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Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial

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Abstract

Elderly patients constitute a large and growing proportion of ST-elevation myocardial infarction (STEMI) patients, yet they have been under-represented or even excluded from reperfusion trials. Despite evidence that fibrinolysis improves outcomes irrespective of age, many elderly STEMI patients still remain undertreated or subject to major delays to primary percutaneous coronary intervention (PCI). The fear of an excessive risk of intracranial hemorrhage (ICH) in these patients can lead to avoidance of potentially life-saving reperfusion treatment, despite the fact that current STEMI guidelines do not exclude the elderly from a pharmaco-invasive strategy. Age-specific dose reductions have been succesfully made to antithrombotic drugs such as clopidogrel and enoxaparin as an adjunct to fibrinolysis, but until recently no dose adjustments for elderly patients have been applied to the fibrinolytic agents. In the pharmaco-invasive STREAM trial, halving the bolus of tenecteplase for patients aged >75 years because of an unacceptably high ICH rate in the elderly was associated with a more favorable safety/efficacy profile. Whether a pharmaco-invasive strategy including half-dose tenecteplase, age- and weight-adjusted enoxaparin, and a tailored P2Y12 inhibitor followed by routine angiography represents a safe and efficacious alternative reperfusion therapy for elderly patients remains to be prospectively assessed in a clinical trial in this age group.

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Authors and Affiliations

  1. University Hospitals Leuven, KU Leuven, Leuven, Belgium

    Peter R. Sinnaeve & Frans Van de Werf

  2. Boehringer Ingelheim, Reims, France

    Thierry Danays

  3. Interuniversity Institute for Biostatistics and Statistical Bioinformatics, KU Leuven, Leuven and University Hasselt, Hasselt, Belgium

    Kris Bogaerts

  4. The Canadian Virtual Coordinating Centre for Global Colloborative Cardiovascular Research, University of Alberta, Edmonton, AB, Canada

    Paul W. Armstrong

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  1. Peter R. Sinnaeve
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  4. Frans Van de Werf
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Correspondence to Paul W. Armstrong.

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No external funding was used in the preparation of this review.

Conflict of interest

Paul W. Armstrong has received honorarium and a grant from Boehringer Ingelheim. Thierry Danays is an employee of Boehringer Ingelheim, France. Kris Bogaerts has received consulting and travel fees through his institution for statistical consulting and support to data monitoring committees for studies by Boehringer Ingelheim. Frans Van de Werf has received grants for multicenter studies with fibrinolytic agents (mainly tenecteplase) supported by Boehringer Ingelheim, and consulting fees/honoraria, payments for lectures, and travel support from Boehringer Ingelheim and AstraZeneca. Peter R. Sinnaeve has no conflicts that might be relevant to the contents of this manuscript.

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Sinnaeve, P.R., Danays, T., Bogaerts, K. et al. Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial. Drugs Aging 33, 109–118 (2016). https://doi.org/10.1007/s40266-016-0345-6

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