Can intravenous (IV) streptokinase (STK) be given to an 80-year-old female with myocardial infarction (MI)?

Streptokinase Use in an 80-Year-Old Female with MI

Primary PCI is strongly preferred over streptokinase for an 80-year-old female with STEMI, but if PCI is unavailable or significantly delayed, streptokinase can be safely administered and provides mortality benefit despite the increased bleeding risk in this age group. 1

Primary Recommendation: PCI Over Fibrinolysis

• The absolute mortality advantage of PCI over fibrinolysis increases dramatically with age, from 1% at age 65 to 6.9% at age >85 years. 1
• In the Senior PAMI trial, patients >70 years receiving PCI had a 55% reduction in death, stroke, or reinfarction compared to fibrinolytic therapy (11.6% vs 18%, p<0.05). 1
• However, in the subgroup of patients >80 years (n=131), no significant difference was found between reperfusion strategies, suggesting both approaches have merit in this age group. 1

When Streptokinase Can Be Used

If PCI cannot be performed within appropriate timeframes, streptokinase is an acceptable and beneficial alternative:

• The ISIS-2 trial demonstrated a 5-week absolute mortality reduction of 38 per 1000 patients aged 60-69 years who received streptokinase. 2
• When combined with aspirin, the mortality benefit increases to 70 per 1000 patients in this age group. 2
• Advanced age alone should not limit the use of reperfusion therapy for eligible elderly patients with STEMI. 1

Safety Profile in the Elderly

Bleeding risks are manageable with appropriate anticoagulation dosing:

• The ExTRACT-TIMI 25 trial (which included 2,532 patients ≥75 years old) demonstrated that with adjusted anticoagulation, major bleeding occurred in only 2.9-3.3% and intracranial hemorrhage in 1.6-1.7% of elderly patients. 1
• This represents significant improvement over older trials where intracranial bleeding rates reached 6.7% in patients aged 76-85 years. 1
• A study of 100 elderly patients receiving streptokinase found no intracranial hemorrhages, with major bleeding in only 3% of patients. 3

Specific Contraindications to Assess

Before administering streptokinase, exclude:

• Active bleeding or bleeding diathesis 4
• Recent stroke or intracranial pathology 4
• Uncontrolled severe hypertension 4
• Recent major surgery or trauma 4

Timing Considerations

• Ideally, streptokinase should be administered within 12 hours of symptom onset. 1
• Late benefit has been observed in elderly patients presenting up to 12 hours after pain onset. 2
• In patients treated >6 hours after infarct, streptokinase produced lower mortality than accelerated rt-PA in the GUSTO trial. 2

Adjunctive Therapy

Essential medications to administer with streptokinase:

• Aspirin 162-325 mg immediately (provides additive mortality benefit). 2
• Adjusted-dose anticoagulation (enoxaparin or UFH with careful dosing for age and renal function). 1
• Beta-blockers within 24 hours if hemodynamically stable. 5

Expected Outcomes

• Clinical evidence of reperfusion occurs in approximately 86% of elderly patients. 6
• Coronary artery patency rates of 85% have been documented in elderly patients receiving streptokinase. 6
• In-hospital mortality with streptokinase in elderly patients ranges from 2-3.4% in contemporary series. 3, 6

Critical Caveat

The decision between PCI and streptokinase depends primarily on time to PCI availability. If PCI can be performed within 90-120 minutes of first medical contact, it is the superior choice. 1 If significant delays are anticipated, streptokinase should not be withheld based on age alone, as the mortality benefit is substantial and the safety profile is acceptable with proper patient selection and anticoagulation management. 1, 2