Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.


Journal Article

CONTEXT:Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE:To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN:The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING:Acute care hospitals in the United States. PATIENTS:A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES:Thirty-day and 1-year survival. RESULTS:A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION:In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Full Text

Cited Authors

  • Berger, AK; Schulman, KA; Gersh, BJ; Pirzada, S; Breall, JA; Johnson, AE; Every, NR

Published Date

  • July 1999

Published In

Volume / Issue

  • 282 / 4

Start / End Page

  • 341 - 348

PubMed ID

  • 10432031

Pubmed Central ID

  • 10432031

Electronic International Standard Serial Number (EISSN)

  • 1538-3598

International Standard Serial Number (ISSN)

  • 0098-7484

Digital Object Identifier (DOI)

  • 10.1001/jama.282.4.341


  • eng