Thrombolysis versus primary angioplasty in older patients with acute myocardial infarction

Although it is effective for appropriate older patients with acute myocardial infarction (AMI), only about 25% of patients 65 years and older are eligible for thrombolytic therapy. Primary percutaneous transluminal coronary angioplasty (PTCA) may be a suitable alternative reperfusion therapy, particularly for older patients with high risk of intracerebral haemorrhage or cardiogenic shock. Randomised trials of primary PTCA versus thrombolytic therapy have demonstrated better efficacy for primary PTCA, whereas the 2 therapies produced comparable results in observational studies. In subset analyses in 2 randomised trials, there were trends toward better outcomes with primary PTCA, although these studies had small numbers of older patients. Results from 3 AMI registries (the Cooperative Cardiovascular Project, the Myocardial Infarction Triage and Intervention Registry, and the National Registry of Myocardial Infarction 2) indicated trends toward improved hospital or 30 day death rates in patients 75 years and older receiving primary PTCA. Older patients who are at high risk of bleeding complications may do better with primary PTCA, although for others with moderate or minimal risk, the 2 therapies are equivalent. More data about long term follow-up and the association between outcomes and hospital and operator volumes for primary PTCA in older patients are needed before a definitive recommendation can be made.