European Heart Journal Advance Access originally published online on November 28, 2005
European Heart Journal 2006 27(2):246; doi:10.1093/eurheartj/ehi660
Mechanisms of death in elderly patients with acute myocardial infarction exposed to fibrinolytic therapy
Department of Medicine
Split University School of Medicine
Spinciceva 1
Split
Croatia
Tel: +38521556048
Fax: +38521556031
E-mail address: spolic{at}kbsplit.hr
Department of Medicine
Split University School of Medicine
Spinciceva 1
Split
Croatia
Department of Medicine
Split University School of Medicine
Spinciceva 1
Split
Croatia
We read with great interest the article ‘Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction’ by Bueno et al.1 dealing with the still unresolved question regarding reperfusion therapy in these patients. Authors provide convincing evidence that fibrinolytic therapy (FT), but not primary angioplasty (PA), increases up to three times the risk of free wall rupture (FWR), in ST-elevation myocardial infarction (STEMI) patients over 75 years. We have already reported in a retrospective study early, within few hours following streptokinase (SK) administration, FWR in elderly STEMI patients.2 In a recent study in elderly STEMI patients (over 70), we have found a really high incidence of FWR after SK, markedly higher than in their non-thrombolysed peers (20/47:47/237; 
2=23.4; P<0.001).3 FWR, but not cardiogenic shock or cardiac arrest, was the main cause of death in SK treated patients, particularly in those over 70. Autopsy invariably revealed massive haemorrhagic infarction with tear close to the centre of infarcted area. None of our patients had a positive history of coronary artery disease; all had prolonged chest pain, resistant to opiates. Although there are some reports that early FT in elderly STEMI patients improves survival and decreases the risk of FWR, and late (>6 h) administration increases the risk of rupture, we did not find such differences.1,4
Although the majority of STEMI patients still receive FT because of the limited availability of primary PA, the risk of FWR in such circumstances, particularly among the elderly, is pronounced. Because of these fatal FT complication, many patients who present with STEMI do not actually receive any type of reperfusion therapy.5 Keeping in mind that elderly population is increasing, and that these persons were often excluded from the randomized STEMI trials, the question of their appropriate management is still open.
We conclude that FWR in STEMI patients over 75 (or even 70) is still underdiagnosed. In the absence of available data from adequately powered randomized trials, we recommend SK only in STEMI patients over 70 presenting early, say within the first 2 h from the onset of pain, with signs and symptoms of acute heart failure (Killip classes III and IV).
References
- Bueno H, Martínez-Sellés M, Pérez-David E, López-Palop R. Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction. Eur Heart J 2005;26:1705–1711.
[Abstract/Free Full Text] - Poli S, Perkovi D,
tula I, Punda A, Lukin A, Rumboldt Z. Early cardiac rupture following streptokinase in patients with acute myocardial infarction: retrospective cohort study. Croat Med J 2000;41:303–306.[Medline] - Novak K, Poli S, Rumboldt M, Lukin A, Carevi V, Rumboldt Z. The mechanisms of death in elderly patients with acute myocardial infarction exposed to fibrinolytic therapy, in press.
- Maggioni AP, Maseri A, Fresco C, Franzosi MG, Mauri F, Santoro E, Tognoni G. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. The Investigators of the Gruppo Italiano per lo Sudio della Sopravvivenza nell'Infarto Miocardico (GISSI-2). N Engl J Med 1993;329:1442–1448.
[Abstract/Free Full Text] - Keely EC, de Lemos JA. Free wall rupture in the elderly: deleterious effect of fibrinolytic therapy on the ageing heart. Eur Heart J 2005;26:1693–1694.
[Free Full Text]
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