Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Viewpoint
  • Published:

Elderly patients should not be denied fibrinolytic therapy

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 520–521 (2007)Cite this article

Randomized controlled trials have established that fibrinolytic therapy is effective for the treatment of patients with ST-segment elevation acute myocardial infarction (STEMI), but elderly individuals have been under-represented in these studies. The number of elderly patients with cardiac conditions is increasing, and a third of those with STEMI are over 80 years of age.1 No large-scale randomized trial has focused specifically on this growing cohort. Compared with their younger counterparts, older patients have higher mortality and more hemorrhagic complications—including intracranial hemorrhage—with fibrinolytic and antithrombotic treatment, regardless of other comorbidities. The pathological process of coronary artery occlusion is not, however, affected by age, and the response to fibrinolytic agents in older patients is similar to that in younger patients. We believe that the elderly should not be denied fibrinolytic therapy on the basis of age alone.

Fibrinolytic therapy is underutilized in the elderly; only 40% of eligible patients between the ages of 75 and 84 years, and 20% of those aged 85 years or older, receive this treatment.1 There are several possible reasons for this age-related treatment bias. The high prevalence in the elderly of atypical symptoms that can mask the time of infarction can lead to diagnostic difficulties. Furthermore, conduction abnormalities, such as bundle branch block, can confound the electrocardiographic changes of ST-segment elevation. The elderly have a high risk of bleeding with fibrinolysis, and often have comorbidities, including cognitive impairment. Patient preferences can also influence the choice of therapy used. Finally, primary percutaneous coronary intervention (PCI), which is particularly suitable for late presenting patients with STEMI—a common situation in elderly patients—might be available and thus contribute to the underuse of fibrinolytic therapy.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

References

  1. Alexander KP et al. (2007) Acute coronary care in the elderly (part II), ST-segment elevation myocardial infarction: a statement for healthcare professionals from the American Heart Association Council of Clinical Cardiology, in collaboration with the Society of Geriatric Cardiology. Circulation 115: 2570–2589

    Article  Google Scholar 

  2. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group (1994) Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 343: 311–322

  3. White HD (2000) Thrombolytic therapy in the elderly. Lancet 356: 2028–2030

    Article  CAS  Google Scholar 

  4. Thiemann DR et al. (2000) Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 101: 2239–2246

    Article  CAS  Google Scholar 

  5. Stenestrand U and Wallentin L for the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA) (2003) Fibrinolytic therapy in patients 75 years and older with ST-segment-elevation myocardial infarction: one-year follow-up of a large prospective cohort. Arch Intern Med 163: 965–971

    Article  Google Scholar 

  6. White HD et al. (1996) Age and outcome with contemporary thrombolytic therapy: results from the GUSTO-I trial. Global Utilization of Streptokinase and TPA for Occluded coronary arteries trial. Circulation 94: 1826–1833

    Article  CAS  Google Scholar 

  7. Holmes DR et al. (1999) Effect of age on outcome with primary angioplasty versus thrombolysis. J Am Coll Cardiol 33: 412–419

    Article  Google Scholar 

  8. Grines CL (2005) A prospective randomized trial of primary angioplasty and thrombolytic therapy in elderly patients with acute myocardial infarction - SENIOR PAMI. In Proceedings of Transcatheter Cardiovascular Therapeutics: 2005 October 16–19; Washington DC, (Ed. Mintz GS) New York: CRF Publications

    Google Scholar 

  9. White HD et al. (2007) Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: results from ExTRACT-TIMI 25. Eur Heart J 28: 1066–1071

    Article  CAS  Google Scholar 

  10. Yusuf S et al. for the OASIS-6 Trial Group (2006) Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction: the OASIS-6 randomized trial. JAMA 295: 1519–1530

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. C-K Wong is an Associate Professor of Cardiology in the Dunedin School of Medicine at the University of Otago, Dunedin,

    Cheuk-Kit Wong

  2. HD White is Director of Coronary Care and Cardiovascular Research in the Green Lane Cardiovascular Service at Auckland City Hospital, and an Honorary Clinical Professor of Medicine at the University of Auckland, Auckland, New Zealand. HD White is also an Advisory Board member of Nature Clinical Practice Cardiovascular Medicine.,

    Harvey D White

Authors
  1. Cheuk-Kit Wong
    View author publications

    Search author on:PubMed Google Scholar

  2. Harvey D White
    View author publications

    Search author on:PubMed Google Scholar

Corresponding author

Correspondence to Harvey D White.

Ethics declarations

Competing interests

HD White has received research support from Alexion Pharmaceuticals, Eli Lilly, Fournier Laboratories, GlaxoSmithKline, Janssen-Cilag, Johnson & Johnson, The Medicines Company, Merck Sharpe & Dohme, Neurone Pharmaceuticals, the NIH, Pfizer, Proctor & Gamble, Roche, sanofi-aventis and Schering-Plough. He has also acted as a Consultant for The Medicines Company and sanofi-aventis. C-K Wong declared no competing interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wong, CK., White, H. Elderly patients should not be denied fibrinolytic therapy. Nat Rev Cardiol 4, 520–521 (2007). https://doi.org/10.1038/ncpcardio0980

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue date:

  • DOI: https://doi.org/10.1038/ncpcardio0980

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing