Myocardial Infarction in the Elderly
Patients aged 75 years and older comprise 36% of all patients with myocardial infarction and 60% of all deaths from myocardial infarction in the US. Data from randomised, placebo-controlled clinical trials and observational data demonstrated a beneficial effect of thrombolytic therapy in eligible patients with acute myocardial infarction younger than 75 years of age. The overall data support the use of thrombolytic therapy in eligible patients with acute myocardial infarction aged 75 years and older. There is an urgent need to conduct a large-scale, prospective, double-blind, randomised, placebo-controlled trial investigating the effect of thrombolytic therapy on the combined endpoint of all-cause mortality plus cerebral bleeding at hospital discharge and at long-term follow-up in eligible patients aged 75 years and older with acute myocardial infarction. Current guidelines for the care of patients with acute myocardial infarction from the American College of Cardiology/American Heart Association support the use of thrombolytic therapy in eligible patients aged 75 years and older who present within 12 hours of symptom onset of acute myocardial infarction as a Class IIa indication, that is, one for which the weight of evidence/opinion is in favour of usefulness/efficacy. Absolute contraindications to thrombolytic therapy include prior haemorrhagic stroke, other cerebrovascular events within 1 year, active internal bleeding, known intracranial neoplasm, suspected aortic dissection, and acute pericarditis. Stroke is a potential risk of the use of thrombolytics.
KeywordsAcute Myocardial Infarction Streptokinase Thrombolytic Therapy Alteplase Left Bundle Branch Block
No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.
- 3.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). Circulation 1999; 100: 1016–30PubMedCrossRefGoogle Scholar
- 4.ISAM Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction (ISAM). Mortality, morbidity, and infarct size at 21 days. N Engl J Med 1986; 314: 1465–71Google Scholar
- 5.Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986; I: 397–402Google Scholar
- 6.AIMS Trial Study Group. Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial. Lancet 1988; I: 545–9Google Scholar
- 7.ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; II: 349–60Google Scholar
- 9.Gruppo Italiano Per Lo Studio Della Streptochinasi Nell’Infarto Miocardico (GISSI). Long-term effects of intravenous thrombolysis in acute myocardial infarction: final report of the GISSI study. Lancet 1987; II: 871–4Google Scholar
- 11.AIMS Trial Study Group. Long-term effects of intravenous anistreplase in acute myocardial infarction: final report of the AIMS study. Lancet 1990; 335: 427–31Google Scholar
- 13.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 randomised trials of more than 1000 patients. Lancet 1994; 343: 311–22Google Scholar
- 16.Gitt AK, Zahn R, Wienbergen H, et al. Thrombolysis for acute myocardial infarction in patients older than 75 years: lack of benefit for hospital mortality but improvement of long-term mortality: results of the MITRA- and MIR-Registries [abstract]. J Am Coll Cardiol 2001 37: 323ACrossRefGoogle Scholar
- 19.GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329: 673–82Google Scholar
- 20.Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO III) Investigators. A comparison of reteplase with alteplase for acute myocardial infarction. N Engl J Med 1997; 337: 1118–23Google Scholar
- 21.Feit F, Breed J, Anderson JL, et al. A randomized, placebo-controlled, trial of tissue plasminogen activator in elderly patients with acute myocardial infarction [abstract]. Circulation 1990 82: III–666Google Scholar