Dr Smith makes a number of important points that deserve comment. Unfortunately, available evidence does not provide a definitive answer concerning thrombolytic benefit in patients older than 75 years. Dr Smith states that "GISSI-1 and ISIS-2 showed highly significant benefit for the elderly." However, a careful examination of these studies suggests otherwise. In GISSI-1, among the subgroup of 1215 patients older than 75 years, the relative risk of death among treated vs untreated patients was 0.87, but the confidence interval around this estimate includes 1 (0.68-1.11). For ISIS-2, among 3411 patients aged 70 years or older, the difference between treated and untreated patients was only marginally significant (relative risk, 0.84; 95% confidence interval, 0.71-0.99).
Gurwitz JH, McLaughlin TJ, Ross-Degnan D, Christiansen CL, Soumerai SB. Thrombolytics Are Not Contraindicated in the Very Old—Reply. Arch Intern Med. 2002;162(18):2139–2140. doi:
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