(Circulation. 2000;101:2239.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Lack of Benefit for Intravenous Thrombolysis in Patients With Myocardial Infarction Who Are Older Than 75 Years
From the Departments of Medicine (D.R.T., J.C., S.P.S., G.G., N.R.P.), Epidemiology (J.C., N.R.P.), Biostatistics (J.C.), and Health Policy and Management (N.R.P.), the Program for Medical Technology and Practice Assessment (D.R.T.), and the Welch Center for Prevention, Epidemiology and Clinical Research (J.C., N.R.P.), Johns Hopkins University, Baltimore, Md; Maryland HealthCare Associates, LLC, Clinton, Md (W.J.O.); and the Delmarva Foundation for Medical Care, Inc (W.J.O.), Easton, Md.
Correspondence to David R. Thiemann, MD, Division of Cardiology, Carnegie 568, Johns Hopkins Hospital, Baltimore, MD 21287-6568. E-mail dthieman{at}mail.jhmi.edu
Background—The benefit of intravenous thrombolytic therapy in elderly patients with myocardial infarction is uncertain. There are no randomized trials of thrombolytic efficacy or observational studies of clinical effectiveness that focus specifically on the elderly.
Methods and Results—To determine whether thrombolytic therapy for elderly patients is associated with a survival advantage in a large observational database, we conducted a retrospective cohort study of 7864 Medicare fee-for-service patients aged 65 to 86 years with the primary discharge diagnosis of acute myocardial infarction who were admitted with clinical and ECG indications for thrombolytic therapy and no absolute contraindications. The study included all US acute care nongovernment hospitals without on-site angioplasty capability. Using proportional-hazards methods, we found that in a comprehensive multivariate model, there was a significant interaction (P<0.001) between age and the effect of thrombolytic therapy on 30-day mortality rates. For patients 65 to 75 years old, thrombolytic therapy was associated with a survival benefit, consistent with randomized trials. Among patients aged 76 to 86 years, thrombolytic therapy was associated with a survival disadvantage, with a 30-day mortality hazard ratio of 1.38 (95% CI 1.12 to 1.71, P=0.003). For these patients, there was no benefit from thrombolytic therapy in any clinical subgroup.
Conclusions—In nationwide clinical practice, thrombolytic therapy for patients >75 years old is unlikely to confer survival benefit and may have a significant survival disadvantage. Reperfusion research that is focused on elderly patients is urgently needed.
Key Words: myocardial infarction • thrombolysis • angioplasty • epidemiology
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