-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]]On Behalf Of john ryan
Sent: 27 June 2001 07:39
To: [log in to unmask]
Subject: Re: Radial head fractures
This leads me to ask a quetion I meant to post last week. I had a 72 year
old lady with an acute inferion M.I. who suffers from von Williebrand's
disease. Would anyone thrombolyse her ?
John
Nobody seems to have picked this question up...
So, for what it's worth, I probably wouldn't thrombolyse this lady, all
other things being equal.
The number needed to treat in inferor MI is a staggering 120,(1) and this
data is based on several large clinical trials of thrombolysis which tend to
recruit younger men with minimal or no co-morbidity. The risk of
intracerebral haemorrhage is increased by advancing age, female sex,
hypertension, low body weight (an arguement for reducing the dose of
thrombolysis), previous anticoagulation and a history of cerebrovascular
disease(2), so this patient appears to have a risk considerably in excess of
that reported in the clinical trials. This, coupled with observational
evidence in real patient populations that thrombolytic therapy may not yield
the expected benefits in patients older than 75 years, and may even be
harmful,(3) would make me very cautious.
As in all cases I would make a final decision based on a range of factors
and in consultation with the patient wherever possible. It's one thing to
know what the evidence is, but much more important to know how this applies
to the patient in front of you.(4) Perhaps urgent angioplasty would provide
the benefits of early reperfusion with less risk?
Jonathan Benger.
SpR, Bristol.
1. Fibrinolytic Therapy Trialists' (FTT) Collaborative Group. Indications
for thrombolytic therapy in suspected myocardial infarction: collaborative
review of early mortality and major morbidity results from all randomised
trials of more than 1000 patients. Lancet 1994;343:311-322.
2. McMechan SR, Adgey AAJ. Age related outcome in myocardial infarction. BMJ
1998;317:1334-1335.
3. Ayanian JZ, Braunwald E. Thrombolytic therapy for patients with
myocardial infarction who are older than 75 years: do the risks outweigh the
benefits? Circulation 2000;101:2224-2226.
4. David L. Sackett.
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