I'd probably go for it too.  There's dying heart muscle which you're better
off with than without.  The fact there is no good evidence for thrombolysis
in this case is more to do with what the old trials looked at when they were
done.  We need new trials/analysis, as Doc has already stated, but until
they are done we have to take an educated view and treat as we feel
appropriate.  Surely that is our job as doctors.  I think passing the
decision on to the patient might be the PC thing to do but as we have
discussed before on the list, is the patient really in a position to take
such a decision?  Certainly inform them of the risks but I'm very much of
the 'this is what I would recommend' school of informed consent and hope the
patient follows.

Simon McCormick

P.S.   It used to be 'this is what I would recommend for my mum or dad' but
now I realise it will soon be 'this is what I would recommend for me'!!!'

----- Original Message -----
From: "Doc Holiday" <[log in to unmask]>
To: "Simon Mccormick" <[log in to unmask]>
Sent: Saturday, April 17, 2004 10:21 PM
Subject: Re: thrombolysis question


> Possible options:
>
> 1.      thrombolyse anyway as regional infarction
> 2.      Wait to see if ST elevation in 2 consecutive leads develops
> 3.      Treat as ACS/ NSTEMI
> 4.      PTCA - yeah, right. Might win the lottery this weekend too!
> 5.      Other
>
>
> --> I'd try for option 4 and, if I also win the lottery then there's TWO
> happy people.
>
> If I failed to get patient to catheter then I will probably wish to
> thrombolyse as well, however I am quite conscious of the fact that if you
> keep trying more and more leads you're quite likely to find your 2
> contiguous ones eventually. The evidence thus far established for
> thrombolysis, however, was NOT produced with a protocol including so many
> leads... What we need, now that thrombolytic agents AND early ECGs AND
good
> scientific methodology are ALL very widely available, is for the various
> lead subgroups to be analysed separately for benefit/risk ratios.
>
> What do you say - if you thrombolyse and obtain a massive cerebral bleed
> with sever permanent consequences and end up trying to justify your
actions
> - you'd find it a challenge to present evidence for thrombolysing this
> patient with the knowledge that the risk is outweighed by the benefits.
> Maybe you'd be needing the lottery win... Although, as I said, I'm tempted
> too!!!
>
> I'll probably present the case to the patient and tell him "I don't know -
> what do YOU wish to have done? Or have YOU just won the lottery..." (in
> which case it's option 4 again and he's paying!)
>
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