The role of reperfusion therapy in paced patients with acute myocardial infarction

Background/Objective Our purpose was to evaluate the effectiveness of reper fusion therapy among elderly paced patients with acute myocardial infarctio n (MI). Current guidelines make no recommendation for the use of reperfusio n therapy among patients who have a paced rhythm during MI. Methods We evaluated 1954 Medicare beneficiaries 65 years and older treated for acute MI between 1994 and 1996 who had a paced rhythm for use of reper fusion therapy. Use of reperfusion therapy was evaluated for associations w ith outcomes by logistic regression and Cox proportional hazards models inc orporating propensity score analysis. Results Reperfusion therapy was used in 171 (8.8%) patients; 70 were treate d with primary PTCA and 101 with thrombolytic therapy. Patients who receive d reperfusion therapy had 30-day mortality rates similar to those who did n ot receive reperfusion (26.3% vs 25.7%, P =.87). Multivariate adjustment fo r mortality risk factors and treatment propensity indicated no survival ben efit associated with reperfusion therapy at 30 days (relative risk [RR] 1.0 7, 95% confidence interval [CI] 0.77-1.43) or long-term follow-up (hazard r atio [HR] 0.86, 95% Cl 0.68-1.10). Mortality risks varied by type of reperf usion therapy. Patients treated with primary percutaneous transluminal coro nary angioplasty were at comparable risk of mortality at 30 days (RR 0.73, 95% Cl 0.40-1.23) but at lower risk at long-term follow-up (HR 0.60, 95% CI 0.40-0.88). Mortality risks were unchanged among patients treated with thr ombolytics at 30 days (RR 1.32, 95% Cl 0.92-1.79) and long-term follow-up ( HR 1.08, 95% Cl 0.82-1.43). Conclusion We find suggestive evidence that primary percutaneous translumin al coronary angioplasty provides a long-term survival benefit in the treatm ent of elderly patients with acute MI who have a paced rhythm.