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April 3, 1991, Vol 265, No. 13 >
ARTICLE | April 3, 1991

Coronary Thrombolysis for the Elderly? FREE

Jerry H. Gurwitz, MD; Robert J. Goldberg, PhD; Joel M. Gore, MD
[+] Author Affiliations

Reprint requests to Program for the Analysis of Clinical Strategies, 333 Longwood Ave, Boston, MA 02115 (Dr Gurwitz).


JAMA. 1991;265(13):1720-1723. doi:10.1001/jama.1991.03460130112032
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Article
References

CARDIOVASCULAR disease ranks as the leading cause of disability and death in the elderly. Although those 65 years of age or older constitute only 13% of the US population,1 80% of all deaths due to acute myocardial infarction (MI) occur in those over the age of 65 years. Of these, 60% occur in patients 75 years of age or older.2 The in-hospital case-fatality rate for initial acute MI increases from 5% in those less than 55 years of age to 32% in those older than age 75.3 Patient age at the time of onset of acute MI also affects survival after hospital discharge.4 For example, results of the Worcester Heart Attack Study indicate a 94% 1-year survival rate among patients with acute MI who are less than 55 years of age and are discharged alive from the hospital, compared with only 77% for those 75 years

REFERENCES

1 +
Soldo BJ, Manton KG.  Demography: characteristics and implications of an aging population . In: Rowe JW, Besdine RW, eds. Geriatric Medicine . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1988;:12-22.
2 +
Kapantais G, Powell-Griner E. Characteristics of Persons Dying of Diseases of the Heart: Preliminary Data From the 1986 National Mortality Followback Survey . Hyattsville, Md: National Center for Health Statistics; 1989;. Advance Data 172.
3 +
Goldberg RJ, Gore JM, Gurwitz JH, et al.  The impact of age on the incidence and prognosis of initial acute myocardial infarction: the Worcester Heart Attack Study . Am Heart J. 1989;;117:543-549.
4 +
Smith SC, Gilpin E, Ahnve S, et al.  Outlook after acute myocardial infarction in the very elderly compared with that in patients aged 65 to 75 years . JAm Coll Cardiol. 1990;;16:784-792.
5 +
Warnes CA, Roberts WC.  Comparison at necropsy by age group of amount and distribution of narrowing by atherosclerotic plaque in 2995 5-mm-long segments of 240 major coronary arteries in 60 men aged 31 to 70 years with sudden coronary death . Am Heart J. 1984;;108:431-435.
6 +
Fisher LD, Maynard C, Rademaker AW, Alderman EL, Mock M.  Age variation in the association between angiographic coronary disease and angina from the Coronary Artery Surgery Study (CASS) . Int J Cardiol. 1989;;24:317-326.
7 +
Applegate WB.  Hypertension in elderly patients . Ann Intern Med. 1989;;110:901-915.
8 +
Powell-Griner E. Characteristic of Persons Dying From Cardiovascular Diseases . Hyattsville, Md: National Center for Health Statistics; 1990;. Advance Data 180.
9 +
Rowe JW.  Health care of the elderly . N Engl J Med. 1985;;312:827-836.
10 +
Grines CL, DeMaria AN.  Optimal utilization of thrombolytic therapy for acute myocardial infarction: concepts and controversies . J Am Coll Cardiol. 1990;;16:223-231.
11 +
Muller DWM, Topol EJ.  Selection of patients with acute myocardial infarction for thrombolytic therapy . Ann Intern Med. 1990;;113:949-960.
12 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet . 1986;;1:397-401.
13 +
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.  Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1987;;1:349-360.
14 +
AIMS trial study group.  Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial . Lancet . 1988;;1:545-549.
15 +
Wilcox RG, von der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR.  Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET) . Lancet . 1988;;2:525-530.
16 +
Rutherford JD, Braunwald E.  Thrombolytic therapy in acute myocardial infarction . Chest . 1990;;97:136S-145S.
17 +
Podgor MJ, Leske MC, Ederer F.  Incidence estimates for lens changes, macular changes, open-angle glaucoma and diabetic retinopathy . Am J Epidemiol. 1983;;118:206-212.
18 +
Mathey DG, Sheehan FH, Schofer J, Dodge HT.  Time from onset of symptoms to thrombolytic therapy: a major determinant of myocardial salvage in patients with acute myocardial infarction . J Am Coll Cardiol. 1985;;6:518-525.
19 +
Koren G, Weiss AT, Hasin Y, et al.  Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase . N Engl J Med. 1985;;313:1384-1389.
20 +
Yusuf S, Collins R, Peto R, et al.  Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction, and side effects from 33 randomized controlled trials . Eur Heart J. 1985;;6:556-585.
21 +
Hackett TP, Cassem NH.  Factors contributing to delay in responding to the signs and symptoms of acute myocardial infarction . Am J Cardiol. 1969;;24:651-658.
22 +
Moss AJ, Wynar B, Goldstein S.  Delay in hospitalization during the acute coronary period . Am J Cardiol. 1969;;24:659-665.
23 +
Yang XS, Willems JL, Pardaens J, De Geest H.  Acute myocardial infarction in the very elderly: a comparison with younger age groups . Acta Cardiol. 1987;;42:59-68.
24 +
Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico.  GISSI-2: A factorial randomised trial of alteplase versus streptokinase and heparin verus no heparin among 12 490 patients with acute myocardial infarction . Lancet . 1990;; 336:65-71.
25 +
Kannel WB, Abbott RD.  Incidence and prognosis of unrecognized myocardial infarction: an update of the Framingham Study . N Engl J Med. 1984;;311:1144-1147.
26 +
Medalie JH, Goldbourt U.  Unrecognized myocardial infarction: five-year incidence, mortality, and risk factors . Ann Intern Med. 1976;;84:526-531.
27 +
Nadelmann J, Frishman WH, Ooi WL, et al.  Prevalence, incidence, and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: the Bronx Aging Study . Am J Cardiol. 1990;;66:533-537.
28 +
Maggioni AP, Franzosi MG, Fresco C, Turazza F, Tognoni G.  GISSI trials in acute myocardial infarction: rationale, design, and results . Chest . 1990;;97:146S-150S.
29 +
Rao AK, Pratt C, Berke A, et al.  Thrombolysis in Myocardial Infarction (TIMI) trial—phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase . J Am Coll Cardiol. 1988;;11:1-11.
30 +
Lew AS, Hod H, Cercek B, Shah PK, Ganz W.  Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase . Am J Cardiol. 1987;;59:1-5.
31 +
Chaitman BR, Thompson B, Wittry MD, et al.  The use of tissue-type plasminogen activator for acute myocardial infarction in the elderly: results from Thrombolysis in Myocardial Infarction phase I, open label studies, and the Thrombolysis in Myocardial Infarction phase II pilot study . J Am Coll Cardiol. 1989;;14:1159-1165.
32 +
Califf RM, Topol EJ, George BS, et al.  Hemorrhagic complications associated with the use of intravenous tissue plasminogen activator in treatment of acute myocardial infarction . Am J Med. 1988;;85:353-359.
33 +
O'Connor CM, Califf RM, Massey EW, et al.  Stroke and acute myocardial infarction in the thrombolytic era: clinical correlates and long-term prognosis . J Am Coll Cardiol. 1990;;16:533-540.
34 +
Tiefenbrunn AJ, Ludbrook PA.  Coronary thrombolysis: it's worth the risk . JAMA. 1989;; 261:2107-2108.
35 +
Gore JM, Sloan M, Price TR, et al.  Intracerebral hemorrhage, cerebral infarction, and subdural hematoma after acute myocardial infarction and thrombolytic therapy in the Thrombolysis in Myocardial Infarction Study: Thrombolysis in Myocardial Infarction, Phase II, pilot and clinical trial . Circulation . 1991;;83:448-459.
36 +
Guerci AD, Gerstenblith G, Brinker JA, et al.  A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty . N Engl J Med. 1987;;317:1613-1618.
37 +
The TIMI Research Group.  Immediate vs delayed catheterization and angioplasty following thrombolytic therapy for acute myocardial infarction . JAMA. 1988;;260:2849-2858.
38 +
The TIMI Study Group.  Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II trial . N Engl J Med. 1989;;320:618-627.
39 +
Rogers WJ, Baim DS, Gore JM, et al.  Comparison of immediate invasive, delayed invasive, and conservative strategies after tissue-type plasminogen activator: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II-A trial . Circulation . 1990;;81:1457-1476.
40 +
Sleight P.  Do we need to intervene after thrombolysis in acute myocardial infarction? Circulation . 1990;;81:1707-1709.
41 +
Naylor CD, Jaglal SB.  Impact of intravenous thrombolysis on short-term coronary revascularization rates: a meta-analysis . JAMA. 1990;;264:697-702.
42 +
Gersh BJ, Kronmal RA, Frye RL, et al.  Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 or older: a report from the Coronary Artery Surgery Study . Circulation . 1983;;67:483-491.
43 +
Holland KJ, O'Neill WW, Bates ER, Pitt B, Topol EJ.  Emergency percutaneous transluminal angioplasty during acute myocardial infarction for patients more than 70 years of age . Am J Cardiol. 1989;;63:399-403.
44 +
Lee TC, Laramee LA, Rutherford BD, et al.  Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age or older . Am J Cardiol. 1990;;66:663-667.
45 +
Peto R.  Misleading subgroup analyses in GISSI . Am J Cardiol. 1990;;66:771.

Figures

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Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Soldo BJ, Manton KG.  Demography: characteristics and implications of an aging population . In: Rowe JW, Besdine RW, eds. Geriatric Medicine . 2nd ed. Boston, Mass: Little Brown & Co Inc; 1988;:12-22.
2 +
Kapantais G, Powell-Griner E. Characteristics of Persons Dying of Diseases of the Heart: Preliminary Data From the 1986 National Mortality Followback Survey . Hyattsville, Md: National Center for Health Statistics; 1989;. Advance Data 172.
3 +
Goldberg RJ, Gore JM, Gurwitz JH, et al.  The impact of age on the incidence and prognosis of initial acute myocardial infarction: the Worcester Heart Attack Study . Am Heart J. 1989;;117:543-549.
4 +
Smith SC, Gilpin E, Ahnve S, et al.  Outlook after acute myocardial infarction in the very elderly compared with that in patients aged 65 to 75 years . JAm Coll Cardiol. 1990;;16:784-792.
5 +
Warnes CA, Roberts WC.  Comparison at necropsy by age group of amount and distribution of narrowing by atherosclerotic plaque in 2995 5-mm-long segments of 240 major coronary arteries in 60 men aged 31 to 70 years with sudden coronary death . Am Heart J. 1984;;108:431-435.
6 +
Fisher LD, Maynard C, Rademaker AW, Alderman EL, Mock M.  Age variation in the association between angiographic coronary disease and angina from the Coronary Artery Surgery Study (CASS) . Int J Cardiol. 1989;;24:317-326.
7 +
Applegate WB.  Hypertension in elderly patients . Ann Intern Med. 1989;;110:901-915.
8 +
Powell-Griner E. Characteristic of Persons Dying From Cardiovascular Diseases . Hyattsville, Md: National Center for Health Statistics; 1990;. Advance Data 180.
9 +
Rowe JW.  Health care of the elderly . N Engl J Med. 1985;;312:827-836.
10 +
Grines CL, DeMaria AN.  Optimal utilization of thrombolytic therapy for acute myocardial infarction: concepts and controversies . J Am Coll Cardiol. 1990;;16:223-231.
11 +
Muller DWM, Topol EJ.  Selection of patients with acute myocardial infarction for thrombolytic therapy . Ann Intern Med. 1990;;113:949-960.
12 +
Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).  Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction . Lancet . 1986;;1:397-401.
13 +
ISIS-2 (Second International Study of Infarct Survival) Collaborative Group.  Randomized trial of intravenous streptokinase, oral aspirin, both, or neither among 17187 cases of suspected acute myocardial infarction: ISIS-2 . Lancet . 1987;;1:349-360.
14 +
AIMS trial study group.  Effect of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo-controlled clinical trial . Lancet . 1988;;1:545-549.
15 +
Wilcox RG, von der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR.  Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction: Anglo-Scandinavian Study of Early Thrombolysis (ASSET) . Lancet . 1988;;2:525-530.
16 +
Rutherford JD, Braunwald E.  Thrombolytic therapy in acute myocardial infarction . Chest . 1990;;97:136S-145S.
17 +
Podgor MJ, Leske MC, Ederer F.  Incidence estimates for lens changes, macular changes, open-angle glaucoma and diabetic retinopathy . Am J Epidemiol. 1983;;118:206-212.
18 +
Mathey DG, Sheehan FH, Schofer J, Dodge HT.  Time from onset of symptoms to thrombolytic therapy: a major determinant of myocardial salvage in patients with acute myocardial infarction . J Am Coll Cardiol. 1985;;6:518-525.
19 +
Koren G, Weiss AT, Hasin Y, et al.  Prevention of myocardial damage in acute myocardial ischemia by early treatment with intravenous streptokinase . N Engl J Med. 1985;;313:1384-1389.
20 +
Yusuf S, Collins R, Peto R, et al.  Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction, and side effects from 33 randomized controlled trials . Eur Heart J. 1985;;6:556-585.
21 +
Hackett TP, Cassem NH.  Factors contributing to delay in responding to the signs and symptoms of acute myocardial infarction . Am J Cardiol. 1969;;24:651-658.
22 +
Moss AJ, Wynar B, Goldstein S.  Delay in hospitalization during the acute coronary period . Am J Cardiol. 1969;;24:659-665.
23 +
Yang XS, Willems JL, Pardaens J, De Geest H.  Acute myocardial infarction in the very elderly: a comparison with younger age groups . Acta Cardiol. 1987;;42:59-68.
24 +
Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico.  GISSI-2: A factorial randomised trial of alteplase versus streptokinase and heparin verus no heparin among 12 490 patients with acute myocardial infarction . Lancet . 1990;; 336:65-71.
25 +
Kannel WB, Abbott RD.  Incidence and prognosis of unrecognized myocardial infarction: an update of the Framingham Study . N Engl J Med. 1984;;311:1144-1147.
26 +
Medalie JH, Goldbourt U.  Unrecognized myocardial infarction: five-year incidence, mortality, and risk factors . Ann Intern Med. 1976;;84:526-531.
27 +
Nadelmann J, Frishman WH, Ooi WL, et al.  Prevalence, incidence, and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: the Bronx Aging Study . Am J Cardiol. 1990;;66:533-537.
28 +
Maggioni AP, Franzosi MG, Fresco C, Turazza F, Tognoni G.  GISSI trials in acute myocardial infarction: rationale, design, and results . Chest . 1990;;97:146S-150S.
29 +
Rao AK, Pratt C, Berke A, et al.  Thrombolysis in Myocardial Infarction (TIMI) trial—phase I: hemorrhagic manifestations and changes in plasma fibrinogen and the fibrinolytic system in patients treated with recombinant tissue plasminogen activator and streptokinase . J Am Coll Cardiol. 1988;;11:1-11.
30 +
Lew AS, Hod H, Cercek B, Shah PK, Ganz W.  Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase . Am J Cardiol. 1987;;59:1-5.
31 +
Chaitman BR, Thompson B, Wittry MD, et al.  The use of tissue-type plasminogen activator for acute myocardial infarction in the elderly: results from Thrombolysis in Myocardial Infarction phase I, open label studies, and the Thrombolysis in Myocardial Infarction phase II pilot study . J Am Coll Cardiol. 1989;;14:1159-1165.
32 +
Califf RM, Topol EJ, George BS, et al.  Hemorrhagic complications associated with the use of intravenous tissue plasminogen activator in treatment of acute myocardial infarction . Am J Med. 1988;;85:353-359.
33 +
O'Connor CM, Califf RM, Massey EW, et al.  Stroke and acute myocardial infarction in the thrombolytic era: clinical correlates and long-term prognosis . J Am Coll Cardiol. 1990;;16:533-540.
34 +
Tiefenbrunn AJ, Ludbrook PA.  Coronary thrombolysis: it's worth the risk . JAMA. 1989;; 261:2107-2108.
35 +
Gore JM, Sloan M, Price TR, et al.  Intracerebral hemorrhage, cerebral infarction, and subdural hematoma after acute myocardial infarction and thrombolytic therapy in the Thrombolysis in Myocardial Infarction Study: Thrombolysis in Myocardial Infarction, Phase II, pilot and clinical trial . Circulation . 1991;;83:448-459.
36 +
Guerci AD, Gerstenblith G, Brinker JA, et al.  A randomized trial of intravenous tissue plasminogen activator for acute myocardial infarction with subsequent randomization to elective coronary angioplasty . N Engl J Med. 1987;;317:1613-1618.
37 +
The TIMI Research Group.  Immediate vs delayed catheterization and angioplasty following thrombolytic therapy for acute myocardial infarction . JAMA. 1988;;260:2849-2858.
38 +
The TIMI Study Group.  Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II trial . N Engl J Med. 1989;;320:618-627.
39 +
Rogers WJ, Baim DS, Gore JM, et al.  Comparison of immediate invasive, delayed invasive, and conservative strategies after tissue-type plasminogen activator: results of the Thrombolysis in Myocardial Infarction (TIMI) phase II-A trial . Circulation . 1990;;81:1457-1476.
40 +
Sleight P.  Do we need to intervene after thrombolysis in acute myocardial infarction? Circulation . 1990;;81:1707-1709.
41 +
Naylor CD, Jaglal SB.  Impact of intravenous thrombolysis on short-term coronary revascularization rates: a meta-analysis . JAMA. 1990;;264:697-702.
42 +
Gersh BJ, Kronmal RA, Frye RL, et al.  Coronary arteriography and coronary artery bypass surgery: morbidity and mortality in patients ages 65 or older: a report from the Coronary Artery Surgery Study . Circulation . 1983;;67:483-491.
43 +
Holland KJ, O'Neill WW, Bates ER, Pitt B, Topol EJ.  Emergency percutaneous transluminal angioplasty during acute myocardial infarction for patients more than 70 years of age . Am J Cardiol. 1989;;63:399-403.
44 +
Lee TC, Laramee LA, Rutherford BD, et al.  Emergency percutaneous transluminal coronary angioplasty for acute myocardial infarction in patients 70 years of age or older . Am J Cardiol. 1990;;66:663-667.
45 +
Peto R.  Misleading subgroup analyses in GISSI . Am J Cardiol. 1990;;66:771.

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