Clinical investigations
Primary angioplasty with routine stenting compared with thrombolytic therapy in elderly patients with acute myocardial infarction

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Abstract

Background

Prior studies have yielded conflicting data on the advantage of primary angioplasty compared with thrombolysis in elderly patients with acute myocardial infarction (AMI). These studies, however, were performed before the contemporary widespread use of intracoronary stents and glycoprotien IIb/IIIa antagonists.

Methods

We prospectively compared the outcome of 130 consecutive elderly patients (aged ≥70 years) with ST-elevation AMI who were admitted to 2 similar neighboring medical centers. Patients were assigned to receive either thrombolytic therapy with accelerated tissue-type plasminogen activator (center I) or primary angioplasty with routine stenting (center II).

Results

Of the patients assigned to receive primary angioplasty, 91% underwent stenting. At 6 months, patients treated with primary angioplasty, compared with those treated with thrombolytic therapy, had a lower incidence of reinfarction (2% vs 14%, P = .053) and revascularization for recurrent ischemia (9% vs 61%, P < .001) and a significant reduction in the prespecified combined end point of death, reinfarction, or revascularization for recurrent ischemia (29% vs 93%, P < .01). Primary angioplasty remained an independent predictor of the triple combined end point after controlling for potential covariables (relative risk 0.63, 95% CI 0.38–0.84). Major bleeding complications were also significantly reduced in the primary angioplasty group (0% vs 17%, P = .03).

Conclusions

Compared with thrombolysis, primary angioplasty with routine stenting in elderly patients with AMI is associated with better clinical outcomes and a lower risk of bleeding complications.

Section snippets

Patient population

This study is a prospective analysis of 130 consecutive patients ≥70 years of age from the greater Tel-Aviv area with ST-elevation AMI. Patients were admitted to the intensive coronary care units (ICCUs) of 2 local medical centers (Soraski Medical Center and Sheba Medical Center, both affiliated with the Tel Aviv University Sackler School of Medicine) between February 1998 and November 1999. Each patient entered the emergency department of the medical center in the vicinity, with similar

Results

Of the 130 patients who comprised the study population, 86 (66%) were admitted to center I and 44 (34%) were admitted to center II. Of the 86 patients who were treated with thrombolytic therapy, 41 (48%) were catheterized during hospitalization because of unsuccessful thrombolysis requiring rescue angioplasty (n = 4), recurrent spontaneous ischemia (n = 30), positive stress test results (n = 6), and after a diagnosis of a ventricular septal defect (n = 1). Coronary angioplasty was performed in

Discussion

Although elderly patients, who comprise as much as 80% of all patients with AMI, have a substantially worse short- and long-term prognosis, acute treatment is usually less vigorous in older patients than younger patients.5 Thrombolytic therapy is often withheld from elderly patients because of the fear of bleeding complications, particularly intracerebral hemorrhage, and the contradictory data on the efficacy of this therapy in the older age group.2, 3, 4, 5, 15, 16, 17, 18, 19, 20 Thus, safer

References (30)

  • M.J. De Boer et al.

    Reperfusion therapy in elderly patients with acute myocardial infarctiona randomized comparison of primary angioplasty and thrombolytic therapy

    J Am Coll Cardiol

    (2002)
  • C.L. Pashos et al.

    Temporal changes in the care and outcomes of elderly patients with acute myocardial infarction, 1987 through 1990

    JAMA

    (1993)
  • J. Gore et al.

    The National Registry of Myocardial Infarction (NRMI) Investigatorscurrent trends in the treatment of elderly patients with acute myocardial infarction

    J Am Coll Cardiol

    (1993)
  • A.P. Maggioni et al.

    Age-related increase on mortality among patients with first myocardial infarction treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI-2)

    N Engl J Med

    (1993)
  • An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction

    N Engl J Med

    (1993)
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