The Literature of Emergency Medicine Critical Care Medicine: An Annotated Bibliography of the Recent Literature

Now that the results of the GUSTO-1 trial have been published, data are available from several large, randomized trials directly comparing the thrombolytic agents most commonly used in the United States. In addition, a number of post-trial substudies have also been published looking at issues relating to the timing of therapy, patient age, etc. These two articles provide an excellent overview and summary of these trials as well as a very practical clinical perspective. The relevant conclusions from more than 100,000 patients randomized in these trials are as follows: First, the choice of a specific thrombolytic therapy is much less important than the time between onset of symptoms and initiation of therapy. In the United States, in-hospital delays average 90 minutes and the development of local in-house (ie, emergency department) programs to speed this process is probably the most cost-effective way to save the greatest number of lives. Second, potential differences in efficacy between agents are reduced after four hours. In general, the agents appear to be effective when administered up to at least 12 hours, particularly for tPA. Additionally, although elderly patients have a higher complication rate when given thrombolytics, they also have a higher benefit rate, so age alone should not be a specific excluder for the use of thrombolytic therapy. Last, fewer than one third of US patients with acute myocardial infarction actually receive thrombolytic therapy and, clearly, improved diagnostic methods are needed. Prehospital-initiated vs hospital-initiated thrombolytic therapy: The myocardial infarction triage and intervention trial. Weaver W, Cerqueira M, Hallstrom A, et al. JAMA 1993;270:1211-1216. Feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group. BMJ 1992;305:548-553. Administration of thrombolytics in the prehospital setting has received a great deal of recent attention. The results have been some-