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Improved Health Benefits of Increased Use of Thrombolytic Therapy

Improved Health Benefits of Increased Use of Thrombolytic Therapy Abstract Background: To quantify population health consequences of increased use of thrombolytic therapy for acute myocardial infarction in the United States. Methods: A decision analytic model was constructed to evaluate treatment-related outcomes for two myocardial infarction treatment strategies: standard therapy and standard therapy plus combination aspirin-thrombolytic therapy. Patients were entered into the model by age, electrocardiographic presentation, and time to medical evaluation. Estimated mortality changes associated with increased use of thrombolytic therapy were calculated both for populations for which thrombolytic therapy is recommended and for specific patient populations for which thrombolytic therapy is not recommended under current guidelines. Sensitivity analyses tested the robustness of results when input variables were altered. Results: If every patient with acute myocardial infarction for whom thrombolytic therapy is recommended under current guidelines were treated with aspirin and a thrombolytic agent, more than 4000 additional lives would be saved annually in the United States. The model projected that approximately 8000 additional lives could be saved if use of thrombolytic therapy were expanded to include the following patient groups: age greater than 75 years (approximately 4500 lives saved), left bundle-branch block on electrocardiogram (approximately 2500 lives saved), and presentation 6 to 12 hours after the onset of chest pain (approximately 2000 lives saved). Sensitivity analysis demonstrated a mortality advantage attributable to the use of thrombolytic therapy in each clinical scenario tested. Conclusions: Providing thrombolytic therapy more aggressively could prevent over 12 000 deaths from acute myocardial infarction each year in the United States.(Arch Intern Med. 1994;154:1605-1609) References 1. Gruppo Italiana per lo Studio dello Streptochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic therapy in acute myocardial infarction . Lancet . 1986;1:397-402. 2. ISAM Study Group. A prospective trial of streptokinase in acute myocardial infarction: mortality, morbidity and infarct size at 21 days . N Engl J Med. 1986; 314:1465-1471.Crossref 3. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;2:349-360. 4. Wilcox RG, Olsson CG, Skene AM, et al, for the ASSET Study Group. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction . Lancet . 1988;2:525-530.Crossref 5. AIMS Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction . Lancet . 1988;1:545-549. 6. Kennedy JW, Ritchie JL, Davis KB, Stadius ML, Maynard C, Fritz JK. The Western Washington Randomized Trial of Intracoronary Streptokinase in Acute Myocardial Infarction: a twelve month follow-up report . N Engl J Med. 1985;312:1073-1078.Crossref 7. Schroder R, Neuhaus KL, Leizorovicz A, for the ISAM Study Group. A prospective placebo-controlled double-blind multicenter trial of intravenous streptokinase in acute myocardial infarction (ISAM): long-term mortality and morbidity . J Am Coll Cardiol. 1987;9:197-203.Crossref 8. Simoons ML, Serruys PW, van den Brand M, et al. Early thrombolysis in acute myocardial infarction . J Am Coll Cardiol. 1986;7:717-728.Crossref 9. Maggioni AP, Franzosi MG, Santoro E, for the Gruppo Italiana per lo Studio dello Streptochinasi nell'Infarto Miocardico II (GISSI-2) and the International Study Group. The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment . N Engl J Med. 1992;327:1-6.Crossref 10. Muller DWM, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy . Ann Intern Med. 1990;113:949-960.Crossref 11. Grines CL, DeMaria AN. Optimal utilization of thrombolytic therapy for acute myocardial infarction . J Am Coll Cardiol. 1990;16:223-231.Crossref 12. Doorey AJ, Michelson EL, Weber FJ, Dreifus LS. Thrombolytic therapy in acute myocardial infarction . J Am Coll Cardiol. 1987;10:1357-1360.Crossref 13. Cragg DR, Friedman HZ, Bonema JD, et al. Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy . Ann Intern Med. 1991;115:173-177.Crossref 14. Lee TH, Weisberg MC, Brand DA, Rouan GW, Goldman L. Candidates for thrombolysis among emergency room patients with acute chest pain . Ann Intern Med. 1989;110:957-962.Crossref 15. Pfeffer MA, Moyé LA, Braunwald E, et al. Selection bias in the use of thrombolytic therapy in acute myocardial infarction . JAMA . 1991;266:528-532.Crossref 16. Kennedy JW. Expanding the use of thrombolytic therapy for acute myocardial infarction . Ann Intern Med. 1990;113:907-908.Crossref 17. Udvarhelyi IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the Medicare population: process of care and clinical outcomes . JAMA . 1992;268:2530-2536.Crossref 18. Krumholz HM, Pasternak RC, Weinstein MC, et al. Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction . N Engl J Med. 1992;327:7-13.Crossref 19. Sherry S, Marder VJ. Mistaken guidelines for thrombolytic therapy of acute myocardial infarction in the elderly . J Am Coll Cardiol. 1991;17:1237-1238.Crossref 20. Detailed Diagnoses and Procedures: National Hospital Discharge Survey . Washington, DC: National Center for Health Statistics; 1989. 21. American Heart Association. 1991 Heart and Stroke Facts . Dallas, Tex: American Heart Association; 1991. 22. Doorey AJ, Michelson EL, Topol EJ. Thrombolytic therapy of acute myocardial infarction: keeping the unfulfilled promises . JAMA . 1992;268:3108-3114.Crossref 23. Levin LA, Jonsson B. Cost-effectiveness of thrombolysis: a randomized study of intravenous rt-TPA in suspected myocardial infarction . Eur Heart J. 1992;13:2-8. 24. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction . N Engl J Med. 1993; 328:673-679.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Improved Health Benefits of Increased Use of Thrombolytic Therapy

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References (31)

Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420140071009
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: To quantify population health consequences of increased use of thrombolytic therapy for acute myocardial infarction in the United States. Methods: A decision analytic model was constructed to evaluate treatment-related outcomes for two myocardial infarction treatment strategies: standard therapy and standard therapy plus combination aspirin-thrombolytic therapy. Patients were entered into the model by age, electrocardiographic presentation, and time to medical evaluation. Estimated mortality changes associated with increased use of thrombolytic therapy were calculated both for populations for which thrombolytic therapy is recommended and for specific patient populations for which thrombolytic therapy is not recommended under current guidelines. Sensitivity analyses tested the robustness of results when input variables were altered. Results: If every patient with acute myocardial infarction for whom thrombolytic therapy is recommended under current guidelines were treated with aspirin and a thrombolytic agent, more than 4000 additional lives would be saved annually in the United States. The model projected that approximately 8000 additional lives could be saved if use of thrombolytic therapy were expanded to include the following patient groups: age greater than 75 years (approximately 4500 lives saved), left bundle-branch block on electrocardiogram (approximately 2500 lives saved), and presentation 6 to 12 hours after the onset of chest pain (approximately 2000 lives saved). Sensitivity analysis demonstrated a mortality advantage attributable to the use of thrombolytic therapy in each clinical scenario tested. Conclusions: Providing thrombolytic therapy more aggressively could prevent over 12 000 deaths from acute myocardial infarction each year in the United States.(Arch Intern Med. 1994;154:1605-1609) References 1. Gruppo Italiana per lo Studio dello Streptochinasi nell'Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic therapy in acute myocardial infarction . Lancet . 1986;1:397-402. 2. ISAM Study Group. A prospective trial of streptokinase in acute myocardial infarction: mortality, morbidity and infarct size at 21 days . N Engl J Med. 1986; 314:1465-1471.Crossref 3. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1988;2:349-360. 4. Wilcox RG, Olsson CG, Skene AM, et al, for the ASSET Study Group. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction . Lancet . 1988;2:525-530.Crossref 5. AIMS Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction . Lancet . 1988;1:545-549. 6. Kennedy JW, Ritchie JL, Davis KB, Stadius ML, Maynard C, Fritz JK. The Western Washington Randomized Trial of Intracoronary Streptokinase in Acute Myocardial Infarction: a twelve month follow-up report . N Engl J Med. 1985;312:1073-1078.Crossref 7. Schroder R, Neuhaus KL, Leizorovicz A, for the ISAM Study Group. A prospective placebo-controlled double-blind multicenter trial of intravenous streptokinase in acute myocardial infarction (ISAM): long-term mortality and morbidity . J Am Coll Cardiol. 1987;9:197-203.Crossref 8. Simoons ML, Serruys PW, van den Brand M, et al. Early thrombolysis in acute myocardial infarction . J Am Coll Cardiol. 1986;7:717-728.Crossref 9. Maggioni AP, Franzosi MG, Santoro E, for the Gruppo Italiana per lo Studio dello Streptochinasi nell'Infarto Miocardico II (GISSI-2) and the International Study Group. The risk of stroke in patients with acute myocardial infarction after thrombolytic and antithrombotic treatment . N Engl J Med. 1992;327:1-6.Crossref 10. Muller DWM, Topol EJ. Selection of patients with acute myocardial infarction for thrombolytic therapy . Ann Intern Med. 1990;113:949-960.Crossref 11. Grines CL, DeMaria AN. Optimal utilization of thrombolytic therapy for acute myocardial infarction . J Am Coll Cardiol. 1990;16:223-231.Crossref 12. Doorey AJ, Michelson EL, Weber FJ, Dreifus LS. Thrombolytic therapy in acute myocardial infarction . J Am Coll Cardiol. 1987;10:1357-1360.Crossref 13. Cragg DR, Friedman HZ, Bonema JD, et al. Outcome of patients with acute myocardial infarction who are ineligible for thrombolytic therapy . Ann Intern Med. 1991;115:173-177.Crossref 14. Lee TH, Weisberg MC, Brand DA, Rouan GW, Goldman L. Candidates for thrombolysis among emergency room patients with acute chest pain . Ann Intern Med. 1989;110:957-962.Crossref 15. Pfeffer MA, Moyé LA, Braunwald E, et al. Selection bias in the use of thrombolytic therapy in acute myocardial infarction . JAMA . 1991;266:528-532.Crossref 16. Kennedy JW. Expanding the use of thrombolytic therapy for acute myocardial infarction . Ann Intern Med. 1990;113:907-908.Crossref 17. Udvarhelyi IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the Medicare population: process of care and clinical outcomes . JAMA . 1992;268:2530-2536.Crossref 18. Krumholz HM, Pasternak RC, Weinstein MC, et al. Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction . N Engl J Med. 1992;327:7-13.Crossref 19. Sherry S, Marder VJ. Mistaken guidelines for thrombolytic therapy of acute myocardial infarction in the elderly . J Am Coll Cardiol. 1991;17:1237-1238.Crossref 20. Detailed Diagnoses and Procedures: National Hospital Discharge Survey . Washington, DC: National Center for Health Statistics; 1989. 21. American Heart Association. 1991 Heart and Stroke Facts . Dallas, Tex: American Heart Association; 1991. 22. Doorey AJ, Michelson EL, Topol EJ. Thrombolytic therapy of acute myocardial infarction: keeping the unfulfilled promises . JAMA . 1992;268:3108-3114.Crossref 23. Levin LA, Jonsson B. Cost-effectiveness of thrombolysis: a randomized study of intravenous rt-TPA in suspected myocardial infarction . Eur Heart J. 1992;13:2-8. 24. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction . N Engl J Med. 1993; 328:673-679.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 25, 1994

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