Thrombolytic therapy for acute myocardial infarction in a 110-year-old man

Thrombolysis for acute myocardial infarction

Thrombolytic therapy has been a major advance in the management of acute myocardial infarction. Unfortunately, it continues to be underused or is administered later than is optimal. Thrombolytic therapy works by lysing infarct artery thrombi and achieving reperfusion, thereby reducing infarct size, preserving left ventricular function, and improving survival. The most effective thrombolytic regimens achieve angiographic epicardial infarct-artery patency in only approximately 50% of patients within 90 minutes. Bleeding requiring transfusion occurs in approximately 5% of patients and stroke in approximately 1.8% with these regimens, which include adjunctive aspirin and intravenous heparin. There are several ways in which reperfusion rates and thus patient outcomes might be improved, such as different dosing regimens of established agents; combinations of different agents; improved adjunctive therapy such as direct antithrombin agents, low-molecular-weight heparin, or glycoprotein IIb/IIIa receptor antagonists; or the development of novel thrombolytic agents with enhanced fibrin specificity, resistance to native inhibitors, or prolonged half-lives allowing bolus administration. All of these strategies are being tested in clinical trials. The best approach currently is to administer thrombolytic therapy as soon as possible to all patients without contraindications who present within 12 hours of symptom onset and have ST-segment elevation on the ECG or new-onset left bundle-branch block, unless an alternative reperfusion strategy is planned.

Optimising thrombolytic therapy in elderly patients with acute myocardial infarction

The incidence of myocardial infarction (MI) and its subsequent mortality increases with age. However, elderly patients are less likely to receive thrombolytic therapy. Among other reasons, this may be because elderly patients with evolving MI often have atypical signs and symptoms and delay their presentation for medical treatment by 2 hours compared with younger patients. The risk of (most often fatal) cerebral bleeding in elderly patients treated with aspirin, heparin and thrombolytic drugs is about 1 to 2 per 1000 patients, and is 2 times higher than in younger patients. In order to decrease the incidence of intracranial haemorrhage in elderly patients with acute MI, thrombolytic treatment should not be recommended in patients at increased risk of cerebral bleeding. Otherwise, the benefit of thrombolytic treatment outweigh the risk; for every 1000 elderly patients treated with thrombolytic drugs, approximately 36 are saved compared with those receiving control treatment.