Clinical studies
Thrombolytic therapy in older patients

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Abstract

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.

Abbreviations

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

Cited by (0)

Dr. Krumholz is a Paul Beeson Faculty Scholar (The John A. Hartford Foundation, The Commonwealth Fund and the Alliance for Aging Research, New York, NY). The analyses upon which this publication is based were performed under Contract Number 500-96-P549, entitled “Utilization and Quality Control Peer Review Organization for the State of Connecticut,” sponsored by the Health Care Financing Administration, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by the Health Care Financing Administration, which has encouraged identification of quality improvement projects derived from analysis of patterns of care, and therefore required no special funding on the part of this Contractor. Ideas and contributions to the author concerning experience in engaging with issues presented are welcomed.