Treating acute myocardial infarction

In reading the article by Louise Pilote and colleagues on changes in the treatment and outcomes of acute myocardial infarction in Quebec1 and the related commentary by Arthur Dodek2 I am reminded of the saying that to a hammer everything looks like a nail.

The authors of both articles speak from the viewpoint of the cardiology clinic and the catheterization suite. Although the results that they present are laudable, ascribing them to “increased use of thrombolytic agents and, more importantly, the increased use of angiography and revascularization procedures”2 ignores the bigger picture.

In my environment, an Ontario tertiary care centre, the vast majority of patients who have a myocardial infarction are treated by emergency physicians and never have primary angiography. This stems from a variety of factors, the most obvious being the lack of availability of angiography outside of business hours. Despite this I would hazard that our statistics on infarct survival mirror the Quebec trend of improvement. Why is this? It is because of an organized emergency medical prehospital system and skilled emergency department staff. If there is an increased use of thrombolytic agents, it must partly, if not completely, be due to the increased thrombolysis in the emergency department.

The time has come to recognize that initial care of patients with myocardial infarction is usually not delivered by the cardiologist but by the emergency physician, often under conditions far more chaotic and stressful than those in the average coronary care unit. To ignore this and only focus on the portion of care delivered by cardiologists is scientific inaccuracy bordering on arrogance.