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Having to make a copayment may not necessarily reduce the use of emergency medical services. Researchers analyzed the hospital records of 1,331 people in an HMO who came to the emergency room with the signs and symptoms of a heart attack. Of these, 602 were required to make a copayment and 729 were not. A copayment requirement did not cause any significant delays in seeking medical care even after adjusting for other factors that might influence emergency room visits. Some studies have shown that copayment requirements lead to reduced use of emergency medical services.

Treatment of acute heart attack with clot-dissolving drugs or angioplasty appears to be equally effective. Angioplasty and drugs called thrombolytics are both used to open blocked arteries. Researchers studied short-term and long-term mortality in 1,050 heart attack patients treated with angioplasty and 2,095 heart attack patients treated with thrombolytics. There was no difference in mortality between the groups in the short- or long-term. Those who received angioplasty used more resources and incurred higher costs. Thrombolytics are easy to administer and do not require technical skill.

Beginning thrombolytic therapy for heart attacks before hospital admission did not significantly improve patients' chances for survival or reduce complications. However, treatment begun within 70 minutes of the onset of symptoms reduced the number of complications and lessened the impact of the attack. Thrombolytic therapy is used to dissolve blood clots or prevent them from forming. A total of 360 patients who called paramedics and were suspected of having a heart attack were randomly assigned to one of two groups. One group received aspirin and thrombolytic therapy before arriving at the hospital; the other group did not. Patients who received treatment before arriving at the hospital began treatment 33 minutes earlier than the other patients. Measurements of the outcome of the two treatment strategies did not differ between the two groups., Objective.--To determine the effect of prehospital-initiated vs hospital-initiated treatment of myocardial infarction on clinical outcome. Design.--Randomized, controlled clinical trial. Setting.--Multicenter study involving 19 hospitals and all paramedic systems in the Seattle, Wash, metropolitan area. Patients.--A total of 360 patients with symptoms for 6 hours or less, no risk factors for serious bleeding, and ST-segment elevation were selected by paramedics and a remote physician for inclusion into the trial. They represented 4% of patients with chest pain who were screened and 21% of those with acute infarction. Interventions.--Patients were allocated to have aspirin and alteplase treatment initiated before or after hospital arrival. Intravenous sodium heparin was administered to both groups in the hospital. Main Outcome Measure.--The primary endpoint was a ranked composite score (combining death, stroke, serious bleeding, and infarct size). The relation between time to treatment and outcome (composite score, infarct size, ejection fraction, and mortality) was also assessed. Results.--Initiating treatment before hospital arrival decreased the interval from symptom onset to treatment from 110 to 77 minutes (P

Patients treated in hospitals with cardiac catheterization facilities were three times more likely to have coronary angiography performed after a heart attack than patients admitted to a hospital without those facilities. Coronary angiography is a diagnostic technique that uses X-rays to visualize the heart and blood vessels after the injection of a contrast medium into the veins. A review of the records of 5,867 patients admitted to 19 Seattle, WA, hospitals for treatment of heart attacks evaluated the likelihood that patients would have angiography performed. A further analysis of 614 patients treated by doctors who worked at both hospitals with the catheterization facilities and those without indicated that the doctors performed the procedure on 73% of their patients at hospitals with on-site facilities. The procedure was only performed on 47% of those admitted to hospitals without cardiac catheterization facilities. There was no association between on-site facilities and in-hospital mortality rates.

The death of muscle tissue that occurs during a heart attack is due to loss of blood flow in a coronary artery, which is typically associated with atherosclerosis (hardening of the vessel due to deposits of fatty plaques) and thrombosis (clot formation). Thrombolytic (clot-breaking) therapy is given to patients following heart attacks to reduce the extent of tissue death and improve survival. However, thrombolysis is most effective when given within two hours after onset of symptoms. Few patients receive treatment this early, and some even delay reporting symptoms for as long as four hours. Studies of the effectiveness of thrombolytic therapy are being performed in eight American cities, and among the study subjects are the determination of the sources of time delay between activation of emergency medical systems (ambulance transport with care given by paramedics) and initiation of thrombolytic therapy in the hospital. The measured time lapses were compared with times estimated by paramedics and physicians. The average time, from phone call to arrival at the hospital, was 46 minutes and was similar in all cities and was much longer than the paramedics' estimates of 28 minutes. The average time delay between hospital arrival and initiation of thrombolytic therapy was 79 minutes in large hospitals and 89 minutes in smaller ones, whereas physicians typically thought the delay was closer to 30 minutes. The combined delays, from emergency phone call to treatment, exceeded the period in which best results can be achieved from thrombolysis. However, study projects in some cities followed protocol-driven prehospital diagnostic strategy, in which electrocardiograms (ECGs) were taken by paramedics and transmitted to emergency medicine physicians. In these projects, the in-hospital delay decreased to 36 minutes. Further, the physicians in some projects prescribed thrombolytic therapy for some patients, which was administered by paramedics. The study clearly shows that most heart attack patients do not receive thrombolytic therapy within the first two hours following symptom development, and adoption of prehospital diagnosis decreases the time delay before treatment. Further study is needed to determine whether further benefit can be achieved by pre-hospital administration of thrombolytic therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

The Myocardial Infarction Triage and Intervention Trial of prehospital versus hospital administration of thrombolytic therapy markedly reduced hospital treatment times, but the 2 groups had similar outcomes. However, patients treated < 70 minutes from symptom onset had better short-term outcomes. The purpose of this study was to determine the long-term influence of very early thrombolytic treatment for acute myocardial infarction. A total of 360 patients were followed for vital status and cardiac-related hospital admissions over a period of 34 +/- 16 months. Patients enrolled in the trial had symptoms for < or = 6 hours, ST-segment elevation on the prehospital electrocardiogram, and no risk factors for serious bleeding. They received aspirin and recombinant tissue plasminogen activator either before or after hospital arrival. Primary end points in this study included long-term survival and survival free of death or readmission to the hospital for angina, myocardial infarction, congestive heart failure, or revascularization. Two-year survival was 89% for prehospital- and 91% for hospital-treated patients (p = 0.46). Event-free survival at 2 years was 56% and 64% for prehospital- and hospital-treated patients, respectively (p = 0.42). In patients treated < 70 minutes from symptom onset, 2-year survival was 98%, and it was 88% for those treated later (p = 0.12). Two-year event-free survival was 65% for patients treated early and 59% for patients treated later (p = 0.80). In this trial, poorer long-term survival was associated with advanced age, history of congestive heart failure, and coronary artery bypass surgery performed before the index hospitalization, but not with time to treatment. [ABSTRACT FROM AUTHOR]