Risk of intracranial haemorrhage with combined fibrinolytic and glycoprotein IIb/IIIa inhibitor therapy in acute myocardial infarction Dichotomous response as a function of age in the GUSTO V trial

Savonitto, Stefano; Armstrong, Paul W.; Lincoff, A. Michael; Jia, Gang; Sila, Cathy A.; Booth, John V.; Terrosu, Pierfranco; Cavallini, C; White, Harvey D.; Ardissino, Diego; Califf, Robert M.; Topol, Eric J.

doi:10.1016/j.ehj.2003.07.004

Cited by 41 publications

(15 citation statements)

References 48 publications

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“…33 In fact, although abciximab plus half-dose reteplase was associated with a lower risk of ICH than was full-dose reteplase in patients Ͻ70 years of age, this risk was higher in patients Ն70 years of age. 64 In the ASSENT-3 trial, the 30-day mortality rate was highest among the group randomized to half-dose tenecteplase plus abciximab (22.3% versus 15.9% for tenecteplase plus unfractionated heparin and 15.6% for tenecteplase plus enoxaparin). In addition, major bleeding was highest in the half-dose-tenecteplase-plus-abciximab group (4.4% versus 2.2% with tenecteplase plus unfractionated heparin and 3.0% with tenecteplase plus enoxaparin).…”

Section: Reduced-or Alternative-dose Regimensmentioning

confidence: 99%

Acute Coronary Care in the Elderly, Part II

Alexander¹,

Newby²,

Armstrong³

et al. 2007

Circulation

460

134

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Background-Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status. Methods and Results-Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment-elevation myocardial infarction in relation to age (Ͻ65, 65 to 74, 75 to 84, and Ն85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment-elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A "one-size-fits-all" approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients. Conclusions-Few trials have adequately described treatment effects in older patients with ST-segment-elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.

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Section: Reduced-or Alternative-dose Regimensmentioning

confidence: 99%

Acute Coronary Care in the Elderly, Part II

Alexander¹,

Newby²,

Armstrong³

et al. 2007

Circulation

460

134

View full text Add to dashboard Cite

show abstract

“…The recommended duration of infusion for MI is longer (up to 72 h) compared with PCI (up to 24 h) [11]. Whether the higher rate of ICH in patients with MI is related to differences in duration of infusion, age, acute hypertension or use of concomitant medication such as thrombolytics or heparin in routine practice needs to be determined [12][13][14]. The higher rate of mechanical ventilation and shorter hospital stay observed in patients with ICH was probably related to the critical condition of the patients following the ICH.…”

Section: Discussionmentioning

confidence: 99%

Intracranial Hemorrhages Associated with Intravenous Platelet Glycoprotein IIB/IIIA Receptor Inhibitors in the United States

Qureshi¹,

Hussain²,

Nasar³

et al. 2005

Cardiovasc Drugs Ther

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“…Concomitant antiplatelet and fibrinolytic therapy which is usually administered in myocardial infarction has been associated with a higher risk of non-intracranial bleeding complications but not of ICH [36,37,38]. On the other hand, this combined therapy is related to a decreased risk of reocclusion and reinfarction after successful thrombolysis [36, 39, 40].…”

Section: Discussionmentioning

confidence: 99%

Influence of Antiplatelet Pre-Treatment on the Risk of Symptomatic Intracranial Haemorrhage after Intravenous Thrombolysis

et al. 2008

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Background: The influence of antiplatelet agents (AP) in the development of a symptomatic intracranial haemorrhage (SICH) after intravenous rt-PA is not well known. We assessed the hypothesis that pre-treatment with AP may increase that risk. Methods: We studied data from consecutive patients with ischaemic stroke treated with intravenous rt-PA within the first 3 h after symptom onset. We recorded the antecedent of any AP therapy previous to thrombolysis. A follow-up CT was performed routinely 24–36 h after the infusion of rt-PA. Intracranial bleeding was categorized according to the criteria of the European Cooperative Acute Stroke Study II (ECASS II) into haemorrhagic infarction type 1 and 2 and parenchymal haemorrhage type 1 and 2. SICH was diagnosed if it was of the parenchymal haemorrhage type, occurred within the first 36 h and was associated with neurological deterioration. Results: Of a total of 605 patients, 137 (22.6%) were pre-treated with AP, most of them (n = 106) with aspirin. Any type of intracranial haemorrhage was observed in 119 patients (19.7%), without differences between the AP (18.4%) and the non-AP (20.2%) groups. Parenchymal haemorrhage was observed in 41 patients (8.5%) and SICH in 26 (4.3%). There was a non-significant rise in the frequency of SICH in the AP group compared with the non-AP group (6.6 vs. 3.6% p = 0.10). Conclusions: Pre-treatment with AP non-significantly increases the risk of SICH and therefore this antecedent should not be a contraindication for intravenous thrombolysis.

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Risk of intracranial haemorrhage with combined fibrinolytic and glycoprotein IIb/IIIa inhibitor therapy in acute myocardial infarction Dichotomous response as a function of age in the GUSTO V trial

Abstract: Although no additional risk of intracranial haemorrhage has been observed with combination therapy in the whole population, a significant age pertreatment interaction exists, with a lower risk with combination therapy in younger patients, and a higher risk in the elderly.

Cited by 41 publications

References 48 publications

Acute Coronary Care in the Elderly, Part II

Acute Coronary Care in the Elderly, Part II

Intracranial Hemorrhages Associated with Intravenous Platelet Glycoprotein IIB/IIIA Receptor Inhibitors in the United States

Influence of Antiplatelet Pre-Treatment on the Risk of Symptomatic Intracranial Haemorrhage after Intravenous Thrombolysis

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