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To the Editor: In their comparison of direct angioplasty and intravenous thrombolysis as reperfusion therapy for elderly patients with acute myocardial infarction, Dr Berger et al¹ concluded that primary angioplasty is associated with modestly lower short- and long-term mortality. However, this conclusion is problematic because of the inherent limitations of data from the Cooperative Cardiovascular Project (CCP).

The study sample of patients who underwent angioplasty is not comparable to the sample of patients who received thrombolytic therapy in several vital respects. The CCP data do not permit an intention-to-treat analysis and thus are susceptible to selection and survival biases. The database cannot identify patients who died while awaiting primary angioplasty or patients in whom primary angioplasty was not attempted after cardiac catheterization—a group that comprises 10% to 19% of the primary-angioplasty groups in randomized trials^2-3 and has a mortality as high as 14.1%,³ several times the mortality of patients who . . . [Full Text of this Article]

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Primary Coronary Angioplasty vs Thrombolysis for the Management of Acute Myocardial Infarction in Elderly Patients
Alan K. Berger, Kevin A. Schulman, Bernard J. Gersh, Sarmad Pirzada, Jeffrey A. Breall, Ayah E. Johnson, and Nathan R. Every
JAMA. 1999;282(4):341-348.
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