Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients

JAMA. 1999 Jul 28;282(4):341-8. doi: 10.1001/jama.282.4.341.


Context: Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known.

Objective: To determine survival after primary PTCA vs thrombolysis in elderly patients.

Design: The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files.

Setting: Acute care hospitals in the United States.

Patients: A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy.

Main outcome measures: Thirty-day and 1-year survival.

Results: A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08).

Conclusion: In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Angioplasty, Balloon, Coronary*
  • Cohort Studies
  • Female
  • Humans
  • Male
  • Morbidity
  • Myocardial Infarction / drug therapy
  • Myocardial Infarction / therapy*
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk
  • Survival Analysis
  • Thrombolytic Therapy*
  • Treatment Outcome