Utilisation of thrombolytic therapy in older patients with myocardial infarction.

Empirical evidence from many countries, obtained from sampling populations of patients admitted to hospital with acute myocardial infarction, has confirmed that elderly patients are significantly less likely to receive thrombolytic therapy. This difference persists after controlling for confounding factors such as admission delay and contraindications to thrombolysis. However, evidence supporting the efficacy of thrombolysis in reducing mortality after acute myocardial infarction is less clear cut in patients aged 75 years or above than in younger patients. These older patients are substantially under-represented in the clinical trials although they constitute one third of the clinical population. Observational studies indicate that older patients are at slightly higher risk than younger patients of experiencing haemorrhagic stroke after thrombolysis. It is, however, unlikely that efficacy and tolerability considerations alone account for the low use of thrombolytics in the elderly as similar trends are seen for other modalities of treatment of acute myocardial infarction. Since older patients have the highest mortality risk after myocardial infarction, they have the greatest potential gain from thrombolytic treatment, assuming a uniform treatment effect across age. The estimated cost effectiveness (cost per quality-adjusted life-year gained) improves with increasing age. It is concluded that patient age should not influence the treatment decision concerning thrombolysis. To ensure that elderly patients receive maximum benefit from this therapeutic advance requires attention to referral patterns from the community, speed of assessment in hospital and a clear treatment policy without age constraints. The effectiveness of these measures should be routinely audited.