Is old age really a reason to withhold thrombolytic therapy?

摘要

Van Oostenbruggc et al (see pages 375-7) of this issue present data on a group of 45 patients aged 80 years or over and compare outcome after thrombolytic therapy to that in a group of patients aged less than 80 years. In their study, older patients have a significantly worse outcome as measured by the modified Rankin scale. There was a non- significant trend towards more intracranial bleeding in the older patients. The authors conclude that their results "question whether the use of rt-PA (recombinant tissue plasminogen activator) is justified in patients over 80 years of age".The authors are ambivalent with regard to thrombolytic therapy, and even more so when it comes to the treatment of elderly patients. As stated in their article, the Third International Stroke Trial (IST3) might answer some of the apparently open questions.1 This trial so far has included 408 patients (as of 7th Aug 2005) and has a planned sample size of 6000 patients. Although IST3 might provide some answers, there are flaws in the design of the trial that may influence the results, one of them being the uncertainty principle. At the current inclusion rate we will not see results before 2010. On the other hand, the CASES study showed that thrombolytic therapy can be performed as a daily routine without losing safety or efficacy.2 Moreover, in this study older patients did not have a higher risk ofintracranial bleeding. As shown in the CASES trial, registers can help to answer some of the questions although they lack the power of large randomised trials. The SITS-MOST register might resolve some of the uncertainty that hangs over thrombolysis. Questions concerning the time window or imaging modality will be tackled in randomised trials such as DIAS2 or ROSIE.