Consequences of overutilization and underutilization of thrombolytic therapy in clinical practice

OBJECTIVES The aim of this study was to evaluate the consequences, measured as mortality and in-hospital stroke, of the use of thrombolytic therapy am ong patients with acute myocardial infarction (AMI), who do not fulfill acc epted criteria or who have contraindications to thrombolytic therapy (i.e., overutilization) and among patients who are withheld thrombolytic treatmen t despite fulfilling indications and having no contraindications (i.e., und erutilization). BACKGROUND The implementation of treatment with thrombolysis in clinical pr actice is not in accordance with the accepted criteria from randomized stud ies. The consequence has been over- and underutilization of thrombolytic th erapy among patients with AMI in clinical practice. The outcome of overutil ization of thrombolytic therapy has not been described previously. METHODS We examined 6,676 consecutive patients admitted to the hospital wit h an AMI and recorded characteristics, in-hospital complications and long-t erm mortality. RESULTS Overall, 41% of the patients received thrombolytic therapy. Thrombo lytic therapy was underutilized in 14.3% and overutilized in 12.9% of the p atients. The use of thrombolytic therapy was associated with reduced mortal ity in every subgroup examined, including patients without an accepted indi cation, with an accepted indication and in patients with prior stroke. The risk ratio of in-hospital stroke was not increased in connection with throm bolytic therapy, not even in patients with Frier 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 evaluat ion of thrombolytic therapy in wider patient categories is warranted. (J Am Coll Cardiol 2001;37:1581-7) (C) 2001 by the American College of Cardiolog y.