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June 4, 1997, Vol 277, No. 21 >
ARTICLE | June 4, 1997

Coronary Thrombolysis for the Elderly: Title and subTitle BreakIs Clinical Practice Really Lagging Behind Evidence of Benefit? FREE

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

Dr Gurwitz has served as a consultant for Genentech, South San Francisco, Calif, for a 1-day period to assist in database analysis. Compensation for his services was paid to the Meyers Primary Care Institute.

Reprints: Jerry H. Gurwitz, MD, The Meyers Primary Care Institute, University of Massachusetts Medical Center and the Fallon Healthcare System, 100 Central St, Worcester, MA 01608.


JAMA. 1997;277(21):1723-1724. doi:10.1001/jama.1997.03540450079040
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References

Given the low survival experience of older persons following acute myocardial infarction,1 claims that thrombolytic therapy is underused in this patient population are particularly disconcerting. Regional, national, and multinational populationbased studies of age-related patterns of thrombolytic use have provided support for these assertions.2,3 It is unclear, however, to what extent these patterns of care reflect age bias in the use of an effective therapy vs the appropriately cautious use of a treatment that carries inherent risks and for which only a limited number of elderly patients with acute myocardial infarction are eligible. In this issue of The JOURNAL, Krumholz et al4 provide evidence suggesting that the answer to this question probably lies somewhere between these 2 extremes.

See also p 1683.

In their study, the authors carefully analyzed data from the medical records of 3093 Medicare beneficiaries, aged 65 years and older, admitted to all acute care

REFERENCES

1 +
Gurwitz JH, Goldberg RJ, Chen Z, Gore JM, Alpert JS.  Recent trends in hospital mortality of acute myocardial infarction—the Worcester Heart Attack Study: have improvements been realized in all age groups? Arch Intern Med . 1994;;154:2202-2208.
2 +
European Secondary Prevention Study Group.  Translation of clinical trials into practice: a European population-based study of the use of thrombolysis for acute myocardial infarction . Lancet . 1996;;347:1203-1207.
3 +
Gurwitz JH, Gore JM, Goldberg RJ, et al.  Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction . Ann Intern Med . 1996;;124:283-291.
4 +
Krumholz HM, Murillo J, Chen J, et al.  Thrombolytic therapy for eligible elderly patients with acute myocardial infarction . JAMA . 1997;;277:1683-1688.
5 +
Ryan TJ, Anderson JL, Antman EM, et al.  ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) . J Am Coll Cardiol . 1996;;28:1328-1428.
6 +
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;;343:311-322.
7 +
The GUSTO (Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries) Investigators.  An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction . N Engl J Med . 1993;;329:673-682.
8 +
Simoons ML, Maggioni AP, Knatterud G, et al.  Individual risk assessment for intracranial hemorrhage during thrombolytic therapy . Lancet . 1993;;342:1523-1528.
9 +
Gore JM, Granger CB, Simoons ML, et al.  Stroke after thrombolysis: mortality and functional outcomes in the GUSTO-1 trial . Circulation . 1995;;92:2811-2818.
10 +
Asch DA, Baron J, Hersey JC, et al.  Omission bias and pertussis vaccination . Med Decis Making . 1994;;14:118-123.
11 +
Beyth RJ, Antani MR, Covinsky KE, et al.  Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med . 1996;;11:721-728.
12 +
Ross AM.  The TTOPP study: lessons from an aborted trial . J Myocardial Ischemia . 1990;;2:65-69.
13 +
Horwitz RI, Viscoli CM, Clemens JD.  Developing improved observational methods for evaluating therapeutic effectiveness . Am J Med . 1990;;89:630-638.
14 +
Gurwitz JH, McLaughlin TJ, Willison DJ, et al.  Delayed hospital presentation in patients who have had acute myocardial infarction . Ann Intern Med . 1997;;126:593-599.
15 +
Dracup K, Alonzo AA, Atkins A, et al.  The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the national heart attack alert program . Ann Intern Med . 1997;;126:645-651.

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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 +
Gurwitz JH, Goldberg RJ, Chen Z, Gore JM, Alpert JS.  Recent trends in hospital mortality of acute myocardial infarction—the Worcester Heart Attack Study: have improvements been realized in all age groups? Arch Intern Med . 1994;;154:2202-2208.
2 +
European Secondary Prevention Study Group.  Translation of clinical trials into practice: a European population-based study of the use of thrombolysis for acute myocardial infarction . Lancet . 1996;;347:1203-1207.
3 +
Gurwitz JH, Gore JM, Goldberg RJ, et al.  Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction . Ann Intern Med . 1996;;124:283-291.
4 +
Krumholz HM, Murillo J, Chen J, et al.  Thrombolytic therapy for eligible elderly patients with acute myocardial infarction . JAMA . 1997;;277:1683-1688.
5 +
Ryan TJ, Anderson JL, Antman EM, et al.  ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction) . J Am Coll Cardiol . 1996;;28:1328-1428.
6 +
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;;343:311-322.
7 +
The GUSTO (Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries) Investigators.  An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction . N Engl J Med . 1993;;329:673-682.
8 +
Simoons ML, Maggioni AP, Knatterud G, et al.  Individual risk assessment for intracranial hemorrhage during thrombolytic therapy . Lancet . 1993;;342:1523-1528.
9 +
Gore JM, Granger CB, Simoons ML, et al.  Stroke after thrombolysis: mortality and functional outcomes in the GUSTO-1 trial . Circulation . 1995;;92:2811-2818.
10 +
Asch DA, Baron J, Hersey JC, et al.  Omission bias and pertussis vaccination . Med Decis Making . 1994;;14:118-123.
11 +
Beyth RJ, Antani MR, Covinsky KE, et al.  Why isn't warfarin prescribed to patients with nonrheumatic atrial fibrillation? J Gen Intern Med . 1996;;11:721-728.
12 +
Ross AM.  The TTOPP study: lessons from an aborted trial . J Myocardial Ischemia . 1990;;2:65-69.
13 +
Horwitz RI, Viscoli CM, Clemens JD.  Developing improved observational methods for evaluating therapeutic effectiveness . Am J Med . 1990;;89:630-638.
14 +
Gurwitz JH, McLaughlin TJ, Willison DJ, et al.  Delayed hospital presentation in patients who have had acute myocardial infarction . Ann Intern Med . 1997;;126:593-599.
15 +
Dracup K, Alonzo AA, Atkins A, et al.  The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the national heart attack alert program . Ann Intern Med . 1997;;126:645-651.

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