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(Circulation. 1996;94:1807-1808.)
© 1996 American Heart Association, Inc.

Articles

Age and Thrombolytic Therapy

Paul M. Ridker, MD; Charles H. Hennekens, MD

the Division of Preventive Medicine (P.M.R., C.H.H.) and Cardiovascular Division (P.M.R.), Brigham and Women's Hospital, Boston, Mass.

Correspondence to Charles H. Hennekens, MD, Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Ave E, Boston, MA 02215-1204.

Key Words: Editorials • thrombolysis • aging • plasminogen activators

	Introduction

 
Among patients 75 years of age and older, mortality after acute coronary occlusion approaches 30% at 1 month and exceeds 50% at 1 year. However, despite evidence from several randomized trials that thrombolytic therapy has clear net benefits¹ and is a cost-effective² treatment in the elderly, older age is a common reason in the United States for withholding treatment among otherwise eligible patients.^{3 4} Such a clinical decision is reinforced by the fact that intracranial hemorrhage, a rare but devastating side effect of thrombolytic therapy, is more likely to occur among older patients as well as among those with hypertension or prior central nervous system disease.^{5 6} Thus, the decision to use thrombolytic therapy among appropriately selected elderly patients must involve a careful assessment of the net benefit-to-risk ratio of a given reperfusion regimen, which should include the fact that available thrombolytic regimens differ in the speed with which they open coronary arteries⁷ as well as in the rates with which they cause intracranial hemorrhage.^{8 9 10}

In this issue of Circulation, White and colleagues¹¹ provide careful and detailed analyses of the landmark GUSTO-1 trial with specific regard to the benefit-to-risk ratio of different reperfusion strategies for patients <65, 65 to 74, 75 to 84, and >85 years of age. Because GUSTO-1 is the only large-scale randomized trial that evaluated front-loaded tissue plasminogen activator (TPA) plus immediate intravenous heparin as well as standard-dose streptokinase with delayed subcutaneous heparin, these data provide the only direct comparison of the two most commonly used thrombolytic regimens . . . [Full Text of this Article]

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