In a pooled analysis of eight trials of fibrinolytic therapy, enrolling more than 50,000 patients, only a third of those screened (range 9-51%) were eventually enrolled. Few patients have absolute contraindications to lytic therapy, such as recent bleeding episodes, major surgery, or previous stroke with residual neurological deficits. The common reasons for exclusion were relative contraindications, such as presentation later than 6 h from symptom onset (13-37%), advanced age with its inherent increased risk of intracranial hemorrhage (2-31%), and lack of "classical" electrocardiographic findings (11-62%) (88,89). Although the Worcester Heart Attack Study Group reported a 175% increase in the use of lytics in acute MI between 1986 and 1993, still only 25.5% of those screened received the therapy (90). Subjects younger than 55 yr were 4.5 X more likely to receive it than patients older than 75 yr. Since it is well established that ineligibility for thrombolytic therapy is associated with a 4- to 8-fold increase in 30-d mortality (91), such patients should be considered for mechanical reperfusion (92).
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