Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial.


Journal Article (Review)

Elderly patients constitute a large and growing proportion of ST-elevation myocardial infarction (STEMI) patients, yet they have been under-represented or even excluded from reperfusion trials. Despite evidence that fibrinolysis improves outcomes irrespective of age, many elderly STEMI patients still remain undertreated or subject to major delays to primary percutaneous coronary intervention (PCI). The fear of an excessive risk of intracranial hemorrhage (ICH) in these patients can lead to avoidance of potentially life-saving reperfusion treatment, despite the fact that current STEMI guidelines do not exclude the elderly from a pharmaco-invasive strategy. Age-specific dose reductions have been succesfully made to antithrombotic drugs such as clopidogrel and enoxaparin as an adjunct to fibrinolysis, but until recently no dose adjustments for elderly patients have been applied to the fibrinolytic agents. In the pharmaco-invasive STREAM trial, halving the bolus of tenecteplase for patients aged >75 years because of an unacceptably high ICH rate in the elderly was associated with a more favorable safety/efficacy profile. Whether a pharmaco-invasive strategy including half-dose tenecteplase, age- and weight-adjusted enoxaparin, and a tailored P2Y12 inhibitor followed by routine angiography represents a safe and efficacious alternative reperfusion therapy for elderly patients remains to be prospectively assessed in a clinical trial in this age group.

Full Text

Duke Authors

Cited Authors

  • Sinnaeve, PR; Danays, T; Bogaerts, K; Van de Werf, F; Armstrong, PW

Published Date

  • February 2016

Published In

Volume / Issue

  • 33 / 2

Start / End Page

  • 109 - 118

PubMed ID

  • 26849132

Pubmed Central ID

  • 26849132

Electronic International Standard Serial Number (EISSN)

  • 1179-1969

Digital Object Identifier (DOI)

  • 10.1007/s40266-016-0345-6


  • eng

Conference Location

  • New Zealand