Medical Therapy for Elderly Patients Who Have Had Myocardial Infarction: Too Little to the Late in Life?

Despite striking progress, cardiovascular diseases remain the leading cause of death in the United States [1]. The short- and long-term effects of myocardial infarction contribute most to this toll. Because the elderly are at greater risk for both total coronary heart disease and death related to acute myocardial infarction (risks increased 6-fold for persons 75 to 84 years of age and 15-fold for those aged 85 years and older compared with persons aged 55 to 64 years) [2], application of effective preventive and treatment measures might be associated with particularly large survival benefits. In this issue, two articles [3, 4] describe opportunities to improve the outcome of elderly patients during and after myocardial infarction.

The understanding of the pathogenesis of myocardial infarction has advanced substantially during the past 15 years. Pathologic, angiographic, and angioscopic observations have led to the concept that coronary occlusion begins with the rupture of a lipid-rich atherosclerotic plaque, which leads to the formation of a thrombus consisting of platelets, fibrin, and other blood elements and to local vasoconstriction [5]. Other observations in animal models and early clinical trials have suggested that reperfusion therapy was feasible and could limit both the size of the infarction and mortality [6].

In the past decade, collaborative research has developed a large and compelling database supporting the survival benefit of antithrombotic (thrombolytic [fibrinolytic] and antiplatelet) therapies in acute myocardial infarction. Thrombolytic therapy was evaluated in nine randomized, controlled trials, each of which consisted of more than 1000 patients suspected of having had acute myocardial infarction (58 600 patients total). An overview of these trials [7] conclusively showed the beneficial effect of therapy in patients presenting with ST-segment elevation or bundle-branch block (respective relative mortality reductions at 5 weeks, 21% [P < 0.001] and 25% [P …