Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

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Abstract

Background

The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.

In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.

This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.

Method

A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.

Results

In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).

With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.

In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.

Conclusion

Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.

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Most cited references 204

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Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility.

P A Barber, J ZHANG, A M Demchuk … (2001)

Thrombolytic therapy for acute stroke (<3 hours) will not have a major impact on death and dependency unless it is accessible to more patients. To determine why patients with ischemic stroke did not receive IV TPA and assess the availability of this therapy to patients with ischemic stroke. Consecutive patients with acute ischemic stroke were prospectively identified at a university teaching hospital between October 1996 and December 1999. Additional patients with ischemic stroke were identified that were admitted to one of three other hospitals in the Calgary region during the study period. The Oxford Community Stroke Programme Classification was used to record type and side of stroke. Of 2165 stroke patients presenting to the university hospital, 1168 (53.9%) were diagnosed with ischemic stroke, 31.8% with intracranial hemorrhage (intracerebral, subarachnoid, or subdural), and 13.9% with TIA. Delay in presentation to emergency department beyond 3 hours excluded 73.1% (854/1168). Major reasons for delay included uncertain time of onset (24.2%), patients waited to see if symptoms would improve (29%), delay caused by transfer from an outlying hospital (8.9%), and inaccessibility of treating hospital (5.7%). Twenty-seven percent of patients with ischemic stroke (314/1168) were admitted within 3 hours of sympton onset and of these 84 (26.7%) patients received IV TPA. The major reasons for exclusion in this group of patients (<3 hours) were mild stroke (13.1%), clinical improvement (18.2%), perceived protocol exclusions (13.6%), emergency department referral delay (8.9%), and significant comorbidity (8.3%). Of those patients who were considered too mild or were documented to have had significant improvement, 32% either remained dependent at hospital discharge or died during hospital admission. Throughout the region there was a total of 1806 ischemic stroke patients (admitted to all four Calgary hospitals). During this study period, 4.7% received IV TPA. The majority of patients are unable to receive TPA for acute ischemic stroke because they do no not reach the hospital soon enough. Of those patients presenting within 3 hours, 27% received the therapy but a further 31% were excluded because their symptoms were either considered too mild or were rapidly improving. Subsequently, a third of these patients were left either dependent or dead, bringing into question the initial decision not to treat.

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Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

John Canto (2000)

Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown. To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome. Prospective observational study. A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States. Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain. Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]). Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229

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Sex differences in stroke care and outcomes: results from the Registry of the Canadian Stroke Network.

, Jiming Fang, Frank Silver … (2005)

Stroke is an important cause of death and disability in women as well as men. However, little is known about sex differences in stroke care and outcomes. The Registry of the Canadian Stroke Network (RCSN) captured data on patients with stroke seen at acute care hospitals across Canada. We used data from phase 1 (July 2001 to February 2002) and phase 2 (June to December 2002) of the RCSN to compare stroke presentation, management, and 6-month outcomes in women and men using multivariable regression techniques to adjust for age and other factors. The study sample included 3323 patients, with 1527 women. Stroke symptoms at presentation were similar in women and men, except that women were more likely to present with headaches and were less likely to have brain stem or cerebellar symptoms. There were no sex differences in the use of neuroimaging, thrombolysis, antithrombotic therapy, or consultations. Women were less likely than men to receive care on an acute stroke unit, but this difference was no longer significant after adjustment for age and other factors. Women were more likely than men to be discharged to long-term care and had greater disability at 6 months. Mortality and quality of life at 6 months were similar in women and men. Among patients participating in the RCSN, there were no major sex differences in stroke presentation or management. Compared with men, women were more often institutionalized and had a slightly worse functional status at 6 months after stroke.

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Author and article information

Journal

Journal ID (nlm-ta): Scand J Trauma Resusc Emerg Med

Title: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine

Publisher: BioMed Central

ISSN (Electronic): 1757-7241

Publication date Collection: 2010

Publication date (Electronic): 6 September 2010

Volume: 18

Page: 48

Affiliations

[1 ]Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, SE-413 45 Göteborg, Sweden

[2 ]School of Health Sciences, University of Borås, the Pre-hospital Research Centre in Western Sweden, SE-501 90 Borås, Sweden

[3 ]Stockholm Pre-hospital Centre, South Hospital, SE-118 83 Stockholm, Sweden

[4 ]Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation. Sahlgrenska Academy at Gothenburg University, Guldhedsgatan 19, SE-413 45 Göteborg, Sweden

Article

Publisher ID: 1757-7241-18-48

DOI: 10.1186/1757-7241-18-48

PMC ID: 2944143

PubMed ID: 20815939

SO-VID: 8d42a048-a3c0-4b9d-966e-8dadefdea229

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

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Preventive and Emergency Medicine Insights

Most cited references 204

Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility.

Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

Sex differences in stroke care and outcomes: results from the Registry of the Canadian Stroke Network.

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