Ak. Berger et al., Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients, J AM MED A, 282(4), 1999, pp. 341-348
Citations number
23
Categorie Soggetti
General & Internal Medicine","Medical Research General Topics
Context Despite evidence from randomized trials that, compared with early t
hrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA)
after acute myocardial infarction (AMI) reduces mortality in middle-aged ad
ults, whether elderly patients with AMI are more likely to benefit from PTC
A or early thrombolysis is not known.
Objective To determine survival after primary PTCA vs thrombolysis in elder
ly 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 20 683 Medicare beneficiaries, who arrived within 12 ho
urs of the onset of symptoms, were admitted between January 1994 and Februa
ry 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 80 356 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 under
going primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mort
ality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk f
actors and admission and hospital characteristics, primary PTCA was associa
ted 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 prim
ary 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 associ
ated with modestly lower short- and long-term mortality rates, In the subgr
oup of patients who were classified as ideal for reperfusion therapy, the o
bserved benefit of primary PTCA was no longer significant.