Patient Delay and Receipt of Thrombolytic Therapy Among Patients with Acute Myocardial Infarction from a Community-Wide Perspective Robert J. Goldberg, PhD, Jerry Gurwitz, MD, Jorge Yarzebski, MD, Joan Landon, MS, Joel M. Gore, MD, JosephS. Alpert, MD, Priscilla M. Dalen, RN, BS, and JamesE. Dalen, MD The duratkm of patient delay from the time of on- set of symptoms of acute myocardtal infarction (AMI) to hospital presentatfon, and the retatfon of delay tkne and various patfent characterfstks to receipt of throinbofytk therapy were examined as part of a communtty-based study of pattents hos- pltalized wfth AMI in the Worcester, Massachu- setts, metropelftan area. In all, 666 patients with validated AMI hospftalized at 16 hospitals in the Worcester mebopofitan area in 1986 and 1966 constftuted the study sample. Patfents delayed on average 4 heurs between noting symptoms sug- gestfve of AMI and presenting to area-wide emer- gency departments with no dgnifkant change ob- served between 19416 and 1988. ‘fhe shorter the thne interval of deky, the greater the likelihood of recefvfng thrombefytk therapy; patients arriving at the emergency department wfthfn 1 heur of the onset of acute symptoms were approxknatefy 2.5 and 6.5 times more likely to recefve tkrombotytlc agents than were those presenting to the hespftal between 4 and 6, and >6 hours, reqectkefy, af- ter the onset of symptoms. Resutts of a muttfvari- ate analysfs showed increasing length of detay, older age, Nstory of hypertensfon or AMI and non-Q-wave AMI to be dgnffkantly associated with failure to receive thrombofytk therapy. (Am J CardiollSS2;70:421425) From the Department of Medicine, University of MassachusettsMedi- cal School, Worcester, and the Program for the Analysis of Clinical Strategic and the Geriatric Research and Traioing Center, Harvard Medical School, and Beth Israel Hospital, Boston, Massachusetts.Thii project was supported by Grant ROl-HL-35434 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland. Manuscript received February 3,1992; wised manuscript received April 27,1992, and accepted May 1,1992. Address for reprints: Robert J. Goldberg, PhD, Department of Medicine, University of Massachusetts Medical School, 55 Lake Ave- nue, North, Worcester, Massachusetts 01655. D espite reductions in the mortality rates from coronary artery disease in the United States over the past 2 decades, there have been limited studies to determine whether this is due to changes in the incidence rates of coronary disease or to improve ments in survival of hospitalized patients.l+* Patient de- lay from the onset of symptoms of acute myocardial infarction (AMI) to the receipt of medical care can af- fect hospital incidence and survival rates of AM1 as well as out-of-hospital death rates from this disease. There are very limited community-based data to determine whether or not the time interval between patient recog- nition of symptoms suggestive of AM1 and hospital ar- rival has changed over time. Furthermore, thrombolytic therapy has been shown to improve in-hospital survival and left ventricular function of patients hospitalized with AMI, and the early use of this treatment appears related to efIicacy.3-7 There is limited information ex- amining the relation between length of patient delay or patient-related characteristics to receipt of thrombolytic therapy. The purpose of the present study was to exam- ine, from a multihospital, community-based perspective, overall and temporal distributions of duration of patient delay from the time of onset of symptoms of AM1 to arrival at the hospital, as well as the relation of these delay times and patient characteristics to receipt of thrombolytic therapy. METHOD6 The study population comprised patients hospital- ized with validated AM1 in 16 university-affiliated and community hospitals in the Worcester, Massachusetts, metropolitan area in 1986 and 1988. The methods of sample ascertainment and diagnostic criteria used in this study were previously described.8-10 In brief, to be considered for study inclusion, patients had to reside in the Worcester metropolitan area and have at least 2 of 3 predefmed criteria consistent with AM1 (supportive clinical history, serum enzyme elevations and serial electrocardiographic changes) present based on review of medical records of patients hospitalized with a pri- mary or secondary discharge diagnosis of AM1 at par- ticipating Worcester metropolitan area hospitals. Each of these medical records was individually reviewed and validated according to the preestablished diagnostic cri- teria. Furthermore, data had to be available in the med- ical records by which the approximate time delay from the onset of symptoms suggestive of AM1 and the time of admission to the emergency room could be assessed. Because data concerning symptoms of AM1 were not PATIENT DELAY AND TH!?OMBOLYTlC THERAPY 421