IN-HOSPITAL AND OUT-OF-HOSPITAL DELAYS IN SUSPECTED ACUTE MYOCARDIAL-INFARCTION - ROLE OF THE PUBLIC, IN-HOSPITAL AND OUT-OF-HOSPITAL STRUCTURES, AND TRANSPORT FACILITIES

The potential impact of thrombolytic agents on mortality and morbidity from coronary artery disease is weakened by in- and out-of-hospital d elays occurring in the management of acute myocardial infarction. The goals of this study were to review the situation 5 years after the pub lication of the GISSI study. From October 1, 1991 to March 31, 1992, a ll the events occurring between symptom onset and in-hospital treatmen t were analyzed for 620 consecutive patients with suspected myocardial infarction seen in the emergency ward of the University Hospital, Gen eva. Among them, 189 (30.5%) had myocardial infarction and 144 (23%) u nstable angina. Mean and median delay between symptom onset and hospit al arrival for the 620 patients were 10 h 02 min and 2 h 55 min respec tively; 117 (19%) patients came straight to the hospital alone, with t he risk of arrhythmic complications en route to the emergency ward but with shorter time delays (mean delay: 6 h 13 min; median delay: 2 h 3 0 min) than the 503 (81%) patients who called out-of-hospital services (mean delay: 10 h 55 min, median delay: 3 h; p<0.04). The latter pati ents accounted for 47% of mean out-of-hospital delay and the out-of-ho spital services for 53%. Minimization or ignorance of symptoms, waitin g for relief from medication and attempts to reach relatives were. res ponsible for long patients' decision times. The mean time between a te lephone call to the central switchboard for medical emergencies (telep hone number 144) and hospital arrival was 46 min; this time delay was increased by a further 34 min when a service for emergency home medica l visits was called, 49 min longer when patients went to outpatient cl inics or to their physician's office and 74 min longer when they telep honed their physicians (all p<0.0001); in particular, while this delay was 1 h 16 min longer when physicians decided for a home visit, and 2 h 59 min longer when they decided for an office visit (both p<0.0001) , only 10% of acute myocardial infarction patients where sent straight to the hospital by their physicians on the basis of the telephone cal l, as compared with 94% by the 144 central switchboard (p<0.0001). Thr ombolytic therapy was given to 24% of acute myocardial infarction pati ents with mean and median time intervals of 52 and 45 min following ho spital arrival. Five years after the publication of the GISSI study re sults, in- and out-of-hospital delays in suspected acute myocardial in farction are still too long and the percentage of thrombolyzed patient s too small. Only large information campaigns directed towards the pub lic and physicians, as well as in- and out-of-hospital services, will improve this situation.