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Objectives-To assess the safety and efficiency with which the accident and emergency (A&E) department provides thrombolytic treatment for patients with acute myocardial infarction (AMI). Methods-A prospective observational study based in a teaching hospital for one year. All patients who presented with the clinical and electrocardiographic indications for thrombolytic treatment were studied. Patients were grouped according to route of admission. After logarithmic transformation, the "door to needle times" ofthe groups were compared using a two tailed Student's t test. Arrhythmias and complications after thrombolytic treatment were noted. The appropriateness of the treatment was assessed retrospectively by review of the clinical records and electrocardiograms, judged against locally agreed eligibility criteria. Results-Data from 153 patients were analysed; 138/153 (90%) patients were admitted via the A&E department. The shortest door to needle times were seen in those patients thrombolysed by A&E staff within the A&E department (mean 43.8 minutes). The transfer of A&E patients to the coronary care unit (CCU) was associated with a significant increase in the door to needle time (mean 58.8 minutes, p = 0.004). Only one malignant arrhythmia occurred during the administration of thrombolysis in the A&E department, and this was managed effectively. No arrhythmias occurred during transfer of thrombolysed patients to the CCU. In every case, the decision to administer thrombolysis was retrospectively judged to have been appropriate. Conclusions-The A&E department provides appropriate, safe, and timely thrombolytic treatment for patients with AMI. Transferring A&E patients to the CCU before thrombolysis is associated with an unnecessary treatment delay. (JAccid Emerg Med 1999;16:325-330)

Objectives-To examine the use of thrombolytic treatment in patients with suspected acute myocardial infarction (AMI) and left bundle branch block (LBBB). To evaluate electrocardiographic criteria for the identification of AMI in the presence of LBBB, and examine the implications of using these criteria in the clinical setting. Methods-A retrospective study over two years, based in two Sheffield teaching hospitals. Patients presenting with LBBB and suspected AMI were studied by analysis of an AMI database. The proportion of patients with LBBB and AMI receiving thrombolysis, and the in-hospital delay before the start of treatment, were used as indicators of current performance.Three predictive criteria were applied to the electrocardiograms (ECGs) retrospectively, and their ability to identify acute ischaemic change assessed. The implications of using the predictive criteria in the clinical setting were explored.Result-Twenty three per cent (5122) of patients with LBBB and AMI did not receive thrombolysis, in the absence of documented contraindications. The mean in-hospital treatment delay for thrombolysed patients was 154 minutes. Forty eight per cent (16/33) of those thrombolysed did not have a final clinical diagnosis of AMI. In the majority of cases (8/12), the decision not to administer thrombolysis was based on a single ECG recording.The presence of any of the predictive electrocardiographic criteria was associated with a diagnosis ofAMI, with a sensitivity of 0.79 (95% confidence interval 0.63 to 0.95), specificity 1, positive predictive value 1, and negative predictive value 0.79. The K scores between four independent observers showed either substantial or near perfect agreement.

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