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      Outcome of Myocardial Infarction in Patients Treated with Aspirin Is Enhanced by Pre-Hospital Administration

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          Abstract

          Objective: Reducing time to reperfusion therapy is one of the goals in the management of acute myocardial infarction (AMI). We assessed the association between timing of aspirin administration and outcome of patients with AMI. Patients: We studied 922 consecutive AMI patients with ST-segment elevation in Killip class I–III on admission. Patients were divided into two groups based upon the timing of emergency aspirin administration: before (early aspirin users) or after (late aspirin users) hospital admission. Results: Early aspirin users (n = 338; 37%) were younger, less likely to be women, and more likely to smoke (p < 0.006) than late users (n = 584; 63%). Other baseline and clinical characteristics were similar. Early aspirin users were more likely to be treated with thrombolysis or primary percutaneous transluminal coronary angioplasty. Compared with late users, early aspirin users had significantly lower in-hospital complications and lower mortality rates at 7 (2.4 vs. 7.3%, p = 0.002) and 30 days (4.9 vs. 11.1%, p = 0.001). By multivariate adjustment, pre-hospital aspirin was an independent determinant of survival at 7 (odds ratio 0.43; 95% confidence interval 0.18–0.92) and at 30 days (odds ratio, 0.60; 95% confidence interval 0.32–1.08). Survival benefit associated with aspirin persisted for subgroups treated or not with reperfusion therapy. Conclusions: Outcome of AMI patients treated with aspirin is improved by pre-hospital administration.Our findings suggest that emergency pre-hospital aspirin might facilitate early reperfusion.

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          Most cited references 5

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          Early thrombolytic treatment in acute myocardial infarction: reappraisal of the golden hour.

          There is conclusive evidence from clinical trials that reduction of mortality by fibrinolytic therapy in acute myocardial infarction is related to the time elapsing between onset of symptoms and commencement of treatment. However, the exact pattern of this relation continues to be debated. This paper discusses whether or not appreciable additional gain can be achieved with very early treatment. The relation between treatment delay and short-term mortality (up to 35 days) was evaluated using tabulated data from all randomised trials of at least 100 patients (n = 22; 50,246 patients) that compared fibrinolytic therapy with placebo or control, reported between 1983 and 1993. Benefit of fibrinolytic therapy was 65 (SD 14), 37 (9), 26 (6) and 29 (5) lives saved per 1000 treated patients in the 0-1, 1-2, 2-3, and 3-6 h intervals, respectively. Proportional mortality reduction was significantly higher in patients treated within 2 h compared to those treated later (44% [95% CI 32, 53] vs 20% [15, 25]; p = 0.001). The relation between treatment delay and mortality reduction per 1000 treated patients was expressed significantly better by a non-linear (19.4-0.6x(+)29.3x-1) than a linear (34.7 - 1.6x) regression equation (p = 0.03). The beneficial effect of fibrinolytic therapy is substantially higher in patients presenting within 2 h after symptom onset compared to those presenting later.
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            Quality of care for Medicare patients with acute myocardial infarction. A four-state pilot study from the Cooperative Cardiovascular Project.

            To develop and test indicators of the quality of care for patients with acute myocardial infarction (AMI). Retrospective medical record review. All acute care hospitals in Alabama, Connecticut, Iowa, and Wisconsin. All hospitalizations for Medicare patients discharged with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, were identified (N = 16,869). Percentage of patients receiving appropriate interventions as defined by 11 quality-of-care indicators derived from clinical practice guidelines that were modified and updated in consultation with a national group of physicians and other health care professionals. We abstracted data from 16,124 (96%) of the hospitalizations, representing 14,108 primary hospitalizations and 2016 hospitalizations resulting from transfers. Potential exclusions to the use of standard treatments in AMI care were common with 90% and 70% of patients having potential exclusions for thrombolytics and beta-blockers, respectively. In cohorts of "ideal candidates" for specific interventions, 83% received aspirin, 69% received thrombolytics, and 70% received heparin during the initial hospitalization; 77% received aspirin and 45% received beta-blockers at discharge. These data demonstrate that many Medicare patients may not be ideal candidates for standard AMI therapies, but these treatments are underused, even in the absence of discernible contraindications. Hospitals and physicians who apply these quality indicators to their practices are likely to find opportunities for improvement.
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              Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis.

              Unlike thrombolytic agents, there are conflicting data regarding the time-dependent effect of aspirin treatment on outcome in acute myocardial infarction (AMI). We sought to evaluate the impact of timing of aspirin administration (before vs after thrombolysis) on mortality of patients with AMI. Our study included 1,200 patients with ST elevation AMI treated with thrombolysis. Early (n = 364) versus late (n = 836) users were defined as those receiving emergency aspirin before versus after initiation of thrombolysis, respectively. Time (median) from symptom onset to initiation of aspirin treatment was significantly shorter in early versus late users (1.6 vs 3.5 hours; p <0.001). There were no significant differences between the 2 groups with respect to baseline clinical characteristics. Early aspirin users were more likely to develop reischemia, to be treated with beta blockers, to be referred to coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery. Early users experienced lower mortality at 7 days (2.5% vs 6.0%, p = 0.01), 30 days (3.3% vs 7.3%, p = 0.008), and 1 year (5.0% vs 10.6%, p = 0.002) than late users. This survival benefit persisted for patients with and without previous aspirin therapy or revascularization and after adjustment for baseline characteristics and therapies at 7 days (odds ratio 0.36, 95% confidence interval 0.15 to 0.79), at 30 days (odds ratio 0.39, 95% confidence interval 0.17 to 0.82), and at 1 year (odds ratio 0.41, 95% confidence interval 0.21 to 0.74). Our study proposes a time-dependent benefit from aspirin in patients with AMI treated with thrombolysis.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2002
                November 2002
                07 November 2002
                : 98
                : 3
                : 141-147
                Affiliations
                aNeufeld Cardiac Research Institute, Tel-Aviv University, Sheba Medical Center, Tel-Hashomer, and bCardiology Department, Rabin Medical Center, Petah-Tikva, Israel
                Article
                66324 Cardiology 2002;98:141–147
                10.1159/000066324
                12417813
                © 2002 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 5, References: 18, Pages: 7
                Categories
                Coronary Care

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