Timing Is Everything

Over the past 20 years, advances in reperfusion therapy with angioplasty and thrombolysis have revolutionized the management of acute myocardial infarction (MI). Use of these therapies has led to impressive reductions in mortality from acute MI.1 Unfortunately, their full potential has not been realized, because many patients do not reach the hospital in time to benefit from them.Studies show that only ≈1 in 5 patients gets to the hospital within 1 hour of the onset of acute MI symptoms; this is the time frame in which they would obtain the greatest benefit from reperfusion.2 We can greatly decrease death and disability among our patients (≈40% of the 1.1 million heart attacks in the United States each year are fatal3) if we motivate and educate them to call 9-1-1 at the earliest suggestion of an acute MI.Data from the Fibrinolytics Therapy Trialists’ Collaborative Group4 indicate that for every hour of delay, 2 lives per 1000 patients are lost. The GUSTO I trial5 and others demonstrated that mortality was 2 times as great if thrombolytic treatment occurred 4 to 6 hours after onset compared with 1 to 2 hours after onset (8.9% versus 4.3%). The GUSTO IIb study6 also showed a time dependency for primary angioplasty, with a 30-day mortality of 1% when angioplasty was performed within 60 minutes of hospital arrival and of 6.4% when it was delayed >90 minutes. In the Myocardial Infarction Triage and Intervention Trial, the rate of death among patients with acute MI who were treated within 70 minutes after the onset of symptoms was 1.3% compared with 8.7% among patients who were treated later.7Research has identified a number of reasons for patient delay in seeking medical treatment for an acute MI. In many cases, patients expect …