Is More Aggressive Management of Acute Myocardial Infarction in the Elderly Justified? Lars Wallentin Uppsala University Hospital, Uppsala, Sweden People older than 75 years of age are at higher risk for cardiovascular events. Reperfusion therapy has been shown to be beneficial in patients with coronary artery disease, but a concern among physicians is that the elderly may be at higher risk for the catastrophic complications of such therapies. In this review, Dr. Wallentin evaluates the available data and asserts that reperfusion therapy, including thrombolytic therapy, should be made available to many elderly patients with acute myocardial infarction Dr. Wallentin began by describing the ongoing controversy among cardiologists regarding the safety and appropriateness of invasive reperfusion therapy in elderly patients with acute myocardial infarction. Clearly, these patients are at higher risk for cardiovascular events such as infarction, stroke, and death. Reperfusion therapy is known to be effective in the general population of patients with coronary artery disease. The important question is whether the potential benefits of aggressive reperfusion therapy outweigh the potential risks --- and whether the elderly are at higher risk for complications of these therapies. Dr. Wallentin observed that one of the difficulties in trying to evaluate this problem rationally is that the median age for acute myocardial infarction in Sweden and many other developed countries is 72 years. Thus, approximately 40% of myocardial infarctions occur in patients over the age of 75 years. In contrast, the median age in clinical trials of thrombolytic therapy and other reperfusion therapies is only 61 years. Therefore, we have very limited safety and efficacy data for the older population. Furthermore, we do know that age has a very important impact on clinical outcomes. Dr. Wallentin cited data from the Swedish Registry of patients: There is a 10% one-year risk of mortality in persons between 60 and 69 years of age, a 23% one-year risk in persons 70 to 79 years of age, and a 44% one-year risk in persons 80 years of age and older. "And this is a lot different than the population we are familiar with in clinical trials." The important question he asked about the increasing risk for mortality with increased age was, "Is this a natural consequence of aging? Or will these patients benefit from therapeutic intervention?" To answer these questions, Dr. Wallentin pointed out that among patients who enter the Cardiac Care Unit, mortality of patients who are found to have a myocardial infarction is much higher than patients who are found not to have had an infarct. Therefore, it is appropriate to assume that if we administer thrombolytic therapy to patients with ST-segment elevations and left bundle branch block on the electrocardiogram, we will dissolve acute thrombi and reduce the number of infarctions that occur. Because higher mortality is associated with the occurrence of infarction rather than with the occurrence of ischemia, we can expect to reduce death rates in this older population through increased use of reperfusion therapy. The results of several large-scale clinical trials support this approach. ISIS-2 demonstrated an increased mortality in patients older than 70 years of age, but also an absolute survival benefit associated with reperfusion. Such therapy resulted in saving 23 lives per 1,000 younger patients and in saving 41 lives per 1,000 older patients. In older patients with ST-segment elevations and left bundle branch block enrolled in the FTT trial, therapy saved 34 lives per 1,000 patients. In GUSTO-I, the same benefit was seen in older patients as in younger patients. The GUSTO-II trial demonstrated that a clear benefit was associated with angioplasty compared with thrombolytic therapy, and there was no difference in this benefit between the older and younger patient subgroups. Current data from 1,550 patients entered prospectively in the Swedish Registry, reported at this meeting for the first time, demonstrate a relative 10% survival benefit (35% versus 39%) with thrombolytic therapy in patients more than 75 years old who have ST-segment elevations and left bundle branch block. This result includes consideration of both mortality and risk of cerebral bleeding. Similar results were reported with data from a German registry. Dr. Wallentin concluded by asking: "So why are we so hesitant to treat these patients with reperfusion therapy?" Reporter: Andre Weinberger, MD Copyright 2000-2013 by HESCO International, Ltd. All rights reserved.