Berger A K, Radford M J, Wang Y, Krumholz H M
Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.
J Am Coll Cardiol. 2000 Aug;36(2):366-74. doi: 10.1016/s0735-1097(00)00723-3.
We compared outcomes following thrombolytic therapy and primary angioplasty with no reperfusion therapy in a population-based cohort of older patients presenting with acute myocardial infarction (AMI) and indications for acute reperfusion.
Evidence supporting the efficacy of acute reperfusion (thrombolytic therapy or primary angioplasty) in the elderly with suspected AMI is not as strong as it is in younger groups.
From a national cohort of Medicare beneficiaries with AMI, we identified 37,983 patients age 65 or older who presented within 12 h of symptom onset with ST elevation or left bundle branch block. A total of 14,341 (37.8%) received thrombolytic therapy and 1,599 (4.2%) underwent primary angioplasty within 6 h of hospital arrival.
After adjustment for demographic, clinical, hospital and physician factors, and co-interventions, thrombolytic therapy was not associated with a better 30-day survival (odds ratio [OR] 1.01; 95% confidence interval [CI]: 0.94 to 1.09) compared with no therapy, whereas primary angioplasty was (OR 0.79; 95% CI: 0.66 to 0.94). At one year, both thrombolytic therapy (OR 0.84; 95% CI: 0.79 to 0.89) and primary angioplasty (OR 0.71; 95% CI: 0.61 to 0.83) were associated with a survival benefit.
In this national sample of older patients, those who received thrombolytic therapy or primary angioplasty had lower mortality at one year compared with those who did not receive a reperfusion strategy. However, only primary angioplasty was associated with better survival at 30 days. Our findings should heighten interest in further investigating the best approach to the treatment of older patients with suspected AMI and ST segment elevation or left bundle branch block.
在一个基于人群的老年急性心肌梗死（AMI）患者队列中，我们比较了溶栓治疗和直接血管成形术与未进行再灌注治疗的结局，这些患者均有急性再灌注的指征。
支持急性再灌注（溶栓治疗或直接血管成形术）对疑似AMI老年患者有效性的证据不如对年轻群体的证据有力。
从一个全国性的患有AMI的医疗保险受益人群队列中，我们确定了37983名65岁及以上的患者，他们在症状发作后12小时内出现ST段抬高或左束支传导阻滞。共有14341名（37.8%）患者接受了溶栓治疗，1599名（4.2%）患者在入院后6小时内接受了直接血管成形术。
在对人口统计学、临床、医院和医生因素以及联合干预进行调整后，与未治疗相比，溶栓治疗与30天更好的生存率无关（优势比[OR]为1.01；95%置信区间[CI]：0.94至1.09），而直接血管成形术则与之相关（OR为0.79；95%CI：0.66至0.94）。在一年时，溶栓治疗（OR为0.84；95%CI：0.79至0.89）和直接血管成形术（OR为0.71；95%CI：0.61至0.83）均与生存获益相关。
在这个全国性的老年患者样本中，与未接受再灌注策略的患者相比，接受溶栓治疗或直接血管成形术的患者在一年时死亡率较低。然而，只有直接血管成形术与30天时更好的生存率相关。我们的研究结果应会激发人们对进一步研究疑似AMI且有ST段抬高或左束支传导阻滞的老年患者的最佳治疗方法的兴趣。
