Woods K L, Ketley D
Department of Medicine and Therapeutics, University of Leicester, England.
Drugs Aging. 1998 Dec;13(6):435-41. doi: 10.2165/00002512-199813060-00003.
Empirical evidence from many countries, obtained from sampling populations of patients admitted to hospital with acute myocardial infarction, has confirmed that elderly patients are significantly less likely to receive thrombolytic therapy. This difference persists after controlling for confounding factors such as admission delay and contraindications to thrombolysis. However, evidence supporting the efficacy of thrombolysis in reducing mortality after acute myocardial infarction is less clear cut in patients aged 75 years or above than in younger patients. These older patients are substantially under-represented in the clinical trials although they constitute one third of the clinical population. Observational studies indicate that older patients are at slightly higher risk than younger patients of experiencing haemorrhagic stroke after thrombolysis. It is, however, unlikely that efficacy and tolerability considerations alone account for the low use of thrombolytics in the elderly as similar trends are seen for other modalities of treatment of acute myocardial infarction. Since older patients have the highest mortality risk after myocardial infarction, they have the greatest potential gain from thrombolytic treatment, assuming a uniform treatment effect across age. The estimated cost effectiveness (cost per quality-adjusted life-year gained) improves with increasing age. It is concluded that patient age should not influence the treatment decision concerning thrombolysis. To ensure that elderly patients receive maximum benefit from this therapeutic advance requires attention to referral patterns from the community, speed of assessment in hospital and a clear treatment policy without age constraints. The effectiveness of these measures should be routinely audited.
来自许多国家的经验证据表明，通过对因急性心肌梗死入院的患者群体进行抽样调查发现，老年患者接受溶栓治疗的可能性显著降低。在控制诸如入院延迟和溶栓禁忌症等混杂因素后，这种差异仍然存在。然而，与年轻患者相比，支持溶栓在降低75岁及以上急性心肌梗死后死亡率方面疗效的证据并不那么明确。尽管老年患者占临床患者总数的三分之一，但他们在临床试验中的代表性严重不足。观察性研究表明，老年患者溶栓后发生出血性中风的风险略高于年轻患者。然而，仅靠疗效和耐受性考虑不太可能解释老年患者溶栓治疗使用率低的原因，因为在急性心肌梗死的其他治疗方式中也观察到类似趋势。由于老年患者心肌梗死后的死亡风险最高，假设年龄对治疗效果无差异，他们从溶栓治疗中获得的潜在益处最大。估计的成本效益（每获得一个质量调整生命年的成本）随着年龄的增长而提高。结论是患者年龄不应影响溶栓治疗的决策。为确保老年患者从这一治疗进展中获得最大益处，需要关注社区转诊模式、医院评估速度以及无年龄限制的明确治疗政策。应定期审核这些措施的有效性。
