STATE-OF-THE-ART PAPER
Reperfusion strategies for acute myocardial infarction in the elderly
Benefits and risks
Rajendra H. Mehta, MD, MS*,
Christopher B. Granger, MD*,
Karen P. Alexander, MD*,
Eduardo Bossone, MD ,
Harvey D. White, MD and
Michael H. Sketch, Jr, MD*,*
* Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
National Research Council of Southern Italy, Brindisi, Italy
Auckland City Hospital, Auckland, New Zealand
Manuscript received June 16, 2004;
revised manuscript received October 3, 2004,
accepted October 18, 2004.
* Reprint requests and correspondence: Dr. Michael H. Sketch, Jr., Box 3157, Duke University Medical Center, Durham, North Carolina 27710 (Email: sketc002{at}mc.duke.edu).
The optimal reperfusion strategy in elderly patients with ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. This lack of consensus stems from the exclusion or under-representation of the elderly in clinical trials. This review evaluates the available literature pertaining to reperfusion therapy for the treatment of STEMI in the elderly. We identified all published studies evaluating the effectiveness of thrombolytic therapy, primary percutaneous coronary intervention (PCI), or adjunctive therapies to reperfusion by conducting an electronic search of MEDLINE through December 2003. Meta-analysis of clinical trials suggests a survival benefit of thrombolytic therapy in the elderly with STEMI, whereas some observational studies have raised concerns about the lack of short-term benefit or possibility of harm with thrombolysis. However, most observational studies demonstrate improved intermediate-term survival with thrombolysis. In contrast, multiple clinical trials and observational studies indicate improved survival and low risk of stroke with primary PCI compared with thrombolysis in elderly patients with STEMI. Information on the efficacy of newer antithrombotic agents as adjunct to thrombolysis or primary PCI is scarce. Available data suggest an increased risk of intracerebral bleeding with the combination of a fibrin-specific agent and a glycoprotein IIb/IIIa receptor antagonist in patients >75 years of age. Clearly targeted large-scale clinical trials are needed to evaluate the relative merits of available reperfusion strategies as well as newer antithrombotic adjunctive therapies in the elderly with STEMI.
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Abbreviations and Acronyms
| | ASSENT = Assessment of Safety and Efficacy of a New Thrombolytic trial | | CI = confidence interval | | HR = hazard ratio | | MIR = Myocardial Infarction Registry | | MITRA = Maximum Individual Therapy in Acute Myocardial Infarction trial | | OR = odds ratio | | PCI = percutaneous coronary intervention | | RR = relative risk | | STEMI = ST-segment elevation myocardial infarction |
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