The clinical course of patients with acute myocardial infarction who are unsuitable for thrombolytic therapy because of the presenting electrocardiogram

Objective To examine the clinical characteristics and 30-day fatality rate among patients with electrocardiograms (ECGs) ineligible for fibrinolysis i n a consecutive series in four general hospitals in the UK. Methods We studied 2439 consecutive patients who were identified from regul ar ward visits, surveillance of results from hospital laboratories, and hos pital discharge coding. Results Thirty percent (732) of patients did not have ECGs eligible for fib rinolysis therapy, while indications were uncertain in 55 (2%), Within the ineligible group, patients presenting with ST depression (n = 294) had a hi gher 30-day fatality rate than those with ST elevation or left bundle branc h block (26% versus 17%; P < 0.001); they represented 40% of the group inel igible for fibrinolysis therapy, or 12% of the total cohort. Thirty-day fat ality rates in patients presenting with pathological Q waves and no diagnos tic ST segment changes (n = 130), those with T wave changes but no other ab normality (n = 168) and those with a normal ECG (n = 128) were 10%, 5% and 3%, respectively. Despite their high fatality rate, fewer patients with ST depression were admitted to coronary care units than those with ECGs eligib le for fibrinolysis therapy (61% versus 85%; P < 0.001) and 23% did not rec eive heparin, The coronary anatomy in a subset of patients with ST depressi on showed two- or three-vessel disease in 79% and left main stenosis in 9%. The rates of coronary revascularisation were low in all groups (< 10%). Conclusion Patients with ECGs ineligible for fibrinolysis therapy are a dis parate group, with a high rate of fatality occurring in patients who presen t with ST depression. The high prevalence of multiple vessel coronary disea se in patients with ST depression suggests that a more active management st rategy is required. Coronary Artery Dis 9:747-752 (C) 1998 Lippincott Willi ams & Wilkins.