Journal of Thrombosis and Thrombolysis

, Volume 14, Issue 1, pp 5–14 | Cite as

Age-Specific Differences in the Use of Thrombolytic Therapy and Hospital Outcomes in Patients with Acute Myocardial Infarction: A Community-Wide Perspective

  • Omar Ali
  • Immad Sadiq
  • Robert J. Goldberg
  • Jorge Yarzebski
  • Darleen Lessard
  • Jerry Gurwitz
  • Joel M. Gore
Article

Abstract

Background: Relatively limited information is available about recent, and trends over time, use of thrombolytic therapy in patients of different ages hospitalized with acute myocardial infarction and the association between use of thrombolytic therapy and hospital outcomes.

Methods: We conducted an observational study of 5601 residents of the Worcester, Massachusetts, metropolitan area (1990 census = 437,000) with confirmed acute myocardial infarction in all local hospitals during 6 one-year periods between 1990 and 1999.

Results: Despite relatively stable use of thrombolytic therapy between 1990 and 1995, decreases in the use of thrombolytic therapy in all patients with acute myocardial infarction were observed in 1997 and 1999. There was a 1.6 fold decrease in the use of thrombolytic therapy between 1990 and 1999 in patients <65 years. Patients 65–74 years (33.7% 1990; 11.7% 1999) and those 75 years and older (10.8% 1990; 6.7% 1999) experienced marked decreases in the receipt of thrombolytic therapy over time. Use of thrombolytic therapy was associated with reduced hospital mortality in each of the four age-specific groups under study (<55, 55–64, 65–74, ≥75) through the degree of benefit on hospital death rates associated with the use of thrombolytic therapy was attenuated after adjustment for additional confounders.

Conclusions: Our findings indicate recent declines in the use of thrombolytic therapy in middle-aged and elderly patients with acute myocardial infarction. The impact of thrombolytic therapy on hospital outcomes was observed in each of our age strata under study though the magnitude of absolute and relative benefit varied according to age.

Miniabstract. Declines in the use of thrombolytic therapy were observed between 1900 and 1999 in a population-based sample of patients with acute myocardial infarction. Use of thrombolytic therapy was associated with improved hospital survival to varying degrees in each of the age groups under study.

acute myocardial infarction age thrombolytics 

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References

  1. 1.
    Goldberg RJ, McCormick D, Gurwitz JH, et al. Age-related trends in short and long-term survival after acute myocardial infarction: a 20 year population-based perspective (1975- 1995). Am J Cardiol1998;82: 1311–1317.Google Scholar
  2. 2.
    Chandra H, Yarzebski J, Goldberg RJ, et al. Age-related trends (1986- 1993) in the use of thrombolytic agents in patients with acute myocardial infarction: the Worcester Heart Attack Study. Arch Intern Med1997;157: 741–746.Google Scholar
  3. 3.
    Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med2000;342: 1878–1886.Google Scholar
  4. 4.
    Concato J, Shah N, Horwitz RJ. Randomized controlled trials, observational studies, and the hierarchy of research designs. N Engl J Med2000;342: 1887–1892.Google Scholar
  5. 5.
    Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA1998;280: 605–613.Google Scholar
  6. 6.
    Goldberg RJ, Gore JM, Alpert JS, Dalen JE. Recent changes in the attack rates and survival rates of acute myocardial infarction (1975- 1981): the Worcester Heart Attack Study. JAMA1986;255: 2774–2779.Google Scholar
  7. 7.
    Goldberg RJ, Gore JM, Alpert JS, Dalen JE. Incidence and case fatality rates of acute myocardial infarction (1975- 1984): the Worcester Heart Attack Study. Am Heart J1988;115: 761–767.Google Scholar
  8. 8.
    Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975- 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol1999;33: 1533–1539.Google Scholar
  9. 9.
    Goldberg RJ, Samad NA, Yarzebski J, et al. Temporal trends (1975- 1997) in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction (Worcester Heart Attack Study). N Engl J Med1999;340: 1162–1168.Google Scholar
  10. 10.
    Spencer FA, Meyer TE, Goldberg RJ, et al. Twenty year trends (1975- 1995) in the incidence, in-hospital, and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol1999;34: 1378–1387.Google Scholar
  11. 11.
    Ryan TJ, Antman EM, Brooks NH, et al. 1999 update: ACC/AHA guidelines for the management of patients with acute myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). Circulation1999;100: 1016–1030.Google Scholar
  12. 12.
    GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico). Effectiveness of intravenous thrombolytic therapy treatment in acute myocardial infarction. Lancet1986;1: 397–401.Google Scholar
  13. 13.
    The GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries) Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med1993;329: 673–682.Google Scholar
  14. 14.
    GISSI (Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico) Investigators. Ten-year follow-up of the first megatrial testing thrombolytic therapy in patients with acute myocardial infarction. Circulation1998;98: 2659–2665.Google Scholar
  15. 15.
    Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1000 patients. Lancet1994;343: 311–322.Google Scholar
  16. 16.
    Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA1992;268: 1417–1422.Google Scholar
  17. 17.
    Gurwitz JH, Gore JM, Goldberg RJ, et al. Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction. National Registry of Myocardial Infarction. Ann Intern Med1996;124: 283–291.Google Scholar
  18. 18.
    Thiemann DR, Coresh J, Schulman SP, et al. Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation2000;101: 2239–2246.Google Scholar
  19. 19.
    ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. 10 year survival among patients with suspected acute myocardial infarction in randomized comparison of intravenous streptokinase, oral aspirin, both or neither: ISIS-2. BMJ1998;316: 1337–1343.Google Scholar
  20. 20.
    Gore JM, Sloan M, Price TR, et al. Intracerebral hemorrhage, cerebral infarction and subdural hematoma af-ter acute myocardial infarction and thrombolytic therapy in the thrombolysis in myocardial infarction study: TIMI Phase II, pilot and clinical trial. Circulation1991;83: 448–459.Google Scholar
  21. 21.
    Longstreth WT, Litwin PE, Weaver WD. Myocardial infarction, thrombolytic therapy and stroke. Stroke1993;13: 161–165.Google Scholar
  22. 22.
    Brass LM, Lichtman JH, Wang Y, et al. Intracranial hemorrhage associated with thrombolytic therapy for elderly patients with acute myocardial infarction—results from the Cooperative Cardiovascular Project. Stroke2000;31: 1802–1811.Google Scholar

Copyright information

© Kluwer Academic Publishers 2002

Authors and Affiliations

  • Omar Ali
    • 1
  • Immad Sadiq
    • 1
  • Robert J. Goldberg
    • 1
  • Jorge Yarzebski
    • 1
  • Darleen Lessard
    • 1
  • Jerry Gurwitz
    • 1
  • Joel M. Gore
    • 1
  1. 1.Department of Medicine, Division of Cardiovascular MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA

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