk (<1% at 30 days) are characterised by younger
encouraged. Furthermore, prehospital E C G diagnosis age, absence of previous coronary artery disease, troponin
may help to select patients for direct coronary angioplasty concentrations within the normal range, and absence
when such treatment is available. Decisions at the of ST-segment depression. Such patients are candidates
patient's home or elsewhere outside hospital have to be for early hospital discharge. In the intermediate group
taken rapidly, usually by physicians or ambulance nurses (risk between 1% and 5%) close monitoring for recurrent
with less experience than a hospital-based cardiologist. ischaemia and an early stress test may help to select
Yet, the benefits of immediate prehospital treatment those who require additional revascularisation and those
outweigh the risk associated with a false-positive who can be managed medically,z9,3In patients selected for
diagnosis. coronary angio-plasty, with or without a stent, a
glycoprotein IIb/IIIa receptor blocker should be continued
Tailored reperfusion therapy until after the procedure, because these drugs offer
Immediate reperfusion therapy is indicated in all patients significant protection from thrombotic events at the time
with symptoms suggestive of evolving myocardial of the angioplasty,z~'z6
28 Holmvang L, Luscher MS, Clemmensen P, Thygesen K, Grande P. Physiopathology and Electrocardiology. Eurff Heart 1993; 14: 969-88.
Very early risk stratification using combined E C G and biochemical 32 TheTask Force on the management of acute myocardial infarction of
assessment in patients with unstable coronary artery disease (a the European Society of Cardiology. Acute myocardial infarction:
thrombin inhibition in myocardial ischaemia [TRIM] substudy). pre-hospital and in-hospital management. Bur HeartJ 1996; 17:
Circulation 1998; 98: 2004-09. 43-63.
29 Geleijnse ML~ Elhandy A~ Kasprzak JD, et al. Safety and prognostic 33 Wood D, Backer G de, Faergeman O, Graham I, Manicia (3,
value of early dobutamine-atropine stress echocardiography in patients Pyorala K. Prevention of coronary heart disease in clinical practice.
with spontaneous chest pain and a nondiagnostic electrocardiogram. J Recommendations of the Second Joint Task Force of European and
Am Coil Cardio11998; 11: 606-11. other Societies on Coronary Prevention. Bur Heart J 1998; 19:
30 Armstrong PW, FuY~ ChangWC, et al. Acute coronary syndromes in 1434-503.
the GUSTO-IIb trial prognostic insights and impact of recurrent 34 Simoons ML~ Brand M van den, IAncoffM, et al. Minimal myocardial
ischaemia. Ciculation 1998; 98: 1860-68. damage during coronary intervention is associated with impaired
31 Task Force of theWorking Group on Exercise Physiology, outcome. Eur Heartff (in press).