Wide variation in the use of thrombolytic therapy among junior doctors in south and central Scotland

Abstract

Objectives: (a) To assess the practice of junior doctors who administer thrombolytic therapy in acute myocardial infarction. (b) To assess whether wider implementation of current guidelines is indicated.

Design: Postal questionnaire survey. Each questionnaire was followed by a reminder.

Setting: Teaching and district general hospitals in Central and Southern Scotland.

Subjects: Two hundred and twelve junior doctors (excluding JHO's) regularly involved in the early assessment and management of patients with acute myocardial infarction.

Results: One hundred and ten questionnaires were returned (response rate 52%). There was wide inter-individual variation in clinical practice regardless of whether subjects worked in teaching or district general hospitals or as cardiologists or non-cardiologists. As many as 12% of respondents administer thrombolytic therapy in the absence of ST elevation or bundle branch block on the presenting ECG. A high percentage of subjects considered diabetic retinopathy, but not a previous history of cerebrovascular disease, a contraindication to thrombolytic therapy. Only 29% and 32% respectively worked in institutions where formal policies existed for streptokinase readministration and rt-PA administration in preference to streptokinase. The administration of thrombolytic therapy in Accident and Emergency departments is not a popular strategy, and the full efficacy of rt-PA is not realised due to inappropriate use or failure to use intravenous heparin.

Conclusions: There is wide variation in clinical practice among junior doctors who administer thrombolytic therapy for acute myocardial infarction. Wider implementation and firmer current national guidelines would ensure that patients presenting with suspected acute myocardial infarction receive optimal therapy.