Skip to main content
SpringerLink
Log in

Thrombolysis Versus Primary Angioplasty in Older Patients with Acute Myocardial Infarction

  • Review Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Although it is effective for appropriate older patients with acute myocardial infarction (AMI), only about 25% of patients 65 years and older are eligible for thrombolytic therapy. Primary percutaneous transluminal coronary angioplasty (PTCA) may be a suitable alternative reperfusion therapy, particularly for older patients with high risk of intracerebral haemorrhage or cardiogenic shock.

Randomised trials of primary PTCA versus thrombolytic therapy have demonstrated better efficacy for primary PTCA, whereas the 2 therapies produced comparable results in observational studies. In subset analyses in 2 randomised trials, there were trends toward better outcomes with primary PTCA, although these studies had small numbers of older patients. Results from 3 AMI registries (the Cooperative Cardiovascular Project, the Myocardial Infarction Triage and Intervention Registry, and the National Registry of Myocardial Infarction 2) indicated trends toward improved hospital or 30 day death rates in patients 75 years and older receiving primary PTCA. Older patients who are at high risk of bleeding complications may do better with primary PTCA, although for others with moderate or minimal risk, the 2 therapies are equivalent.

More data about long term follow-up and the association between outcomes and hospital and operator volumes for primary PTCA in older patients are needed before a definitive recommendation can be made.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. US Bureau of the Census. Current population reports, special studies: 65+ in the United States. Washington, DC: US Government Printing Office, 1996: 23–190

    Google Scholar 

  2. Graves EJ, Owings MR. 1995 summary: National Hospital Discharge Survey: advance data from vital and health statistics. No. 291. Hyattsville (MD): National Center for Health Statistics, 1997

    Google Scholar 

  3. Maynard C, Litwin PE, Martin JS, et al. Treatment and outcome of acute myocardial infarction in women 75 years and older: findings from the MITI Registry. Cardiol Elderly 1993; 1: 121–5

    Google Scholar 

  4. Gurwitz JH, Col NF, Avorn J. The exclusion of the elderly and women from clinical trials in acute myocardial infarction. JAMA 1992; 268: 1417–22

    Article  PubMed  CAS  Google Scholar 

  5. Fibrinolytic Therapy Trialists (FIT) Collaborative Group. Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311–22

    Google Scholar 

  6. Krumholz HM, Pasternak RC, Weinstein MC, et al. Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with acute myocardial infarction. N Engl J Med 1992; 327: 7–13

    Article  PubMed  CAS  Google Scholar 

  7. Ramanathan K, Ellis CJ, White HD. Thrombolytic therapy for the elderly: pharmacoeconomic considerations. Drugs Aging 1996; 8: 237–44

    Article  PubMed  CAS  Google Scholar 

  8. Verstraete M, Collen D. Optimising thrombolytic therapy in elderly patients with acute myocardial infarction. Drugs Aging 1996; 8: 17–22

    Article  PubMed  CAS  Google Scholar 

  9. Ryan TJ, Anderson JL, Antman EL, et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996; 28: 1328–428

    Article  PubMed  CAS  Google Scholar 

  10. Krumholz HM, Murillo JE, Chen H et al. Thrombolytic therapy for eligible elderly patients with acute myocardial infarction. JAMA 1997; 277: 1683–8

    Article  PubMed  CAS  Google Scholar 

  11. Weaver WD, Litwin PE, Martin JS, et al. Age, use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Coll Cardiol 1991; 18: 657–62

    Article  PubMed  CAS  Google Scholar 

  12. Gurwitiz 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. Ann Intern Med 1996; 124: 283–91

    Google Scholar 

  13. Gurwitz JH, McLaughlin TJ, Willison DJ, et al. Delayed hospital presentation in patients who have had acute myocardial infarction. Ann Intern Med 1997; 126: 593–9

    PubMed  CAS  Google Scholar 

  14. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2. Circulation 1998; 97: 1150–6

    Article  PubMed  CAS  Google Scholar 

  15. The Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Arteries (GUSTO) Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 674–83

    Google Scholar 

  16. Gurwitz JH, Goldberg RJ. Coronary thrombolysis for the elderly: is clinical practice really lagging behind evidence of benefit? JAMA 1997; 277: 1723–4

    Article  PubMed  CAS  Google Scholar 

  17. Mattos LA, Cano MN, Maldonado G, et al. The use of primary coronary angioplasty in acute myocardial infarction in patients over 70 years of age. Arq Bras Cardiol 1992; 58: 181–7

    PubMed  CAS  Google Scholar 

  18. Stone GW, Grines CL, Vlietstra R, et al. Primary angioplasty is the preferred therapy for women and the elderly with acute myocardial infarction-results of the Primary Angioplasty in Myocardial Infarction (PAMI) trial [abstract]. J Am Coll Cardiol 1993; 21: 330A

    Google Scholar 

  19. Ross AM. The TTOPP study: lessons from an aborted trial. J Myocardial Ischemia 1990; 2: 65–9

    Google Scholar 

  20. ONeill W, Timmis GC, Bourdillon PD, et al. A prospective randomized trial of intracoronary streptokinase versus coronary angioplasty for acute myocardial infarction. N Engl J Med 1986; 314: 812–8

    Article  CAS  Google Scholar 

  21. Grines CL, Browne KF, Marco J, et al. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. N Engl J Med 1993; 328: 673–9

    Article  PubMed  CAS  Google Scholar 

  22. Zijlstra F, deBoer MJ, Hoorntje CA, et al. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med 1993; 328: 680–4

    Article  PubMed  CAS  Google Scholar 

  23. Gibbons RJ, Holmes DR, Reeder GS, et al. Immediate angioplasty compared with the administration of a thrombolytic agent followed by conservative treatment for myocardial infarction. N Engl J Med 1993; 328: 685–91

    Article  PubMed  CAS  Google Scholar 

  24. Ribeiro EE Silva LA, Carneiro R, et al. Randomized trial of direct coronary angioplasty versus intravenous streptokinase in acute myocardial infarction. J Am Coll Cardiol 1993; 22: 376–80

    Article  PubMed  CAS  Google Scholar 

  25. The Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) Angioplasty Substudy Investigators. Aclinical trial comparing primary coronary angioplasty with tissue plasminogen activator for acute myocardial infarction. N Engl J Med 1997; 336: 1621–8

    Article  Google Scholar 

  26. Weaver WD, Simes RJ, Betriu A, et al. Comparison of primary coronary angioplasty and intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review. JAMA 1997; 278: 2093–8

    Article  PubMed  CAS  Google Scholar 

  27. O’Neill WW, deBoer MJ, Gibbons RJ, et al. Lessons from the pooled outcome of the PAMI, ZWOLLE and Mayo Clinic randomized trials of primary angioplasty versus thrombolytic therapy of acute myocardial infarction. J Invasive Cardiol 1998; 10: A4–10

    Google Scholar 

  28. Holmes DR, Berger PB, White HD. The effect of age on outcomes in primary PTCA versus lysis for myocardial infarction: the GUSTO IIb substudy [abstract]. Circulation 1997; 96: 1–595

    Google Scholar 

  29. Every NR, Parsons LS, Hlatky M, et al. Acomparison of thrombolytic therapy with primary coronary angioplasty for acute myocardial infarction. N Engl J Med 1996; 335: 1253–60

    Article  PubMed  CAS  Google Scholar 

  30. Tiefenbrunn AJ, Chandra NC, French WJ, et al. Clinical experience with primary percutaneous transluminal coronary angioplasty compared with alteplase (recombinant tissue-type plasminogen activator) in patients with acute myocardial infarction; a report from the Second National Registry of Myocardial Infarction (NRMI-2). J Am Coll Cardiol 1998; 31: 1240–5

    Article  PubMed  CAS  Google Scholar 

  31. Berger AK, Breall JA, Johnson AE, et al. Primary angioplasty vs thrombolytic therapy in the elderly: the CCP experience [abstract]. Circulation 1997; 96: 1–595

    Google Scholar 

  32. Jollis JG, Peterson ED, DeLong ER, et al. The relation between volume of coronary angioplasty procedures at hospitals treating Medicare beneficiaries and short-term mortality. N Engl J Med 1994; 331: 1625–9

    Article  PubMed  CAS  Google Scholar 

  33. Jollis JG, Peterson ED, Nelson CL, et al. Relationship between physician and hospital coronary angioplasty volume and outcome in elderly patients. Circulation 1997; 95: 2485–91

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Health Services, University of Washington, and Health Services Research and Development, Department of Veterans Affairs, Seattle, Washington, USA

    Charles Maynard

  2. Department of Medicine and Health Services Research and Development, Department of Veterans Affairs, Department of Medicine, University of Washington, Seattle, Washington, USA

    Nathan R. Every

Authors
  1. Charles Maynard
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nathan R. Every
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Charles Maynard.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Maynard, C., Every, N.R. Thrombolysis Versus Primary Angioplasty in Older Patients with Acute Myocardial Infarction. Drugs & Aging 14, 427–435 (1999). https://doi.org/10.2165/00002512-199914060-00003

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/00002512-199914060-00003

Keywords

Search

Navigation