Reperfusion revisited

The field of thrombolytic treatment for a variety of clinical conditions has progressed extremely rapidly over the past decade. Unfortunately, answers to questions of the greatest interest to practicing physicians remain ambiguous. They include the following: For which problems should thrombolytic treatment be the treatment of choice? Which patients should receive thrombolytic treatment, and which should not? Which of the available thrombolytic agents is "best" for which problem in which patient? In this situation of clinical ambiguity, our experience with thrombolysis in AMI is instructive. The problems for which thrombolytic treatment are indicated have in common the attribute that they are "time-sensitive"; that is, optimal benefit is achieved with earlier initiation of treatment. We have learned that to minimize delay, emergency physicians must proactively agree with our colleagues in cardiology, family practice, internal medicine, pulmonary medicine, etc., on issues of patient selection, drug selection, and ancillary therapy. It is too late to argue such issues once the patient with a thrombotic or embolic disorder has arrived in the emergency department. By cooperating in advance, we can ensure our patients the maximum benefit from timely administration of this potent therapy while protecting them from avoidable complications and expense from its medically inappropriate use.