III. CARDIOVASCULAR THERAPY IN THE ELDERLY
A. Thrombolytic Therapy
Patients 70 years or older with an acute myocardial infarct are at high risk for serious events. Thrombolytic therapy may prevent death and further morbidity. Unfortunately, in patients older than 75 there is an increased risk of intracranial bleeding. This excessive risk must be balanced against any possible benefit derived from thrombolytic therapy. The incidence of intracranial hemorrhage in this age group is greater than 1.5% for alteplase (tissue plasminogen activator, t-PA) and tenectaplase, but greater than 0.5% for streptokinase.
Although intracranial hemorrhage incidence is lower with streptokinase, it is not the drug of choice in North
America. Fortunately, in the UK, Europe, and worldwide the less expensive agent streptokinase is still the most widely used pharmacologic reperfusion therapy. Throm-bolytic agents that are effective but cause less intra-cranial bleeding than alteplase and tenectaplase in the elderly would be important additions to the therapeutic armamentarium.
B. Percutaneous Intervention
Because thrombolytic therapy carries a major risk of intracranial hemorrhage and stroke in patients over age 75, randomized clinical trials have confirmed the beneficial effects of primary coronary angioplasty with intracoronary stents. PCI is superior to thrombolytic therapy and is preferred if skilled cardiologists and facilities are readily available.