Thrombolytic therapy for patients with myocardial infarction who are older than 75 years. Do the risks outweigh the benefits?

Thrombolytic therapy represents a major advance in the care of patients with acute myocardial infarction (AMI) that has developed over the past 2 decades. In a meta-analysis of the 9 largest randomized trials conducted between 1982 and 1992 and involving 58 000 patients, this treatment was shown to reduce 35-day mortality, particularly in patients younger than 75 years who had evidence of ST-segment elevation or bundle-branch block and who were treated within 12 hours of the onset of symptoms.1 Among the 5754 patients in these trials who were ≥75 years, thrombolytic therapy was associated with an absolute reduction in mortality of 1% (1 life saved for every 100 patients treated), a reduction that did not approach statistical significance. Given the powerful evidence of benefit in younger patients (including those between 65 and 74 years) and the potential benefit in older patients, guidelines for the care of AMI from the American Heart Association and the American College of Cardiology have supported the use of this treatment for patients ≥75 years who present with ST elevation within 12 hours of symptom onset as a class IIa indication, ie, one for which the “weight of evidence/opinion is in favor of usefulness/efficacy.”2 Contrary to this perspective, an observational study by Thiemann et al3 in this issue of Circulation indicates that thrombolytic therapy is not beneficial and could actually be harmful in patients older than 75 years. (May 16, 2000)