The role of predicted intracranial bleeding risk in the choice of reperfusion strategy in patients with acute myocardial infarction.

OBJECTIVES: Intracranial haemorrhage after thrombolytic therapy for acute myocardial infarction occurs in 0.5-3% of patients. Prediction models have been developed to predetermine the intracranial bleeding risk, but have rarely been used for assigning the optimal reperfusion strategy. This might result in the use of thrombolytic therapy when primary PTCA would be preferable.
METHODS: Prospective data were gathered in 1365 candidates for reperfusion therapy. Risk of intracranial haemorrhage was determined with a risk score derived from large-scale clinical trials. Patients were divided into three groups based on their risk of intracranial haemorrhage: <1%, 1-3% and >3% and stratified by age.
RESULTS: An intracranial bleeding risk exceeding 3% was found in 120 patients (9%). These high-risk patients were often treated with thrombolysis (87%). Intracranial bleeding actually occurred in four out of 120 patients (3.3%) in this highest risk group, while no bleeding occurred in the other risk groups.
CONCLUSION: The actual incidence of intracranial bleeding is similar to the predicted bleeding risk in high-risk patients. These high-risk patients are predominantly older than 70 years. Nearly all patients exceeding a 3% risk of intracranial haemorrhage were treated with thrombolytic therapy. Primary angioplasty should be preferred in patients aged over 70 years since success rates of direct PTCA are no worse in elderly compared with younger patients.