• thrombolysis
• coronary heart disease

• FTT, fibrinolytic therapy trialists
• ISIS-2, second international study of infarct survival
• t-PA, tissue plasminogen activator

Thrombolysis is established therapy for acute myocardial infarction. The recent National service framework for coronary heart disease¹ seeks proof of its rapid delivery in all hospitals in England in the near future. Witnessing a stroke, of which the majority are fatal, after delivering a thrombolytic agent brings home to clinicians how narrow the therapeutic benefit from these agents can be. Faced with the individual patient, the prospect of minor gain against the rare potential for death or serious disability weighs heavily in decision making; doctors treat patients not populations. An article by Thiemann and colleagues² suggested that elderly patients have nothing to gain from thrombolysis, indeed they may be harmed (fig 1). The claims have raised an interesting debate. Can such non-randomised studies, however large the patient numbers and elegant the statistics, replace information from the randomised trial? Probably not, yet extrapolation from trials that include low risk, relatively young patients may be equally inappropriate.

Age appears not to affect in any fundamental way the pathology of the culprit lesion of acute myocardial infarction. However, the extent of associated disease in the coronaries is likely to be greater and co-morbid conditions are common. The dramatic rise of mortality with age makes clear that elderly patients are different in a major way from their younger counterparts. Similarly the higher mortality of those after myocardial infarction, when not entered in to trials …