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Risk of intracranial haemorrhage with combined fibrinolytic and glycoprotein IIb/IIIa inhibitor therapy in acute myocardial infarction: Dichotomous response as a function of age in the GUSTO V trial

European Heart Journal, ISSN: 0195-668X, Vol: 24, Issue: 20, Page: 1807-1814
2003
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Background: Intracranial haemorrhage is an important limitation to pharmacologic reperfusion therapy for acute myocardial infarction. The combination of a glycoprotein IIb/IIIa inhibitor, half-dose plasminogen activator and reduced-dose heparin has been evaluated as an alternative to standard fibrinolytic therapy in this setting. Methods and results: We evaluated the relation between univariate and multivariate predictors of intracranial haemorrhage and the effect of treatment with either reteplase alone (10 U bolus twice, 30 min apart) with standard-dose heparin (5000 U bolus followed by an infusion of 1000 U h for patients ≥80 kg and 800 U h for those <80 kg) or combination therapy with abciximab (0.25 mg/kg bolus and 0.125 μg/kg/min for 12 h) and half-dose reteplase (two boluses of 5 U 30 min apart) with reduced-dose heparin (60 U kg bolus, maximum 5000 U, followed by an infusion of 7 U kg h ) in the 16 588 patients randomized in the GUSTO V trial. Overall, the incidence of intracranial haemorrhage was similar in the two groups (0.6% vs 0.6%; OR 1.05, 95% CI 0.71, 1.56). The median (25th-75th) time from drug administration to intracranial haemorrhage was 5.5 (3.4-11) hours with combination therapy and 9.2 (5.9-22) hours with reteplase (P=0.048). Among the multivariable predictors of intracranial haemorrhage, only age showed a significant interaction with treatment effect (age per treatment interaction chi-square 4.60, P=0.032) with a lower risk of combination therapy for younger patients and a higher risk for the elderly. Conclusions: Although no additional risk of intracranial haemorrhage has been observed with combination therapy in the whole population, a significant age per treatment interaction exists, with a lower risk with combination therapy in younger patients, and a higher risk in the elderly. © 2003 Published by Elsevier Ltd on behalf of The European Society of Cardiology.

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