Thrombolytic therapy increases risk of cardiac rupture in the elderly

Unlike primary angioplasty, thrombolytic therapy increases the risk of cardiac rupture in patients 75 years of age or older with a first acute myocardial infarction (AMI), according to a report in the September issue of the European Heart Journal. "Thrombolysis is an acceptable therapy for AMI in the elderly, particularly when primary angioplasty is not an option," Dr. Hector Bueno from Hospital General Universitario "Gregorio Maranon, Madrid, told Reuters Health. "However, it is associated with an early hazard due to the increased risk of cardiac rupture." Dr. Bueno and associates investigated the effect of thrombolytic therapy on short-term mortality using data from 706 consecutive patients at least 75 years old admitted with a first AMI. In this population, 46% received reperfusion therapy, 23% received intravenous thrombolysis, and 23% underwent primary angioplasty. Confirmed wall rupture occurred about three times more often among patients receiving thrombolytic therapy (16.5%) than among those undergoing primary angioplasty (4.3%) or reperfusion (5.6%), the authors report. The incidence among patients treated with thrombolysis was much higher in those admitted more than 6 hours after symptom onset (33.3%) than in those admitted earlier (15.1%), the results indicate. The risk was also higher among women and among patients with an anterior wall myocardial infarction, the investigators report. In multiple logistic regression analyses, thrombolytic therapy emerged as the most powerful independent predictor of free wall rupture, the researchers note. The differences in free wall rupture incidence did not translate into significant differences in in-hospital mortality among the three groups, the report indicates. Patients treated with thrombolysis more than 6 hours after symptom onset, however, showed a trend to higher mortality. "Probably primary angioplasty is a better option as it is not associated with an increase in early risk," Dr. Bueno said. "However, observational studies show that both therapies are associated with a long-term survival advantage." "Clearly, the risk-benefit ratio favors primary percutaneous coronary intervention over fibrinolytic therapy and thus we recommend that patients over 75 years should be transferred for primary percutaneous coronary intervention whenever a patient can be transferred in under 2 hours to a ready and waiting cardiac catheterization laboratory," write Drs. Ellen C. Keeley and James A. de Lemos from University of Texas Southwestern Medical Center, Dallas, in a related editorial. "When this is not possible," the editorialists add, "we recommend that fibrinolytic therapy be administered if it can be done within 6 hours of symptom onset, but that platelet glycoprotein IIb/IIIa inhibitors be avoided and that only unfractionated heparin be used with t-PA-based regimens." Eur Heart J 2005;26:1693-1694,1705-1711.

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