Thrombolytic Therapy for Eligible Elderly Patients With Acute Myocardial Infarction

Krumholz, Harlan M.; Murillo, Jaime; Chen, Jersey; Vaccarino, Viola; Radford, Martha J.; Ellerbeck, Edward F.; Wang, Yun

doi:10.1001/jama.1997.03540450039032

Cited by 145 publications

(86 citation statements)

References 20 publications

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“…However, in our prospective cohort study involving more than 50 hospitals, 26.5% of otherwise appropriate candidates did not receive reperfusion therapy. Similar underuse of reperfusion therapy has been demonstrated among acute STEMI patients presenting within 6 h of symptom onset in the United States (15,38). Likewise, in the Global Registry of Acute Coronary Events (39), only 70% of eligible STEMI patients received reperfusion therapy.…”

Section: Discussionmentioning

confidence: 67%

“…We believe this test case is helpful on two scores. First, lower risk patients with STEMI represent the end of the prognostic spectrum where treatment gaps are expected to be less obvious than among patients who are at high risk of adverse events due to cardiacspecific factors or general comorbidity (14,15). Thus, this cohort enabled us to test whether the treatment-risk paradox is demonstrable within a lower risk group, thereby showing whether this is a continuous and graded relationship even among relatively lower risk patients.…”

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confidence: 99%

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Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Parker

Naylor

Chong

et al. 2006

Canadian Journal of Cardiology

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BACKGROUND: Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined. METHODS: Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated riskadjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status. RESULTS: Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P<0.001). The number rather than the type of pre-existing conditions inversely correlated with the use of reperfusion therapy. While the impact of baseline risk and pre-existing conditions was additive, pre-existing conditions exerted a greater impact on the nonuse of reperfusion therapy than did baseline risk. CONCLUSIONS: A treatment-risk paradox is demonstrable even within a cohort of lower risk patients with ST segment elevation myocardial infarction. These findings are consistent with the view that these clinical decisions are more likely to be attributable to concerns about patient frailty or side effects than to a misunderstanding of treatment benefits.

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Section: Discussionmentioning

confidence: 67%

mentioning

confidence: 99%

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Parker

Naylor

Chong

et al. 2006

Canadian Journal of Cardiology

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“…3,9 The study sample includes Medicare patients Ն65 years of age from nongovernmental acute-care hospitals with a principal discharge diagnosis of AMI, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 410, with those with a fifth digit of 2 (indicating subsequent episode of care) excluded. Patients were identified during an 8-month period (varying in each state) in 1994 and 1995 by means of hospital bills (UB-92 claims data) in the Medicare National Claims History File.…”

Section: Methodsmentioning

confidence: 99%

“…1,2 Many patients who are eligible for thrombolytic therapy may not be treated in part because of concern about specific patient characteristics associated with hemorrhagic complications, especially hemorrhagic stroke. [3][4][5][6] Information about the risk of intracranial hemorrhage associated with thrombolytic therapy in clinical practice is limited, especially among the elderly, 5 who are also at greater overall risk. 7 Most of the information about the risk of hemorrhage comes from clinical trials or studies with small …”

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confidence: 99%

Intracranial Hemorrhage Associated With Thrombolytic Therapy for Elderly Patients With Acute Myocardial Infarction

Brass

Lichtman²,

Wang³

et al. 2000

Stroke

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143

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Background and Purpose-Intracranial hemorrhage is a serious complication of thrombolytic therapy for acute myocardial infarction, especially among the elderly, but little information exists on estimating risk. Better estimation of risk in individual patients may allow for withholding or using alternate therapies among those at highest risk. Methods-To quantify the risk and identify predictors of intracranial hemorrhage associated with thrombolytic therapy, we performed a retrospective cohort study using data from medical charts. The study involved nearly all acute-care hospitals in the United States. All Medicare patients discharged with a principal diagnosis of acute myocardial infarction during a 9-month period in 1994 to 1995 were included. The main outcome measure was intracranial hemorrhage among those treated with thrombolytic therapy. Results-The rate of intracranial hemorrhage was 1.43% (455 of 31 732). In a logistic model, age Ն75 years, female, black race, prior stroke, blood pressure Ն160 mm Hg, tissue plasminogen activator (versus other thrombolytic agent), excessive anticoagulation (international normalized ratio Ն4 or prothrombin time Ն24), and below median weight (Յ65 kg for women; Յ80 kg for men) were independent predictors. A risk stratification scale was developed on the basis of these factors: with none or 1 of the factors (nϭ6651), the rate of intracranial hemorrhage was 0.69%; with 2 factors (nϭ10 509), 1.02%; with 3 factors (nϭ9074), 1.63%; with 4 factors (nϭ4298), 2.49%; and with Ն5 factors (nϭ1071), 4.11% (Mantel-Haenszel; PϽ0.001). Conclusions-The rate of intracranial hemorrhage in older patients after treatment with thrombolytic therapy exceeds 1%.Readily available factors can identify elderly patients with acute myocardial infarction at high and low risk for intracranial hemorrhage associated with thrombolytic therapy. (Stroke. 2000;31:1802-1811.)

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“…Physicians are frequently risk averse in case selection, performing interventions on lower-risk patients despite greater clinical benefit to higher-risk patients. [1][2][3] In some cases, especially when data are collected on detailed clinical risk factors, these differences can be controlled using standard statistical methods. In other cases, when unmeasured patients characteristics affect both the decision to treat and the outcome, these differences cannot be removed using standard techniques.…”

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confidence: 99%

Analysis of Observational Studies in the Presence of Treatment Selection Bias

Stukel¹,

Fisher²,

Wennberg³

et al. 2007

JAMA

683

267

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N THE FACE OF THE FINANCIAL, practical, and ethical challenges inherent in undertaking randomized clinical trials (RCTs), investigators often use observational data to compare the outcomes of different therapies. These comparisons may be biased due to prognostically important baseline differences among patients, often as a result of unobserved treatment selection biases. Unmeasurable clinical and social interactions in the diagnostic-treatment pathway, and physicians' knowledge of unmeasured prognostic variables, may affect treatment decisions and outcomes. Physicians are frequently risk averse in case selection, performing interventions on lower-risk patients despite greater clinical benefit to higher-risk patients. [1][2][3] In some cases, especially when data are collected on detailed clinical risk factors, these differences can be controlled using standard statistical methods. In other cases, when unmeasured patients characteristics affect both the decision to treat and the outcome, these For editorial comment see p 314.

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Thrombolytic Therapy for Eligible Elderly Patients With Acute Myocardial Infarction

Cited by 145 publications

References 20 publications

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Intracranial Hemorrhage Associated With Thrombolytic Therapy for Elderly Patients With Acute Myocardial Infarction

Analysis of Observational Studies in the Presence of Treatment Selection Bias

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