title: Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.
abstract: BACKGROUND
  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.
  
  
  METHODS
  The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files.
  
  
  METHODS
  Acute care hospitals in the United States.
  
  
  METHODS
  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.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Institute for Cardiovascular Sciences, Department of Medicine, Georgetown University Medical Center, Washington, DC 20007, USA.
authors.forename: A K
authors.initials: AK
authors.lastname: Berger
authors.forename: K A
authors.initials: KA
authors.lastname: Schulman
authors.forename: B J
authors.initials: BJ
authors.lastname: Gersh
authors.forename: S
authors.initials: S
authors.lastname: Pirzada
authors.forename: J A
authors.initials: JA
authors.lastname: Breall
authors.forename: A E
authors.initials: AE
authors.lastname: Johnson
authors.forename: N R
authors.initials: NR
authors.lastname: Every
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D015331:Cohort Studies; D005260:Female; D006801:Humans; D008297:Male; D009017:Morbidity; D009203:Myocardial Infarction / Q000188:drug therapy / Q000628:therapy*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D016896:Treatment Outcome