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Editor's Correspondence
October 14, 2002

Thrombolytics Are Not Contraindicated in the Very Old

Arch Intern Med. 2002;162(18):2139-2140. doi:

The article by Soumerai et al1 regarding the effectiveness of thrombolytic therapy in the elderly was an interesting and important analysis, but, similar to Thiemann et al2 in their article questioning the use of thrombolytics in the elderly, they start with the premise that the data of the Fibrinolytic Therapy Trialists' (FTT) Collaborative Group3 (combined data from 9 placebo-controlled thrombolytic trials involving at least 1000 patients) demonstrated only minimal benefit for those older than 75 years. In fact, in the latter study, the data for the elderly was terribly misrepresented because only 5 of the 9 studies (GISSI-1 [Gruppo Italiano per lo Studio della Sopravivenza nell'Infarto Miocardio],4 ISIS-2 [Second International Study of Infarct Survival Collaborative Group],5 ISIS-3 [Third International Study of Infarct Survival Collaborative Study Group],6 EMERAS [Estudio Multicentro Estreptoquinsa Republicas de America del Sur],7 and LATE [Late Assessment of Thrombolytic Efficacy Study Group]8) included significant numbers of elderly patients, and there were major problems with the latter 3.6-8 GISSI-1 and ISIS-2 showed highly significant benefit for the elderly even though they included many patients who presented more than 6 hours after symptom onset. ISIS-3, EMERAS, and LATE inappropriately diluted this positive data: ISIS-3 compared the use of thrombolytics with placebo only in patients whose indication for thrombolytic therapy was unclear, whether because presentation was more than 6 hours after symptom onset or because of lack of ST elevation. EMERAS and LATE included only patients with 6 to 24 hours of symptoms, and ST elevation was not required for entry. According to White,9 the FTT data for the elderly were recently reanalyzed by the FTT secretariat. Approximately 3300 patients older than 75 years who presented within 12 hours of symptom onset and with either ST elevation or bundle branch block were randomized to treatment with a thrombolytic or placebo; 35-day mortality was reduced from 29.4% to 26.0% (P = .03), or 34 lives saved per 1000 treated. This absolute mortality reduction is as great as that for any other group. To my knowledge, the data referred to by Dr White have not been published. Their publication would be of great value in this debate, and would provide the best evidence possible that thrombolytic therapy should not be withheld on the basis of age alone.

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