AGE AND OUTCOME WITH CONTEMPORARY THROMBOLYTIC THERAPY - RESULTS FROMTHE GUSTO-I TRIAL

Background Elderly patients with acute myocardial infarction have much to gain from reperfusion with thrombolytic therapy but are also at in creased risk of adverse events. We examined outcomes according to age of patients receiving thrombolysis in an international trial. Methods and Results Patients were randomized to streptokinase plus subcutaneou s heparin, streptokinase plus intravenous heparin, accelerated tissue plasminogen activator (TPA) plus intravenous heparin, or streptokinase and TPA plus intravenous heparin. Clinical outcomes at 30 days (death , stroke, and nonfatal, disabling stroke) and 1-year mortality were su mmarized descriptively for patients aged <65 (n=24 708), 65 to 74 (n=1 1 201), 75 to 85 (n=4625), and >85 years (n=412) and assessed as conti nuous functions of age. Older patients had a higher-risk profile with regard to baseline clinical and angiographic characteristics. Mortalit y at 30 days increased markedly with age (3.0%, 9.5%, 19.6%, and 30.3% in the four groups, respectively), as did stroke, cardiogenic shock, bleeding, and reinfarction. Combined death or disabling stroke occurre d less often with accelerated TPA in all but the oldest patients, who showed a weak trend toward a lower incidence with streptokinase plus s ubcutaneous heparin: odds ratio 1.13; 95% confidence interval 0.6, 2.1 . Similarly, accelerated TPA treatment resulted in lower 1-year mortal ity in all but the oldest patients (47% TPA versus 40.3% streptokinase ). Conclusions Lower mortality and greater net clinical benefit were s een with accelerated TPA in patients aged less than or equal to 85 yea rs. Because data are limited for patients aged >85 years, the relative superiority of a given thrombolytic regimen cannot be determined. The interactions of stroke and mortality with newer thrombolytic strategi es must be examined explicitly in older patients.