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(Circulation. 2000;101:2224.)
© 2000 American Heart Association, Inc.

Editorial

Thrombolytic Therapy for Patients With Myocardial Infarction Who Are Older Than 75 Years

Do the Risks Outweigh the Benefits?

John Z. Ayanian, MD, MPP; Eugene Braunwald, MD

From the Division of General Medicine (J.Z.A.) and the Cardiovascular Division (E.B.), Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School; the Department of Health Care Policy, Harvard Medical School (J.Z.A.); and the Partners HealthCare System (E.B.), Boston, Mass.

Correspondence to John Z. Ayanian, MD, MPP, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115. E-mail ayanian@hcp.med.harvard.edu

Key Words: myocardial infarction • thrombolysis • angioplasty • aging • outcome and process assessment (health care)

Thrombolytic therapy represents a major advance in the care of patients with acute myocardial infarction (AMI) that has developed over the past 2 decades. In a meta-analysis of the 9 largest randomized trials conducted between 1982 and 1992 and involving 58 000 patients, this treatment was shown to reduce 35-day mortality, particularly in patients younger than 75 years who had evidence of ST-segment elevation or bundle-branch block and who were treated within 12 hours of the onset of symptoms.¹ Among the 5754 patients in these trials who were 75 years, thrombolytic therapy was associated with an absolute reduction in mortality of 1% (1 life saved for every 100 patients treated), a reduction that did not approach statistical significance. Given the powerful evidence of benefit in younger patients (including those between 65 and 74 years) and the potential benefit in older patients, guidelines for the care of AMI from the American Heart Association and the American College of Cardiology have supported the use of this treatment for patients 75 years who present with ST elevation within 12 hours of symptom onset as a class IIa indication, ie, one for which the "weight of evidence/opinion is in favor of usefulness/efficacy."²

Contrary to this perspective, an observational study by Thiemann et al³ in this issue of Circulation indicates that thrombolytic therapy is not beneficial and could actually be harmful in patients older than 75 years. These investigators assessed the 30-day mortality among patients aged 65 to 86 years in the United States who . . . [Full Text of this Article]

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