In Paul Armstrong's review article on fibrinolytic therapy for acute ST-segment elevation myocardial infarction, the fibrinolytic or thrombolytic treatment recommended for the case presented is not completely supported by the evidence cited.1 In the Fibrinolytic Therapy Trialists' study a nonsignificant reduction in mortality of 1% was observed in the group of patients over 75 years of age who were administered fibrinolytics.2 Armstrong also cited a subgroup analysis confined to patients in the same age group who received fibrinolysis within 12 hours of symptom onset, in which there was an absolute risk reduction of 3.4% in the treated group.3 In contrast, a retrospective and nonrandomized study mentioned by Armstrong showed a survival disadvantage in those patients over 75 years of age given thrombolytics.4 In the treated group, there was an excess mortality of 2.6%. The author of this last study has commented in CMAJ on this finding.5 Therefore, the evidence for administering fibrinolytics to patients older than 75 years does not appear to be as strong as in younger age groups.
A further issue relating to the patient presented in Armstrong's article is the decreased benefit of fibrinolysis in patients with an inferior infarction. In the Fibrinolytic Therapy Trialists' study, the absolute risk reduction in patients with inferior infarctions was 0.9% whereas it was 3.7% in patients with anterior infarctions.2
Given the fixed risk of complications of fibrinolysis in elderly people, in particular intracranial hemorrhage, one might question whether the risks are in fact outweighed by the benefits in the patient presented and how the information about these risks and benefits might be transmitted to the patient and her family to obtain informed consent before administration of fibrinolysis.6
References
- 1.Armstrong PW. New advances in the management of acute coronary syndromes: 2. Fibrinolytic therapy for acute ST-segment elevation myocardial infarction. CMAJ 2001;165(6):791-7. [PMC free article] [PubMed]
- 2.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. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Lancet 1994;343: 311-22. [PubMed]
- 3.White HD. Thrombolytic therapy in the elderly [editorial]. Lancet 2000;356:2028-30. [DOI] [PubMed]
- 4.Thiemann DR, Coresh J, Schulman SP, Gerstenblith G, Oetgen WJ, Powe NR. Lack of benefit of intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000;101:2239-46. [DOI] [PubMed]
- 5.Thiemann DR, Schulman SP. Thrombolytics in elderly patients: A triumph of hope over experience? CMAJ 2001;164(9):1301-3. [PMC free article] [PubMed]
- 6.McGouran RC. Modern doctoring. J R Coll Physicians Lond 2000;34:582-3. [PMC free article] [PubMed]