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CLINICAL STUDY: MYOCARDIAL INFARCTION

Consequences of overutilization and underutilization of thrombolytic therapy in clinical practice

Michael Mundt Ottesen, MD^*, Lars Køber, MD, DMSc^*, Stig Jørgensen, MD, Christian Torp-Pedersen, MD, DMSc, FACC^* on behalf of the TRACE Study Group

^* Department of Cardiology, Gentofte University Hospital of Copenhagen, Copenhagen, Denmark
Department of Internal Medicine, Amager Hospital of Copenhagen, Copenhagen, Denmark, on behalf of the TRACE Study Group

Manuscript received June 21, 2000; revised manuscript received November 20, 2000, accepted January 12, 2001.

Reprint requests and correspondence: Dr. Michael Ottesen, Department of Cardiology P, Projektgruppen, Gentofte University Hospital of Copenhagen, DK-2900, Hellerup, Denmark
otte{at}heart.dk

OBJECTIVES

The aim of this study was to evaluate the consequences, measured as mortality and in-hospital stroke, of the use of thrombolytic therapy among patients with acute myocardial infarction (AMI), who do not fulfill accepted criteria or who have contraindications to thrombolytic therapy (i.e., overutilization) and among patients who are withheld thrombolytic treatment despite fulfilling indications and having no contraindications (i.e., underutilization).

BACKGROUND

The implementation of treatment with thrombolysis in clinical practice is not in accordance with the accepted criteria from randomized studies. The consequence has been over- and underutilization of thrombolytic therapy among patients with AMI in clinical practice. The outcome of overutilization of thrombolytic therapy has not been described previously.

METHODS

We examined 6,676 consecutive patients admitted to the hospital with an AMI and recorded characteristics, in-hospital complications and long-term mortality.

RESULTS

Overall, 41% of the patients received thrombolytic therapy. Thrombolytic therapy was underutilized in 14.3% and overutilized in 12.9% of the patients. The use of thrombolytic therapy was associated with reduced mortality in every subgroup examined, including patients without an accepted indication, with an accepted indication and in patients with prior stroke. The risk ratio of in-hospital stroke was not increased in connection with thrombolytic therapy, not even in patients with prior stroke (relative risk = 0.237, 95% confidence interval: 0.031 to 1.810, p = 0.17).

CONCLUSIONS

With the large benefit known to be associated with thrombolytic therapy and the favorable result of thrombolytic therapy in patients with contraindications observed in this study, we conclude that a formal evaluation of thrombolytic therapy in wider patient categories is warranted.

Abbreviations and Acronyms   AMI = acute myocardial infarction   ECG = electrocardiogram   FTT = Fibrinolytic Therapy Trialist Collaborative Group   TRACE = TRAndolapril Cardiac Evaluation study

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