The need for rapid treatment of coronary syndromes has been recognised for many years. Despite recent emphasis on the benefits of rapid thrombolysis, the main advantage of early presentation remains resuscitation from ventricular fibrillation. Defibrillation has been estimated to save about six times as many lives as thrombolytic treatment,1 but patients must reach medical assistance in time for it to be effective.

On average, patients delay more than an hour before seeking help for symptoms of acute myocardial infarction, and about another hour elapses before they arrive at hospital.2-4 Attempts to shorten patient delay by education campaigns have been generally ineffective5 and, in recent years, efforts have been mainly directed towards expediting transport and hospital treatment of patients with myocardial infarction.2,3,6 In Australia, these efforts include fast-track pathways and delivering thrombolysis in emergency departments, before cardiological review.2,7 Significant improvements in call-to-needle times have been achieved,6 but, as Kelly and colleagues document in this issue of the Journal (page 381),2 not all patients are treated as rapidly as is desirable.

The study by Kelly et al is particularly useful because it includes many of the patients treated with thrombolysis in Victoria over their study period of 30 months, and includes patients from rural and urban regions. Their data show that patients from rural areas delay longer before seeking attention and are slower to receive treatment than patients from large urban areas. While the association between delay in treatment and increased mortality in this study is likely to be partly confounded by unmeasured variables, few would dispute that these delays increase infarct size and the likelihood of dying during and after hospitalisation. Delayed treatment of myocardial infarction is one more manifestation of the geographic gradient in healthcare and outcomes in Australia.8

Controlled trials have shown that prehospital thrombo-lysis reduces mortality by about 20%.9 Prehospital thrombolysis is particularly suitable for remote regions with long ambulance transport times, and has been successfully implemented overseas without the use of mobile intensive care units.10 Even in urban areas, significant reductions in treatment delay have been achieved (between 30 and 60 minutes9), perhaps partly because a diagnosis is established before patients arrive at hospital and the hospital assessment process is circumvented. Yet, in Australia, prehospital thrombolysis has not been implemented in a systematic way. Kelly et al identify many of the barriers to the use of prehospital thrombolysis, including lack of appropriate ambulance equipment and failure to train and empower paramedics and nurses to give thrombolysis.2 They argue for a "bottom up" approach where individual healthcare ser-vices develop and own their strategies. Unfortunately, by itself, this is unlikely to effect change because of the complex funding mix of healthcare services in Australia and the parlous financial state of many rural health services.

While rural and regional centres struggle to treat patients expeditiously with limited resources, metropolitan hospitals with cardiac catheterisation laboratories are moving steadily towards infarct angioplasty instead of thrombolysis.11 Whether this proceeds on a 24-hour basis depends mainly on the ability of individual cardiology departments to corral the necessary resources from their hospitals and the willingness of their staff to work nights and weekends. There is a strong body of evidence showing that infarct angioplasty is a better treatment than thrombolysis,12 but it is certainly more expensive to institute upfront. Proponents argue that it is cost effective compared with thrombolysis as it reduces hospital stay, but experience has taught hospital administrators to be wary of these claims as they rarely result in real cost savings. However, there is little doubt that infarct angioplasty is here to stay and that it will improve outcomes from myocardial infarction in patients fortunate enough to have access to it. If current trends continue, it has the potential to further increase the disparity in outcomes between rural and urban patients with myocardial infarction.

How then should we respond to the data provided by Kelly and colleagues? Time delays in administering thrombolysis need to be seen in the context of the emergence of widespread use of infarct angioplasty and the particular geographic difficulties imposed by the Australian setting. In areas with transport times of more than 20 minutes, systematic use of prehospital thrombolysis could substantially improve outcomes at a modest cost. In urban areas, rapid transit to a facility with the ability to perform percutaneous transluminal coronary angioplasty (PTCA) is likely to become the standard. A combination of the two strategies could also be trialed in patients from areas without rapid access to PTCA (so called facilitated infarct angioplasty).

Finally, in the debate about how best to achieve early revascularisation, it should not be forgotten that most of the delay occurs before the patient contacts the ambulance service and that, in this period, death is usually the result of ventricular fibrillation. As no strategy has been identified that encourages patients to present earlier, research should be directed towards improving the treatment of cardiac arrest with interventions such as prehospital thrombolysis13 and public access defibrillators.14