Effective use of thrombolytic therapy (and other reperfusion strategies such as PCI) requires incorporation into an efficiently managed emergency ward-based system (8,9,178) that is tailored to each specific hospital's capabilities and strategic preferences (i.e., toward primary PCI or thrombolytic therapy). The importance of developing and implementing such a strategy consistently and efficiently cannot be overemphasized. Outcomes appear to be determined more importantly by the care with which a strategy is developed and implemented than whether thrombolytic therapy or primary PCI forms the preferred approach to reperfusion.
Of the more than 5 million patients presenting with chest pain annually to paramedics or emergency departments, only a small percentage will be candidates for thrombolytic therapy (approx 5-10%) (179,180). However, the importance of rapidly identifying, triaging, and treating these patients cannot be overemphasized. Patients with chest pain are rapidly screened with a targeted history, physical examination, and ECG, within 10 min of arrival. They are then assigned to one of four or five chest pain pathways (definite STE/BBB AMI, unstable angina/non-STE MI, probable unstable angina, possible unstable angina, or noncardiac chest pain) (8,9). In the STE/BBB AMI group, further screening for thrombolytic contraindications is rapidly performed and treatment begun.
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