Primary angioplasty for elderly patients with myocardial infarction: theory, practice and possibilities.

The appropriate method of reperfusion for patients 75 years with ST-elevation acute myocardial infarction (AMI) is one of the great enigmas of acute care cardiology. The population at risk is large, comprising roughly one-third of AMI patients and more than one half of AMI mortality (1). Yet there have been no randomized trials focusing specifically on these high-risk patients who have been notably underrepresented in randomized trials. Meta-analyses of large randomized trials of thrombolytic therapy (2,3) have found diminished relative benefit from thrombolytic therapy but persistent absolute benefit, with 1.0 to 3.4 lives saved per 100 patients treated. Two large observational studies (4,5) suggest that for patients 75 years, thrombolytic therapy involves no benefit and possible harm, despite the fact that elderly thrombolytic patients actually are healthier than those managed without reperfusion therapy. Given the limitations of both randomized trials, whose protocolcontrolled therapy and ideal patients are sometimes quite different from community practice, where patients tend to be older, with a longer symptom-to-presentation interval, greater comorbidity and more relative contraindications; and of observational studies, which are inherently liable to unmeasured selection bias, expert opinion has remained conflicted.