Of 2886 patients monitored during acute myocardial infarction, 500 were observed within one hour of the onset of symptoms. Half of the early admission group were admitted in response to emergency 999 calls and 435 of them travelled in resuscitation ambulances, where surveillance for arrhythmias was instituted. Pulmonary oedema occurred in 130 patients (26%), cardiogenic shock supervened in 60 (12%), and 115 (23%) died in hospital. Ventricular fibrillation was observed in 98 patients (20%). Forty two of them survived to be discharged, including 20 of the 24 with primary fibrillation which had occurred first in hospital. In only one case did primary ventricular fibrillation occur after the first 10 hours of onset of illness. Sinus bradycardia, atrial fibrillation, ventricular tachycardia, and ventricular fibrillation were all observed more frequently in patients admitted within one hour after the onset of symptoms than in those admitted later.An element of selection is inevitable when early admission is encouraged by the existence of a resuscitation ambulance system; this will depend in part on the early recognition of risk and the geographical location of the attack. These factors may bias the group towards relatively high risk. Nevertheless, prompt admission after myocardial infarction should improve survival by permitting successful management both of ventricular fibrillation and of other arrhythmias which may influence short term and long term prognosis. IntroductionLittle information is available in world reports on the complications of myocardial infarction when patients come under observation very early after the onset of symptoms. A series representing an unselected population cannot be obtained because data are collected only from those who seek treatment. In 1971 Adgey and colleagues reported' on the incidence of arrhythmias among 284 patients observed within one hour in a mobile coronary care unit manned by medical staff and, at that time, intended to operate in response to calls from general practitioners. Selection may not necessarily be similar in a community encouraged to make use of the emergency (999) telephone system for patients with severe chest pain or collapse; the Belfast results may also have been influenced by the availability of medical skills.Information on the results of early intervention is of particular value because of a resurgence of interest in prehospital care and early hospital admission. In Britain the Department of Health no longer actively discourages the creation of new coronary care and resuscitation ambulance programmes.2 3 District health authorities considering setting up such schemes within financial constraints will wish to know the potential benefits of early intervention.Taking advantage of data collected since the creation of an ambulance system4 -6 based on emergency services without direct medical intervention, we have reviewed retrospectively the records of 500 patients with confirmed myocardial infarction observed within 60 minutes of the onset of chest ...

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Treatment with nadroparin for 6+/-2 days provides similar efficacy and safety to treatment with unfractionated heparin, for the same period, in the therapeutic management of acute unstable angina or non-Q wave myocardial infarction, and may be easier to administer. A prolonged regimen of nadroparin (14 days) does not provide any additional clinical benefit.

Extended training for ambulance staff increases the likelihood of successful resuscitation from out-of-hospital cardiopulmonary arrest. Though instruction in defibrillation must have the highest priority, full paramedical training can bring appreciable additional benefits.

In six patients (five male, one female) a purpuric rash developed 7-15 days after the administration of anisoylated plasminogen streptokinase activator complex. In each case there was purpura, particularly of the extensor surfaces of the legs. In two patients the rash also affected the extensor surfaces of their arms. The lesions varied from areas of purpura (3-7 mm in diameter) to necrotic vesicles (figure). The rash began to resolve after 2-5 days and had completely disappeared after three weeks. The table gives further details of the patients.Five of the six patients developed arthralgia with swelling around their ankles as well as the rash. Of these, three had abdominal distension with colicky abdominal pain and diarrhoea. One patient with abdominal symptoms had melaena; endoscopy showed that the gastric mucosa was purpuric. These abdominal symptoms had a similar time course to the rash. No patient had clinical evidence of progressive renal impairment, although urinalysis showed mild proteinuria and haematuria in two patients.No fall in haemoglobin concentration was detected, even in the patient who had melaena. Similarly, the platelet counts in each patient remained