The patient with acute myocardial infarction who does not receive reperfusion treatment

Acute myocardial infarction is still the most common cause of death in most western industrialised countries. Thrombolysis as well as primary angioplasty have been proven to be effective treatments for acute myocardial infarction, resulting in a significant reduction in mortality.1-6 Based on the findings of large randomised trials, the current guidelines of the American College of Cardiology and the American Heart Association7 therefore recommend the use of thrombolytic treatment in patients with acute myocardial infarction who present to the hospital within 12 hours of symptom onset, regardless of age and sex. For patients with contraindications to thrombolytic treatment or who are at increased risk of bleeding, primary angioplasty is recommended. Despite these evident beneficial effects of early reperfusion treatment and the strong recommendations for its use, prospective observational studies have shown that only a minority of patients with acute myocardial infarction receive any reperfusion treatment.8 9 Rogers and colleagues9reported a reperfusion rate of 35.1% among 240 989 consecutive patients with acute myocardial infarction in the national registry of myocardial infarction in the USA; this is substantially lower than the 51–62% of patients with acute myocardial infarction who it is deemed should be eligible for thrombolysis.10 Consequently the hospital mortality was more than twice as high in the patient group without reperfusion as compared to that with reperfusion treatment (13.1% v 5.9%, p < 0.01). Using a decision analysis model, Fendrick and associates11showed that more than 10 000 deaths annually are attributable to the underutilisation of thrombolytic treatment for acute myocardial infarction in the USA. Large German prospective observational registries of acute myocardial infarction documented higher reperfusion rates: the 60 minutes myocardial infarction project,12 involving 14 980 patients enrolled consecutively between 1992 and 1994, observed a reperfusion rate of 53%; and the myocardial infarction registry (MIR),13 …