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Alan K. Berger, MD; Kevin A. Schulman, MD; Bernard J. Gersh, MB, ChB, DPhil; Sarmad Pirzada, MD, MPH; Jeffrey A. Breall, MD, PhD; Ayah E. Johnson, PhD; Nathan R. Every, MD, MPH

JAMA. 1999;282:341-348.

Context  Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known.

Objective  To determine survival after primary PTCA vs thrombolysis in elderly patients.

Design  The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files.

Setting  Acute care hospitals in the United States.

Patients  A total of 20,683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy.

Main Outcome Measures  Thirty-day and 1-year survival.

Results  A total of 80,356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08).

Conclusion  In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Author Affiliations: Institute for Cardiovascular Sciences, Division of Cardiology (Drs Berger, Schulman, Gersh, and Breall), and the Clinical Economics Research Unit, Department of Medicine (Drs Berger, Schulman, and Johnson), Georgetown University Medical Center, Washington, DC; Delmarva Foundation for Medical Care Inc, Easton, Md (Dr Berger); and the Northwest Health Services Research and Development Field Program, Veterans Affairs Puget Sound Healthcare System and Cardiovascular Outcomes Research Center and the Division of Cardiology, University of Washington, Seattle (Drs Pirzada and Every). Dr Berger is currently a fellow in the Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn.

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