CLINICAL STUDIES
Effect of age on outcome with primary angioplasty versus thrombolysis
David R. Holmes, Jr., MD, FACC*,
Harvey D. White, DSc, FACC ,
Karen S. Pieper, MS ,
Stephen G. Ellis, MD, FACC ,
Robert M. Califf, MD, FACC and
Eric J. Topol, MD, FACC
* Mayo Clinic and Foundation, Rochester, Minnesota, USA
Green Lane Hospital, Auckland, New Zealand
Duke Clinical Research Institute, Durham, North Carolina, USA
Cleveland Clinic Foundation, Cleveland, Ohio, USA
Manuscript received June 9, 1998;
revised manuscript received August 21, 1998,
accepted October 2, 1998.
Reprint requests and correspondence: David R. Holmes, Jr., MD, Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905
Objectives
The purpose of this study was to determine how risks associated with increasing age differed in patients treated with percutaneous transluminal coronary angioplasty versus thrombolysis.
Background
Advancing age is a risk factor for adverse outcome in patients with acute myocardial infarction. Primary angioplasty has been thought to be particularly beneficial in higher risk patients including the elderly. There is, however, limited data on any differential incremental benefit of angioplasty compared with thrombolysis in candidates for either treatment.
Methods
In the GUSTO-IIb angioplasty substudy, 1,138 patients were randomized to receive primary angioplasty or accelerated tissue-type plasminogen activator (t-PA). The effect of age on outcome was assessed as a discrete and continuous variable for each treatment group. Models using age as a linear factor as well as cubic spline transformations were used for the major end points of 30-day death or disabling stroke; death or reinfarction; and death, reinfarction or disabling stroke.
Results
For each 10-year patient group, outcome was improved with angioplasty (n = 565) compared with t-PA (n = 573). Irrespective of treatment, however, risk increased with age. After adjusting for baseline characteristics, each increment of 10 years of age increased the risk of death or myocardial infarction by 1.32 (95% confidence interval 1.04 to 1.76, p = 0.022). For all adverse outcomes, this incremental effect of increasing age was constant.
Conclusions
Advancing age is associated with worse outcomes, and the risks increase in proportion to age. Although primary angioplasty improves outcomes over thrombolysis, it does not appear to be more beneficial in older than in younger patient groups. The incremental adverse effect of age does not vary by treatment strategy.
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Abbreviations and Acronyms
| | CI | = 95% confidence interval | | GUSTO-I | = Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries—I | | GUSTO-II | = Global Use of Strategies to Open Occluded Coronary Arteries—II | | IV | = intravenous | | TIMI | = Thrombolysis in Myocardial Infarction | | t-PA | = tissue-type plasminogen activator |
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