CLINICAL STUDIES
Thrombolytic therapy in older patients
Alan K. Berger, MD*,
Martha J. Radford, MD, FACC*   ,
Yun Wang, MS and
Harlan M. Krumholz, MD, FACC* 
* Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
Qualidigm®, Middletown, Connecticut, USA
Section of Chronic Disease Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut, USA
Manuscript received September 24, 1999;
revised manuscript received January 21, 2000,
accepted March 29, 2000.
Reprint requests and correspondence: Dr. Harlan M. Krumholz, Yale University School of Medicine, 333 Cedar St., P.O. Box 208025, New Haven, Connecticut 06520-8025
harlan.krumholz{at}yale.edu
OBJECTIVES
We compared outcomes following thrombolytic therapy and primary angioplasty with no reperfusion therapy in a population-based cohort of older patients presenting with acute myocardial infarction (AMI) and indications for acute reperfusion.
BACKGROUND
Evidence supporting the efficacy of acute reperfusion (thrombolytic therapy or primary angioplasty) in the elderly with suspected AMI is not as strong as it is in younger groups.
METHODS
From a national cohort of Medicare beneficiaries with AMI, we identified 37,983 patients age 65 or older who presented within 12 h of symptom onset with ST elevation or left bundle branch block. A total of 14,341 (37.8%) received thrombolytic therapy and 1,599 (4.2%) underwent primary angioplasty within 6 h of hospital arrival.
RESULTS
After adjustment for demographic, clinical, hospital and physician factors, and co-interventions, thrombolytic therapy was not associated with a better 30-day survival (odds ratio [OR] 1.01; 95% confidence interval [CI]: 0.94 to 1.09) compared with no therapy, whereas primary angioplasty was (OR 0.79; 95% CI: 0.66 to 0.94). At one year, both thrombolytic therapy (OR 0.84; 95% CI: 0.79 to 0.89) and primary angioplasty (OR 0.71; 95% CI: 0.61 to 0.83) were associated with a survival benefit.
CONCLUSIONS
In this national sample of older patients, those who received thrombolytic therapy or primary angioplasty had lower mortality at one year compared with those who did not receive a reperfusion strategy. However, only primary angioplasty was associated with better survival at 30 days. Our findings should heighten interest in further investigating the best approach to the treatment of older patients with suspected AMI and ST segment elevation or left bundle branch block.
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Abbreviations and Acronyms
| | AMI | = acute myocardial infarction | | ACC | = American College of Cardiology | | AHA | = American Heart Association | | CABG | = coronary artery bypass surgery | | CCP | = Cooperative Cardiovascular Project | | CI | = confidence interval | | GUSTO | = Global Utilization of Steptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries | | ICD-9-CM | = International Classification of Diseases, 9th Revision, Clinical Modification | | LBBB | = left bundle branch block | | OR | = odds ratio | | PT | = prothrombin time | | ROC | = receiver operating characteristics | | tPA | = tissue plasminogen activator |
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