Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic

Impact of age on procedural and 1-year outcome in percutaneous transluminal coronary angioplasty: a report from the NHLBI Dynamic Registry

BACKGROUND

Older age has been associated with adverse outcomes in patients undergoing percutaneous coronary intervention (PCI). As PCI technology evolves and the US population becomes proportionally older, assessment of PCI in older age groups is essential.

METHODS

From the National Heart, Lung, and Blood Institute Dynamic Registry, 4620 PCI-treated patients (1997 to 1999) were studied. Differences in clinical presentation, treatment strategy, and inhospital and 1-year outcomes were compared between patient age groups: younger (<65 years, n = 2537); older (65 to 79 years, n = 1776); and elderly (> or =80 years, n = 307).

RESULTS

Older and elderly patients had more cardiac and comorbid noncardiac conditions and more extensive and complex arteriosclerosis, including stenoses in bypass grafts. Stent use was similar as age increased (72% vs 73% vs 73%), as was the use of IIb/IIIa receptor antagonists (29% vs 26% vs 28%). Rates of successful treatment of all attempted lesions were 93%, 92%, and 89%, respectively. Adjusted relative risks of inhospital death (1.0 vs 2.91 vs 3.64) and myocardial infarction (1.0 vs 1.35 vs 2.57) increased by age group, as did 1-year mortality rates (1.0 vs 1.87 vs 3.02). However, the relative magnitude of excess mortality rates at 1 year was comparable to that observed by age in the US general population. Age was not associated with 1-year risk of myocardial infarction or coronary artery bypass grafting.

CONCLUSIONS

Although new technologies may allow for treatment of complex disease in older and elderly patients with comorbid disease, the increased procedural risk remains substantial in these patients. After PCI, the long-term relative risk of death is similar to that expected among persons of similar ages in the general population.

Reperfusion in acute myocardial infarction: current concepts

Myocardial reperfusion is the treatment of choice in acute myocardial infarction. Pharmacological thrombolysis restores coronary artery patency in about two thirds of patients with acute myocardial infarction. However, mechanical reperfusion with primary angioplasty and stenting achieves higher patency rates with less complications, especially in high-risk patients. Adjunctive pharmacotherapy and new device technology may improve the outcome of primary angioplasty. Facilitated angioplasty using a combination of half-dose thrombolysis, platelet glycoprotein IIb/IIIa antagonists, and early intervention, appears to be a promising strategy for the treatment of acute myocardial infarction in the modern era. The efficacy and safety of this approach are currently evaluated in several ongoing trials.

Correlates of procedural complications and a simple integer risk score for percutaneous coronary intervention

OBJECTIVES

Our goals were to identify clinical and angiographic risk factors associated with major cardiovascular complications of percutaneous coronary intervention (PCI) (in-hospital death, Q-wave myocardial infarction, urgent or emergent coronary artery bypass surgery and stroke) and to construct a simple score for risk stratification.

BACKGROUND

Both clinical and angiographic features influence risk of PCIs.

METHODS

Percutaneous coronary interventions performed between January 1, 1996, and December 31, 1999, were analyzed. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of procedural complications using baseline, angiographic and procedural characteristics. The risk score was tested in a validation-set consisting of all procedures performed in the year 2000.

RESULTS

Among 5,463 procedures, 5 clinical and 3 angiographic variables were significantly correlated with procedural complications: cardiogenic shock, left main coronary artery disease, severe renal disease, urgent or emergent procedure, congestive heart failure class III or higher, thrombus, multivessel disease and older age. In the validation-set, the model fitted the data adequately; the average receiver operating characteristic curve area was 0.782 (standard deviation, 0.018).

CONCLUSIONS

Eight variables were combined into a convenient bedside risk scoring system that estimates the risk of complications after PCIs.

Age and the risk of in-hospital death: insights from a multihospital study of intensive care patients

OBJECTIVES

To determine independent relationships between age and the risk of in-hospital death.

DESIGN

Retrospective cohort study.

SETTING

Thirty-eight intensive care units (ICUs) in 28 hospitals in a large Midwest metropolitan region.

PARTICIPANTS

One hundred fifty-six thousand, one hundred thirty-six consecutive admissions to medical, surgical, neurological, and mixed medical/surgical ICUs between March 1, 1991, and March 31, 1997.

MEASUREMENTS

In-hospital death rates were compared at successive 5-year age intervals, adjusting for gender, diagnosis, admission source, comorbidity, and acute physiology scores. Acute physiology scores were determined using a validated methodology based on abnormalities in 17 physiological measures collected during the first 24 hours of ICU admission.

RESULTS

The adjusted odds of death increased with each 5-year age increment. For example, relative to patients younger than 35, adjusted odds of death in patients aged 40 to 44, 50 to 54, 60 to 64, 70 to 74, 80 to 84, and 90 and older were 1.51, 1.73, 2.38, 2.98, 3.86, and 4.74, respectively. In stratified analyses, age-related increases in the odds of death were somewhat higher in surgical than medical patients or patients with lower severity of illness at admission. Although acute physiology scores had excellent discrimination in all age groups, discrimination decreased with age (e.g., c-statistics of 0.928 and 0.835 in patients younger than 45 and 85 and older, respectively).

CONCLUSION

Our findings demonstrate incremental increases in the risk of hospital death associated with age that was independent of severity of illness and other prognostic factors. Although the current results may be less biased by differences in treatment goals than studies of general hospitalized patients, the lower discrimination of physiology scores in older patients suggests that unmeasured factors (e.g., functional status, patient preferences for care, differences in physician practices) may be of greater prognostic importance in older than in younger patients.

Predictors and prognosis of suboptimal coronary blood flow after primary coronary angioplasty in patients with acute myocardial infarction

We hypothesized that certain clinical and angiographic characteristics on presentation predict suboptimal infarct artery flow after percutaneous intervention during acute myocardial infarction (AMI). The goal of angioplasty (percutaneous transluminal coronary angioplasty [PTCA]) during AMI is the prompt restoration of normal flow to achieve myocardial reperfusion. However, inadequate epicardial coronary flow is observed in 10% to 20% of patients. From 2 large randomized trials-Global Use of Strategies To open Occluded arteries in Acute Coronary Syndromes-IIb, and Randomized Placebo-Controlled Trial of Platelet glycoprotein IIb/IIIa Blockade With Primary Angioplasty for Acute Myocardial Infarction-patients undergoing primary PTCA during AMI were included in the analysis. A multivariate logistic model was used to identify factors associated with final Thrombolysis In Myocardial Infarction (TIMI) flow grade < or =2. The 891 patients were aged (mean +/- SD) 61 +/- 12 years, 75% were men, and 39% had an anterior wall AMI. Patients underwent PTCA within 4.8 +/- 3.2 hours from the onset of chest pain. The incidence of final TIMI 3 flow was 81%. TIMI flow grade < or =2 was independently associated with increasing age (odds ratio [OR] 1.39 for every 10 years, 95% confidence interval [CI] 1.19 to 1.62), increasing heart rate (OR 1.16 for every 10 beats, 95% CI 1.05 to 1.28), and presence of visible thrombus on baseline angiogram (OR 1.89, 95% CI 1.18 to 3.05). Conversely, baseline TIMI 2 or 3 flow grade (OR 0.46, 95% CI 0.28 to 0.75) and left circumflex intervention (OR 0.42, 95% CI 0.23 to 0.79) correlated with normal postprocedural coronary flow. Mortality was significantly higher in patients with TIMI < or =2 than TIMI 3 flow grade (10.2% vs 1.5%, p <0.001, respectively). Thus, angiographic evidence of thrombus and 2 pivotal clinical characteristics, advanced age and elevated heart rate, predict lack of adequate coronary reperfusion. Conversely, the presence of normal or near-normal coronary flow before intervention correlates with a good angiographic result. Mortality risk is increased in patients with postprocedural suboptimal angiographic coronary flow.