JE Simon, MB, ChB, MRCP (UK), Calgary Stroke Program, Seaman Family MR Research Centre, Department of Clinical Neurosciences, University of Calgary, Calgary, AB.
MD Hill, MD, MSc, FRCPC, Director, Stroke Unit, Associate Professor, Calgary Stroke Program, Departments of Clinical Neurosciences / Medicine / Community Health Sciences, University of Calgary, Calgary, AB.

Despite the fact that stroke is both common and devastating in older patients, very little randomized controlled data is available on the efficacy or safety of thrombolysis in older age groups. We review literature from both randomized control studies and case series data treating older patients, and look at the hemorrhage rate and mortality associated with thrombolysis. In addition, we examine risk markers, other than age, for a poor outcome. We suggest that older age alone is not a contraindication to thrombolytic therapy.

Key words: ischemic stroke, tPA, thrombolysis, hemorrhage risk.

A Review of the Literature

Alan K. Berger, MD, Sections of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN, USA.

While elderly patients (aged = 75 years) represent a small segment of the general population, they account for disproportionate morbidity and mortality associated with acute myocardial infarction. Consequently, the efficacy and utilization of reperfusion therapy--thrombolysis and primary coronary angioplasty/stenting--remain highly relevant. A randomized clinical trial of thrombolysis in the elderly has never been performed, although subgroup analyses have suggested a benefit. The effectiveness of thrombolysis in the elderly has been challenged by observational studies documenting unexpectedly high mortality. The efficacy of primary coronary angioplasty/stenting is now well established and growing evidence suggests this approach is superior to thrombolysis in the elderly.
Key words: geriatrics, thrombolysis, primary coronary angioplasty, acute myocardial infarction, guidelines.

Dr. Ruth Hubbard
Lecturer

Dr. M. Sinead O'Mahony
Senior Lecturer,
University Department of Geriatric Medicine,
University of Wales,
College of Medicine, Wales, UK.

Introduction
Stroke is the second most common cause of mortality in much of the developed world and leads to an estimated 4.4 milllion deaths per year, worldwide.¹ It also causes significant morbidity. Thirty percent of patients with a stroke will die within the first three months and half of the remaining patients will have significant long-term disability.

Stroke is particularly a problem of older people. The risk of stroke doubles with each decade of life after 35 years, such that two thirds of all strokes occur in patients over the age of 65 years. People over 75 years are the fastest growing population in North America. Any treatment that improves outcomes in elderly patients with stroke is potentially of huge importance.

Until recently, there was no effective therapy or management strategy to reduce stroke mortality and disability. Two interventions have been shown to result in some benefit--stroke units and aspirin therapy. Stroke Unit care is associated with 70 fewer deaths or dependencies per 1000 patients treated.