Consequences of overutilization and underutilization of thrombolytic therapy in clinical practice

Abstract

With the large benefit known to be associated with thrombolytic therapy and the favorable result of thrombolytic therapy in patients with contraindications observed in this study, we conclude that a formal evaluation of thrombolytic therapy in wider patient categories is warranted.

Diagnosing acute myocardial infarction in the setting of left bundle branch block: prevalence and observer variability from a large community study

“…Given the large gains in survival and the relatively small risk of a major bleeding complication, the greater harm would seem to be in undertreating. In a study of 6676 consecutive patients with AMI, Ottesen and colleagues found that the 4-year mortality among the undertreated group was 45.6% as compared with 25.8% among those appropriately treated (risk ratio 0.74, 95% CI 0.60-0.91) with thrombolysis [37]. The 30-day and 4-year mortality among those overtreated was not significantly different than those fulfilling standard criteria and without contraindictions.…”

Interaction between arrival time and thrombolytic treatment in determining early outcome of acute myocardial infarction

“…Maximising the rate of treatment within existing criteria should be the primary objective, 16 together with greater application of primary angioplasty where appropriate. 17 Nevertheless, on the basis of evidence from other investigators, 12 there may also be a need to extend indications for thrombolysis to patients in whom it would normally be considered inappropriate. Prolonged cardiopulmonary resuscitation, for example, is normally regarded as a contraindication to thrombolysis but a recent study has effectively refuted this.…”

“…Indeed, the TRACE investigators found that "overutilisation" of thrombolytic treatment among patients not fulfilling standard indications was associated with reduced mortality and concluded that treatment should be evaluated in wider patient categories, particularly those with a bleeding risk based on events some time in the past. 12 …”

On the origins and development of evidence-based medicine and medical decision making

“…There is good evidence for over-utilization of treatments when compared with generally accepted guidelines [14] and underutilization of treatments of demonstrated effectiveness [15]. Variations have been related to local clinical culture [16], the specialty or clinical training of physicians [17], to geography [18], clinical setting, or to socio-economic status, race or ethnicity of the patients [19].…”