Researcher urges caution when considering fibrinolytics for elderly STEMI patients

A study presented at TCT 2018 questioned the benefits of “drip-and-ship” for elderly patients with ST-segment elevation myocardial infarction (STEMI), finding patients in their 80s or older who were transferred with fibrinolytic therapy for PCI had an eight-fold risk of hemorrhagic stroke but no survival advantage.

“We were expecting that they would have an increased incidence in bleeding,” presenting author Gbolahan O. Ogunbayo, MD, a cardiology fellow at the University of Kentucky Medical Center, told Cardiovascular Business. “We just weren’t expecting that it would be that high.”

Specifically, the unadjusted odds of hemorrhagic stroke were 1.6 percent in patients who received the clot-busting drugs and 0.2 percent in those who didn’t. After adjusting for potential confounders, the researchers found the incidence of intracerebral hemorrhage was 7.12 times higher in patients treated with fibrinolytics.

In-hospital mortality was 12.5 percent in transferred patients who only received PCI and 11.3 percent among those who received PCI plus fibrinolytics, a statistically insignificant difference.

“The question always remains in these patients … why don’t you just transfer them to a center where they can actually get PCI instead of trying to give them a fibrinolytic that might increase their risk of bleeding?” Ogunbayo said. “Especially given that when they get to that hospital where they get PCI they’re still going to get medications that will further increase their risk (of bleeding).”

Ogunbayo and colleagues used the Nationwide Inpatient Sample (NIS) to identify 13,157 STEMI patients 80 or older who received PCI between 2010 and 2014 after being transferred from another healthcare facility. A total of 7.1 percent underwent fibrinolytic therapy (FT).

The results mirrored those from a related study which Ogunbayo’s group published Sept. 30 in Catheterization and Cardiovascular Interventions. That NIS analysis spanned the same timeframe and included nearly 150,000 STEMI patients 80 or older—regardless of whether they underwent PCI or were transferred from one facility to another.

Just like in PCI transfer patients, an eight-fold increased risk of hemorrhagic stroke was observed with fibrinolytics (2.4 percent versus 0.3 percent) without a significant benefit in in-hospital mortality (18.5 percent with FT; 21.5 percent without FT).

Ogunbayo said European guidelines recommend giving half doses of FT to patients 75 and older, an amendment that was prompted when the researchers of a 2003 trial noticed elderly patients had a much higher risk of intracerebral hemorrhage. Those researchers changed their study protocol to provide half doses to those patients, Ogunbayo said.

But American guidelines for FT don’t include an age-specific caveat, leaving clinicians to trust their instincts when gauging individual patients’ risk.

Ogunbayo noted individualizing therapy with the help of guidelines is better than following those recommendations to a tee. Even so, he’d suggest thinking not twice—but four times—before using clot-busting drugs in patients older than 75.  

“In my practice if I were to give fibrinolytic therapy, my first goal would be to do no harm,” he said. “And in that case—just knowing what I know—I think I would probably err on the side of caution and not give elderly patients fibrinolytic therapy just because I know the harm that it could cause.”