| Objective:With the aging of the human body, the elderly patients with acute myocardial infarction have experienced apparent decay of cardiovascular anatomy, organizational structure and physiological function with complex clinical conditions, poor prognosis and high natural fatality rate. Therefore, the rational selection of safe and effective treatment strategies is of great significance to reduce the mortality of the elderly AMI patients and improve its prognosis. At present, the urokinase thrombolytic therapy is the most widely used measure for acute myocardial infarction and reperfusion in primary hospitals in China, while seldom used in elderly patients because of potential risk of serious complications. This study applied the reduced urokinase thrombolytic therapy to the elderly acute STEMI patients older than 75 years old, evaluated the effectiveness risk/ ratio of the urokinase thrombolytic therapy in elderly patients by comparisons of the clinical thrombolytic recanalization rate, bleeding and other adverse reactions, and total short and long term adverse cardiac events between the conservative treatment group and the younger elderly standard thrombolytic group, to provide references for reasonable choices of treatment strategies for the elderly acute STEMI patients.Methods82 acute STEMI patients older than 75 years old who have received emergency and medical in-patient treatment in our hospital from January 2004 to October 2008 were selected in line with the diagnosed standard of 2004 ACC/AHA treatment guidelines of acute myocardial infarction. They were 59 males and 23 females with duration of 2 to 12 hours. Regarding the risk factors, they include:47 cases with smoking history,41 cases with hypertension,16 cases with diabetes, and 9 cases with high blood cholesterol. Regarding the infarct locations, they include:31 cases at the anterior,6 cases at the extensive anterior,16 cases at the former partitions,20 cases at the inferior,12 cases with heart failure (KillipⅡ～Ⅲgrade), and 12 cases with severe arrhythmia (sinus bradycardia heart rate less than 50 times/minute, multi-derived ventricular contraction, a short array ventricular tachycardia,Ⅱdegrees and above atrioventricular block, etc.). None patients had absolute contraindication and relative contraindication of thrombolytic therapy according to the guide. All patients were randomly divided into two groups including 39 cases who received reduced urokinase thrombolysis and 43 cases who received conventional conservative treatment (the elderly control group).Two groups were of no significant differences in age, gender, disease duration, risk factors, infarct location and complications. At the same time,45 acute STEMI patients younger than 75 years old (42～74 years old) were selected. They were 33 males and 12 females with duration of 1 to 12 hours. Regarding the risk factors, they include:29 cases with smoking history, 26 cases with hypertension,9 cases with diabetes, and 9 cases with high blood cholesterol. Regarding the infarct locations, they include:13 cases at the anterior,5 cases at the extensive anterior,12 cases at the former partitions,15 cases at the inferior,4 cases with heart failure, and 3 cases with severe arrhythmia. They received the standard-dose urokinase thrombolytic therapy as a younger elderly standard thrombolytic group. Except the age factor, they were of no significant statistical difference in the clinical characteristics compared with the elderly thrombolytic group.All patients were given rest, oxygen, vital sign and ECG monitoring, sedation, pain relief (morphine, nitrates, etc.), elimination of arrhythmia, correcting heart failure, anti-thrombosis,β-blockers, angiotensin converting enzyme inhibitor (ACEI) and other conventional treatment as being diagnosed. On this basis, the elderly thrombolytic group was given a standard dose of 75% of urokinase (produced by Nanjing Pharmaceutical Factory),1～1.2 million U of which was added into 100ml of 0.9% of sodium chloride infusion and completely infused within 30min, and the younger elderly thrombolytic group was given the infusion of a standard dose of 1.5 million U of urokinase. Both groups were given preoperative routine record of 12-lead electrocardiogram, myocardial enzymes examination, blood routine examination, coagulation time test, and blood preparation. After the start of the thrombolytic treatment,12-lead ECG was recorded every 0.5h, once myocardial enzymes examination, symptom changes inquiry and adverse reactions observation were required every 2～4h. The elderly control group was of no difference to the thrombolytic group except the thrombolytic therapy. The clinical thrombolytic recanalization rate, major bleeding adverse reactions, average stay and total short and long term adverse cardiac events (including recurrent angina, myocardial infarction, heart failure, severe arrhythmia, and mortality) of both groups were observed and compared. All data analysis was carried out by SPSS13.0 package. The measurement data was indicated with mean±standard deviation and analyzed by t test. The count data was analyzed by X2 test.Results1. The results of the elderly reduced thrombolysis group showed 22 cases of clinical recanalization (56.4%),3 cases of cardiac death on discharge (7.7%),3 cases of heart failure (KillipⅡ～Ⅲgrade) (7.7%),3 cases of severe arrhythmia (7.7%), and 3 cases of mild bleeding adverse reactions (7.7%), including 2 cases of skin and mucous membrane petechiae, and 1 case of positive fecal occult blood test who relieved by suspension of anti-thrombosis treatment and adopting gastric mucosa protection symptomatic treatment, and no intracranial hemorrhage patient and no patient dead due to bleeding. The average hospital stay was 14.35±2.79 days. The six-month follow-up results showed 5 cases of cardiac death (12.8%),2 cases of recurrent angina,1 case of reinfarction,3 cases of severe arrhythmia, and 4 cases of heart failure. 2. The results of the elderly control group showed 6 cases of clinical vascular reperfusion (14%),8 cases of cardiac death on discharge (18.6%),6 cases of heart failure (KillipⅡ～Ⅲgrade) (14.0%),5 cases of severe arrhythmia (11.1%), and no bleeding patients. The average hospital stay was 18.62±3.35 days. The six-month follow-up results showed 11 cases of cardiac death (25.6%),2 cases of recurrent angina pectoris,3 cases of reinfarction,5 cases of serious arrhythmia, and 5 cases of heart failure.3. The results of the younger elderly thrombolysis group showed 30 cases of clinical vascular reperfusion (66.7%),2 cases of cardiac death on discharge (4.4%),2 cases of heart failure (KillipⅡ～Ⅲgrade) (4.4%),3 cases of severe arrhythmia (6.7%), and 2 cases of mild bleeding adverse reactions (7.7%) of skin and mucous membrane petechiae. The average hospital stay was 13.08±3.21 days. The six-month follow-up results showed 3 cases of death,3 cases of recurrent angina pectoris,1 case of reinfarction,4 cases of serious arrhythmia, and 3 cases of heart failure.4. According to the statistical analysis, compared to the elderly control group, the elderly reduced thrombolysis group has relatively higher rate of clinical vascular reperfusion (56.4% to 14%, P=0.000), less cardiac death but of no significant difference and no significant increase of bleeding risk. And the six-month follow-up results showed significant decline of total cardiac adverse events (38.5% to 60.5%, P=0.047). While all above-mentioned indicators were of no significant difference compared with the younger elderly thrombolysis group.ConclusionIt may be a safe and effective way to apply the reduced urokinase thrombolytic therapy on the elderly acute STEMI patients in strictly controlled circumstances.
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