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| |  Angioplasty Offers Slightly Better Survival For Some Elderly Heart Attack Patients CHICAGO, IL - July 27, 1999 -- Elderly patients with heart attack who receive primary angioplasty within six hours of arriving at the hospital had slightly better rates of survival than patients who received early thombolysis (drugs that dissolve blood clots). Among the subgroup of patients who were classified as ideal for either reperfusion therapy, no difference in survival was found, according to an article in tomorrow’s issue of The Journal of the American Medical Association. Alan Berger, M.D., formerly of Georgetown University Medical Center in Washington, D.C., and colleagues studied a total of 20,683 Medicare beneficiaries who arrived within 12 hours of the onset of acute myocardial infarction (AMI, or heart attack) symptoms to determine the rate of survival at 30 days and one year after receiving either percutaneous transluminal coronary angioplasty (or PTCA, a procedure that widens narrowed coronary arteries by inserting an inflatable balloon) or thrombolysis within six hours of arrival at the hospital. The patients were part of the Cooperative Cardiovascular Project (CCP) and admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI eligible for reperfusion therapy (any treatment strategy aimed at restoring normal blood flow to clogged or narrowed coronary arteries). The researchers report that from the CCP database, 80,356 patients had an AMI at the time they arrived at a hospital and met the inclusion criteria of the study. Of these, 18,645 patients (23.2 percent) received thrombolysis and 2,038 patients (2.5 percent) underwent PTCA within a six-hour time frame. Patients undergoing PTCA had a slightly lower rate of death than thrombolysis patients at 30 days (8.7 percent versus 11.9 percent) and after one year (14.4 percent versus 17.6 percent). After adjusting for a number of variables, the researchers found that PTCA patients had a 26 percent lower risk of death at 30 days and a 12 percent lower risk of death after one year compared to thrombolysis patients. However, in a subgroup of AMI patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA treatment was not statistically significant after one year, the authors write. The authors write that the study’s findings support a number of previous AMI treatment studies that demonstrated a trend toward decreased mortality in elderly patients who underwent primary PTCA. The data also suggest that elderly patients (a group with an inherently increased risk of mortality) may achieve a greater benefit with coronary intervention compared with the general population. "Our findings argue that there may be a modest mortality benefit from the use of primary PTCA in elderly patients with AMI," the authors write. "However, because the mortality benefit at one year was small and further diminished in the ideal subset of patients, we do not believe that our findings support a policy of triage of the elderly to primary PTCA. "Rather, these findings are most consistent with the current American College of Cardiology/American Heart Association guideline recommendation that suggests that primary PTCA should be used as an alternative to thrombolysis therapy only if performed in a timely fashion by individuals skilled in the procedure and supported by experienced personnel in high-volume centres. "Because the overall rate of reperfusion in appropriate patients was low, efforts would best be concentrated on increasing the proportion of eligible patients treated with either form of reperfusion. Choice of reperfusion therapy should be based on the expertise of an individual hospital." AMI is the leading cause of death in elderly patients. The choice of an optimal management strategy for treating patients with AMI has been the subject of multiple clinical trials, the authors write. But the results of randomised trials may be difficult to extrapolate to elderly patients, who are more likely to have extensive coronary artery disease, additional risk factors for heart disease and other medical conditions that may influence decisions about the appropriate reperfusion strategy.
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