The Role of Reperfusion Therapy in Paced Patients
Background/Objective. Our purpose was to evaluate the effectiveness of reperfusion therapy among elderly paced patients with acute myocardial infarction (MI). Current guidelines make no recommendation for the use of reperfusion therapy among patients who have a paced rhythm during MI.
Methods. We evaluated 1954 Medicare beneficiaries 65 years and older treated for acute MI between 1994 and 1996 who had a paced rhythm for use of reperfusion therapy. Use of reperfusion therapy was evaluated for associations with outcomes by logistic regression and Cox proportional hazards models incorporating propensity score analysis.
Results. Reperfusion therapy was used in 171 (8.8%) patients; 70 were treated with primary PTCA and 101 with thrombolytic therapy. Patients who received reperfusion therapy had 30-day mortality rates similar to those who did not receive reperfusion (26.3% vs 25.7%, P = .87). Multivariate adjustment for mortality risk factors and treatment propensity indicated no survival benefit associated with reperfusion therapy at 30 days (relative risk [RR] 1.07, 95% confidence interval [CI] 0.77-1.43) or long-term follow-up (hazard ratio [HR] 0.86, 95% CI 0.68-1.10). Mortality risks varied by type of reperfusion therapy. Patients treated with primary percutaneous transluminal coronary angioplasty were at comparable risk of mortality at 30 days (RR 0.73, 95% CI 0.40-1.23) but at lower risk at long-term follow-up (HR 0.60, 95% CI 0.40-0.88). Mortality risks were unchanged among patients treated with thrombolytics at 30 days (RR 1.32, 95% CI 0.92-1.79) and long-term follow-up (HR 1.08, 95% CI 0.82-1.43).
Conclusion. We find suggestive evidence that primary percutaneous transluminal coronary angioplasty provides a long-term survival benefit in the treatment of elderly patients with acute MI who have a paced rhythm.

As the nation's population ages, cardiac pacemaker use is increasing at a rate of 6% annually, to >112,00 implantations per year in the United States. Because of their advanced age and coronary risk factors, paced patients are at increased risk for acute coronary syndromes, including acute myocardial infarction (MI). Despite their increased risk, current American College of Cardiology/American Heart Association guidelines make no recommendation for the use of reperfusion therapy among patients who have a paced rhythm during their MI. In contrast, reperfusion therapy is recommended for patients with a left bundle branch block who have electrocardiographic features similar to those of paced patients. Uncertainty regarding the role of reperfusion therapy among paced patients with symptoms suggestive of MI likely reflects the absence of data concerning the effectiveness of reperfusion therapy among paced patients. To address this issue, we undertook an analysis of the Cooperative Cardiovascular Project (CCP), a data set of US Medicare beneficiaries hospitalized for acute MI.