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Age-related differences in in-hospital mortality and the use of thrombolytic therapy for acute myocardial infarction

Jean-Marc Boucher^*, Normand Racine, Thao Huynh Thanh, Elham Rahme, James Brophy^*, Jacques LeLorier^*, Pierre Théroux and The Quebec Acute Coronry Care Working Group

From the *Département de Médecine, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Que.; the Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Que.; the Department of Medicine, Montreal General Hospital, McGill University, Montreal, Que.; and the Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, Que. ¶Members of the Executive of the Working Group are listed at the end of the article.Members of the Executive of the Quebec Acute Coronary Care Working Group: Chair: Dr. Pierre Théroux, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Qué. Members: Drs. Peter Bogaty, Institut de Cardiologie de Québec, Université Laval, Québec, Qué.; James Brophy, Département de Médicine, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Qué.; Franz Dauwe, Hôpital de Chicoutimi, Chicoutimi, Qué.; Jean Diodati, Jewish General Hospital, McGill University, Montréal, Qué. (at the time of writing); David Fitchett, Royal Victoria Hospital, McGill University, Montréal, Qué. (at the time of writing); Thao Huynh Thanh, Department of Medicine, Montreal General Hospital, McGill University, Montréal, Qué.; Pierre Laramée, Centre Hospitalier Universitaire de Montréal, Hôpital Notre Dame, Université de Montréal, Montréal, Qué.; James Nasmith, Hôpital Sacré-Coeur, Université de Montréal, Montréal, Qué.; and Normand Racine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Qué.

Background: Recent guidelines have acknowledged that thrombolysis decreases mortality from acute myocardial infarction (AMI) independently of age. The purpose of this study was to determine the age-related rates of thrombolytic administration and in-hospital mortality and the variables related to the use of thrombolytic therapy for patients with AMI.

Methods: A prospective cohort analysis involved a registry of 44 acute care Quebec hospitals that enrolled 3741 patients with AMI between January 1995 and May 1996. The main outcomes of interest were crude and adjusted age-related in-hospital mortality rates and rates of use of thrombolytic therapy.

Results: In-hospital mortality rates increased dramatically with age from 2.1% in patients with AMI who were less than 55 years of age to 26.3% in those who were 85 years of age or older. Overall, 35.8% of the patients received thrombolysis. There was a pronounced inverse gradient in the use of thrombolysis with age, ranging from 46.2% in the youngest age group (< 55 years) to 9.5% in the oldest group ( 85 years). After adjustment for potential confounders, the older patients remained significantly less likely to receive thrombolytic therapy. Compared with patients who were less than 55 years of age, the odds ratio of receiving thrombolytic therapy was 0.68 (95% confidence interval [CI] 0.52–0.89) for patients aged 65–74 years, 0.48 (95% CI 0.35–0.65) for patients aged 75–84 years and 0.13 (95% CI 0.06–0.26) for patients aged 85 years or more. Other variables related to thrombolytic therapy were diabetes (odds ratio [OR] 0.77, 95% CI 0.59–1.00), cerebrovascular disease (OR 0.46, 95% CI 0.30–0.72), angina (OR 0.73, 95% CI 0.56–0.95), typical chest pain (OR 2.56, 95% CI 1.88–3.47), ST elevation (OR 8.93, 95% CI 7.24–11.00), Q wave MI (OR 5.26, 95% CI 4.20–6.60) and increased length of time between onset of symptoms and arrival at hospital.

Interpretation: Age is an important independent predictor of in-hospital mortality and lower thrombolytic use following AMI. Other studies are required to further evaluate the appropriateness of thrombolytic therapy for elderly patients.

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