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Sir,In their informative article, Constantine and Thenabadu1 identify reasons for delay in initiating thrombolysis, including failure to diagnose acute myocardial infarction at the time of admission. This resulted from a lack of specific electrocardiogram (ECG) changes or a failure to recognise them. This concurs with previously published observations regarding diagnostic difficulty when the admitting physician is faced with a patient with prolonged chest pain, a history of ischaemic heart disease and previous myocardial infarction with suspicious but equivocal ECG changes.2 On other occasions, the history is atypical but an ECG suggests infarction. Uncertainties in deciding whether chest pains are due to unstable angina or infarction inevitably delays thrombolysis. Comparison with a previous ECG can be helpful in establishing a correct diagnosis.
A further proposal to reduce in-patient delay for those patients being admitted for the second or subsequent time would be to issue at-risk patients with their ECG and to encourage them to carry them at all times. Immediate comparison would facilitate the detection of fresh ECG changes, removing diagnostic doubt and thereby allowing appropriate treatment to be efficiently administered.
This letter was shown to the authors who responded as follows:
Sir,We appreciate the response to our paper on time delay to thrombolytic therapy. The proposal to reduce in-patient time delay by encouraging high-risk patients to carry their ECG at all times is important. However, our experience has been negative. Introducing a ‘risk score’ based on ECG, echocardiography and simple electrophysiological interpretation like duration of loss of sinus arrhythmia may be more practicable in our context.
Troponin I and troponin T are highly sensitive and specific markers of myocardial necrosis. Recently, Hamm et al 1-1 showed that troponin-negative patients were at low risk for myocardial events after an episode of acute chest pain. Troponin T and troponin I may become important markers in the management of patients with acute chest pain in the future.