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Effectiveness of Thrombolytic Therapy for Acute Myocardial Infarction in the Elderly
Cause for Concern in the Old-Old
Stephen B. Soumerai, ScD;
Thomas J. McLaughlin, ScD;
Dennis Ross-Degnan, ScD;
Cindy L. Christiansen, PhD;
Jerry H. Gurwitz, MD
Arch Intern Med. 2002;162:561-568.
Background National guidelines have encouraged increased use of thrombolytic therapy
for elderly patients with acute myocardial infarction (AMI). However, evidence
supporting thrombolytic therapy in patients 75 years and older is lacking.
In a retrospective cohort study of 2659 elderly AMI patients, we determined
the association between thrombolytic use and in-hospital mortality by age
and among patients with or without absolute or relative contraindications
to thrombolytic treatment.
Methods We abstracted the medical records of 2659 elderly patients admitted
with AMI at 37 Minnesota community hospitals between 1992 and 1996. The main
outcome measure was in-hospital mortality, controlling for demographic, clinical,
comorbidity, and severity-of-illness variables.
Results Sixty-three percent of 719 eligible patients received thrombolytic therapy.
Twenty-seven percent of thrombolytic recipients had absolute contraindications
to treatment. Patients receiving thrombolytic agents had fewer and less severe
comorbidities than those not receiving thrombolytic therapy. There was a 4%
increase in the odds of death for every 1-year increase in age for all thrombolytic
recipients vs nonrecipients (odds ratio [OR], 1.04 per year; 95% confidence
interval [CI], 1.01-1.08; P = .03). Among patients
with 1 or more contraindication, the OR for death associated with thrombolytic
use was 1.57 (95% CI, 1.03-2.40; P = .04). The adjusted
odds of death among eligible thrombolytic recipients (vs nonrecipients) increased
significantly with age (OR, 1.08 per year; 95% CI, 1.02-1.14; P = .008). Among eligible patients aged 80 to 90 years, the predicted
odds of death among thrombolytic recipients vs nonrecipients was 1.4. Among
eligible patients younger than 80 years, thrombolytic use was associated with
reduced mortality.
Conclusions Our findings suggest the need for more research on the effectiveness
of thrombolytic therapy for AMI patients 75 years and older and for more careful
selection of elderly patients for this treatment.
From the Department of Ambulatory Care and Prevention, Harvard Medical
School and Harvard Pilgrim Health Care, Boston, Mass (Drs Soumerai, McLaughlin,
and Ross-Degnan); the Boston University School of Public Health, Health Services
Department and Center for Health Quality, Outcomes, and Economic Research
at Veterans Affairs Health Services Research and Development, Bedford, Mass
(Dr Christiansen); and The Meyers Primary Care Institute, University of Massachusetts
Medical School, and the Fallon Healthcare System, Worcester (Dr Gurwitz).
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