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Wu X, Yang D, Zhao Y, Lu C, Wang Y. Effectiveness of percutaneous coronary intervention within 12 hours to 28 days of ST-elevation myocardial infarction in a real-world Chinese population. PLoS One 2013; 8:e58382. [PMID: 23554888 PMCID: PMC3595272 DOI: 10.1371/journal.pone.0058382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 02/04/2013] [Indexed: 11/24/2022] Open
Abstract
Objectives Percutaneous coronary intervention( PCI) for ST-elevation myocardial infarction (STEMI) has been widely accepted for patient who come within 12 hours, but for those who come to the hospital late (12 hours to 28 days) the long-term data and possible predictors are limited regarding ‘hard’ endpoints in ‘real world’. Methods The registry data of all 5523 consecutive patients admitted due to an incident STEMI (12 hours to 28 days) in our center were analyzed. Patients were divided into 3 age groups (age<65; age = 65–74; age ≥75) and two therapeutic groups including conservative and PCI group. The primary endpoints included 30-day mortality and 1-year mortality. Results The clinical characteristics include female gender; history of diabetes mellitus, previous myocardial infarction, cerebral vascular disease, chronic renal failure, atrial fibrillation, hypertension, anemia, gastric bleeding; presentation of ventricular tachycardia/ventricular fibrillation, pneumonia, heart failure, multiple organ failure and cardiogenic shock. The ratio of all the above factors increased with the age getting older (all p<0.05), while that of the PCI decreased significantly with ageing (53.9%, 36.3% and 21.7%). Except hypertension, all the other factors were less seen in the PCI group than in the conservative group (p<0.01). Pooled estimates, based on type of therapy and age groups, PCI resulted in significantly lower 30-day and 1-year mortality. Cox analysis showed the positive predictors for 30 days and 1 year mortality were heart failure, cerebral vascular disease, chronic renal failure, ventricular tachycardia/ventricular fibrillation, age, female, gastric intestinal bleeding, cardiogenic shock, multiple organ failure, while PCI was a negative predictor. ROCs analysis showed AUCs were always higher for PCI group. Conclusions The elderly have more comorbidities and higher rates of mortality, mandating thorough evaluation before acceptance for PCI. PCI between 12 hours to 28 days in all ages of patients including the elderly with STEMI is significantly more effective than conservative therapy.
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Affiliation(s)
- Xingli Wu
- Institute of Geriatric Cardiology, China PLA General Hospital, Beijing, China.
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Antonsen L, Jensen LO, Terkelsen CJ, Tilsted HH, Junker A, Maeng M, Hansen KN, Lassen JF, Thuesen L, Thayssen P. Outcomes after primary percutaneous coronary intervention in octogenarians and nonagenarians with ST-segment elevation myocardial infarction: From the Western Denmark heart registry. Catheter Cardiovasc Interv 2013; 81:912-9. [DOI: 10.1002/ccd.24591] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 07/26/2012] [Accepted: 07/30/2012] [Indexed: 11/08/2022]
Affiliation(s)
- Lisbeth Antonsen
- Department of Cardiology; Odense University Hospital; Odense; Denmark
| | | | | | | | - Anders Junker
- Department of Cardiology; Odense University Hospital; Odense; Denmark
| | - Michael Maeng
- Department of Cardiology; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | | | | | - Leif Thuesen
- Department of Cardiology; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Per Thayssen
- Department of Cardiology; Odense University Hospital; Odense; Denmark
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Murphy JC, Kozor RA, Figtree G, Hansen PS, Rasmussen HH, Ward MR, Nelson GI, Bhindi R. Procedural and in-patient outcomes in patients aged 80 years or older undergoing contemporary primary percutaneous coronary intervention. EUROINTERVENTION 2012; 8:912-9. [DOI: 10.4244/eijv8i8a140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Medina HM, Cannon CP, Fonarow GC, Grau-Sepulveda MV, Hernandez AF, Frank Peacock W, Laskey W, Peterson ED, Schwamm L, Bhatt DL. Reperfusion strategies and quality of care in 5339 patients age 80 years or older presenting with ST-elevation myocardial infarction: analysis from get with the guidelines-coronary artery disease. Clin Cardiol 2012; 35:632-40. [PMID: 22744844 DOI: 10.1002/clc.22036] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/31/2012] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Data regarding reperfusion strategies, adherence to national guidelines, and in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients age ≥80 years are limited. The aim of this study was to determine current reperfusion trends, medical treatment, and in-hospital mortality during STEMI in older adults. HYPOTHESIS Among patients aged 80 or above presenting with STEMI, adherence to guidelines, length of stay, and in-hospital mortality would be better in those receiving reperfusion versus those who did not. METHODS Using the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) database, we examined care and in-hospital outcomes of STEMI patients ≥80 years old. Use of evidence-based therapies and quality measures were analyzed by reperfusion strategies. RESULTS A total of 5339 patients age ≥80 years hospitalized with STEMI were included. Of these, 42.8% (n = 2285) underwent primary percutaneous coronary intervention (PPCI), 4.8% (n = 255) underwent thrombolysis (TL), and 52.4% (n = 2799) received no reperfusion (NR). Patients with NR were more likely to be older, female, have lower body mass index, and higher prevalence of renal insufficiency and heart failure compared with PPCI or TL patients. During the last decade, there was a significant increase in the use of PPCI compared with TL as the main reperfusion strategy in this population. Adjusted in-hospital mortality in PPCI patients was lower compared with NR patients (odds ratio [OR]: 0.41, 95% confidence interval [CI]: 0.35-0.49); also, patients undergoing PPCI or TL had lower mortality compared with NR patients (OR: 0.47, 95% CI: 0.40-0.55). CONCLUSIONS Among patients ≥80 years old admitted with STEMI to GWTG-CAD hospitals, less than half undergo mechanical or pharmacological reperfusion. However, the proportion of patients undergoing PPCI has increased substantially over the 8-year study period. Patients undergoing PPCI or TL had lower in-hospital mortality compared with the NR strategy.
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Affiliation(s)
- Hector M Medina
- Department of Medicine, Montefiore Medical Center, Division of Cardiology, Albert Einstein College of Medicine, Bronx, New York, USA
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Franken M, Nussbacher A, Liberman A, Wajngarten M. ST Elevation Myocardial Infarction in the elderly. J Geriatr Cardiol 2012; 9:108-14. [PMID: 22916055 PMCID: PMC3418898 DOI: 10.3724/sp.j.1263.2011.12297] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 05/07/2012] [Accepted: 05/14/2012] [Indexed: 11/25/2022] Open
Abstract
Acute coronary syndromes (ACS) are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials from which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.
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Affiliation(s)
- Marcelo Franken
- INCOR Heart Institute, University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44-05403-000, São Paulo, Brasil
| | - Amit Nussbacher
- INCOR Heart Institute, University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44-05403-000, São Paulo, Brasil
| | - Alberto Liberman
- PUC- Campinas Medical School, Rodovia Dom Pedro I, km 136, Parque das Universidades Campinas (SP), CEP13086-900, Brasil
| | - Mauricio Wajngarten
- INCOR Heart Institute, University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44-05403-000, São Paulo, Brasil
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Primary percutaneous coronary intervention for acute myocardial infarction in the elderly aged ≥75 years. Catheter Cardiovasc Interv 2012; 79:50-6. [DOI: 10.1002/ccd.22810] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 08/28/2010] [Accepted: 08/31/2010] [Indexed: 11/07/2022]
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Abstract
This article contains a review of the main developments in the field of geriatric cardiology reported during 2011. The principle focus is on research into the characteristics of elderly patients with heart failure, arrhythmias (e.g. into atrial fibrillation and implantable cardioverter-defibrillators), ischemic heart disease and percutaneous interventions.
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Abstract
Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.
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Affiliation(s)
- Amelia Carro
- Cardiovascular Sciences Research Centre, Division of Clinical Sciences, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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van der Giessen WJ. Primary PCI: false positives versus false negatives. Neth Heart J 2011; 16:323-4. [PMID: 18958254 DOI: 10.1007/bf03086172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- W J van der Giessen
- Department of Cardiology, Thoraxcentre, Erasmus MC, Rotterdam, and Interuniversity Cardiology Institute of the Netherlands, ICIN-KNAW, Utrecht, the Netherlands
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Abstract
The aging of the population worldwide will result in increasing numbers of elderly patients, among whom heart disease is the leading cause of death. Changes in cardiovascular physiology with normal aging and prevalent comorbidities result in differences in the effects of common cardiac problems as well as the response to their treatments. Patient-centered goals of care such as maintenance of independence and reduction of symptoms may be preferred over increased longevity. New less-invasive treatments are likely to improve outcomes in elderly patients who previously have been considered at prohibitive risk for traditional procedures. Clinical trials enrolling elderly patients are limited and recommendations for management from younger patients frequently lack evidence-based support in patients aged >75 years.
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Josseaume J, Duchateau FX, Burnod A, Pariente D, Beaune S, Leroy C, Judde de la Rivière E, Huot-Maire V, Ricard-Hibon A, Juvin P, Mantz J. Observatoire du sujet âgé de plus de 80 ans pris en charge en urgence par le service mobile d’urgence et de réanimation. ACTA ACUST UNITED AC 2011; 30:553-8. [DOI: 10.1016/j.annfar.2011.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 03/11/2011] [Indexed: 10/18/2022]
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Koutouzis M, Grip L, Matejka G, Albertsson P. Primary percutaneous coronary interventions in nonagenarians. Clin Cardiol 2011; 33:157-61. [PMID: 20235207 DOI: 10.1002/clc.20720] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The optimal treatment of very elderly patients with ST elevation myocardial infarction (STEMI) is not yet defined. The aim of this study is to present the feasibility and safety of primary percutaneous coronary interventions (PCI) in nonagenarians. METHODS A retrospective analysis of all patients who underwent primary PCI due to STEMI between 2004 and 2008 was performed. Patients age 90 years or older at the time of the procedure were identified and studied. RESULTS Twenty-two patients fulfilled the study criteria (median age 92 years; range, 90-97 years; 50% women). The procedural success rate was 82%. Bare metal stent implantation was performed in 82% of the procedures, whereas only balloon angioplasty was performed on the rest of them. One patient experienced a minor bleeding complication. Procedural mortality was 9% (2 out of 22 patients), and it was due to "no flow" phenomenon in both patients. In-hospital mortality was 27% (6/22 patients) and 30-day mortality was 32% (7/22 patients). All 3 patients with Killip class III-IV on admission died within 30 days compared with 4 of the 19 patients with Killip class I-II (P = 0.023). Furthermore, of 11 patients with anterior infarction, 7 died within 30 days compared with none of the 11 patients with infarction of other location (P = 0.004). CONCLUSIONS Although primary PCI is feasible in patients 90 years or older suffering from STEMI, the short-term mortality rate is high especially in patients with anterior infarct location and/or severely depressed myocardial function.
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Affiliation(s)
- Michael Koutouzis
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Ezekowitz JA, Kaul P. The epidemiology and management of elderly patients with myocardial infarction or heart failure. Heart Fail Rev 2011; 15:407-13. [PMID: 20213185 DOI: 10.1007/s10741-010-9162-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Heart disease is important in elderly patients. The treatment of myocardial infarction and heart failure are particularly important and will continue to play an important role across the globe. Advances in treatment of myocardial infarction have made tremendous inroads in the short and long term survival of patients, young and old, however, many currently employed strategies have not been tested in patients who are elderly, who paradoxically, form a growing subset of patients with heart disease. A similar paradigm exists in heart failure for both diagnosis and treatment. Attention to this issue is important when selecting treatment strategies and a focus on the goals of care is critical when decisions for care must be undertaken.
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Affiliation(s)
- Justin A Ezekowitz
- Division of Cardiology, University of Alberta, 2C2 WMC, 8440-112 Street, Edmonton, Alberta T6G 2B7, Canada.
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Salinas P, Galeote G, Martin-Reyes R, Perez-Vizcayno M, Hernandez-Antolin R, Mainar V, Moreu J, de la Torre J, Zueco J, Tello A, Jimenez-Valero S, Sanchez-Recalde A, Calvo L, Plaza I, Alfonso F, Mariscal F, Lopez de Sa E, Macaya C, Lopez-Sendon JL, Moreno R. Primary percutaneous coronary intervention for ST-segment elevation acute myocardial infarction in nonagenarian patients: results from a Spanish multicentre registry. EUROINTERVENTION 2011; 6:1080-1084. [DOI: 10.4244/eijv6i9a188] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Newell MC, Henry JT, Henry TD, Duval S, Browning JA, Christiansen EC, Larson DM, Berger AK. Impact of age on treatment and outcomes in ST-elevation myocardial infarction. Am Heart J 2011; 161:664-72. [PMID: 21473964 DOI: 10.1016/j.ahj.2010.12.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/06/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVES We hypothesized that older patients in a regional ST-elevation myocardial infarction (STEMI) transfer program would attain comparable treatment to younger patients. BACKGROUND Older patients have been either excluded or underrepresented in STEMI clinical trials. Observational studies suggest that these patients are less likely to receive adjunctive pharmacologies and reperfusion therapy-thrombolysis or percutaneous coronary intervention (PCI)-and therapy is frequently delayed. METHODS We identified a consecutive series of 2,262 STEMI patients (March 2003-December 2008) who either presented or were transferred to Abbott Northwestern Hospital for PCI (<65 years [n = 1285], 65-74 years [n = 436], 75-84 years [n = 381], and ≥85 years [n = 160]). Main outcome measures included time-to-reperfusion therapy, adjunctive medications received, and all-cause mortality. RESULTS Overall time-to-reperfusion therapy was similar across age strata-94 minutes (<65 years), 101 minutes (65-74 years), 106 minutes (75-84 years), and 103 minutes (≥85 years). No difference in adjunctive antiplatelet or anticoagulant medications was seen at hospital admission, and only slight differences in standard post-myocardial infarction medication use were seen by age at hospital discharge. Age was an independent predictor of in-hospital and yearly mortality up to 5 years (1-year mortality 3.4% [<65 years], 9.2% [65-74 years], 15.2% [75-84 years], and 28.9% [≥85 years]; P < .0001). CONCLUSIONS Older patients receive similar care to younger patients when treated in a regional STEMI transfer program. Although all-cause mortality in the elderly is increased, the absolute rates are lower than previously established. Our data suggest primary PCI (including transfer) can be applied to all appropriate STEMI patients, regardless of age.
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Shih H, Lee B, Lee RJ, Boyle AJ. The aging heart and post-infarction left ventricular remodeling. J Am Coll Cardiol 2011; 57:9-17. [PMID: 21185495 DOI: 10.1016/j.jacc.2010.08.623] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 08/17/2010] [Accepted: 08/24/2010] [Indexed: 12/28/2022]
Abstract
Aging is a risk factor for heart failure, which is a leading cause of death world-wide. Elderly patients are more likely than young patients to experience a myocardial infarction (MI) and are more likely to develop heart failure following MI. The poor clinical outcome of aging in cardiovascular disease is recapitulated on the cellular level. Increase in stress exposure and shifts in signaling pathways with age change the biology of cardiomyocytes. The progressive accumulation of metabolic waste and damaged organelles in cardiomyocytes blocks the intracellular recycling process of autophagy and increases the cell's propensity toward apoptosis. Additionally, the decreased cardiomyocyte renewal capacity in the elderly, due to reduction in cellular division and impaired stem cell function, leads to further cardiac dysfunction and maladaptive responses to disease or stress. We review the cellular and molecular aspects of post-infarction remodeling in the aged heart, and relate them to the clinical problem of post-infarction remodeling in elderly patients.
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Affiliation(s)
- Henry Shih
- Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, California 94143, USA
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Appleby CE, Ivanov J, Mackie K, Džavík V, Overgaard CB. In-hospital outcomes of very elderly patients (85 years and older) undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2011; 77:634-41. [DOI: 10.1002/ccd.22729] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 06/21/2010] [Accepted: 06/30/2010] [Indexed: 11/05/2022]
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Lin CJ, Liu CF, Kung CT, Sun CK, Lin YC, Leu S, Chua S, Yeh KH, Wu CJ, Chen YL, Yip HK. The Prognostic Value of Atrial Fibrillation on 30-Day Clinical Outcome in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Int Heart J 2011; 52:153-8. [DOI: 10.1536/ihj.52.153] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Cheng-Jei Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Chu-Feng Liu
- Emergency Department, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Chia-Te Kung
- Emergency Department, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Cheuk-Kwan Sun
- Division of General Surgery, Department of Surgery, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yu-Chun Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Steve Leu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Sarah Chua
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Kuo-Ho Yeh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Chiung-Jen Wu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
| | - Hon-Kan Yip
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine
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Forman DE, Chen AY, Wiviott SD, Wang TY, Magid DJ, Alexander KP. Comparison of outcomes in patients aged <75, 75 to 84, and ≥ 85 years with ST-elevation myocardial infarction (from the ACTION Registry-GWTG). Am J Cardiol 2010; 106:1382-8. [PMID: 21059425 DOI: 10.1016/j.amjcard.2010.07.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 07/14/2010] [Accepted: 07/14/2010] [Indexed: 11/25/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) is common in older adults and has high age-related mortality. We describe contemporary STEMI care using the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Network Registry-Get With The Guidelines (ACTION-GWTG) database. Patients with STEMI (n = 30,188) from 285 ACTION-GWTG sites from January 1, 2007 to June 30, 2008 were grouped by age (<75, 75 to 84, and ≥ 85 years) to compare baseline characteristics, reperfusion, and in-hospital outcomes. In this population, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥ 85 years old (the oldest old). Compared to younger patients, the oldest-old patients (median age 88 years, interquartile range 86 to 91) were more often women, had more hypertension, and end-organ co-morbidity (heart failure and stroke, p <0.0001 for all). More than 42% of the oldest old were also cited as having contraindications to reperfusion, but with absolute or relative contraindications noted in only 10%, and patient preference was the most common reason indicated (45%). Even in reperfusion-eligible patients, the oldest old were less likely to receive it. Although patients who received reperfusion had better outcomes than those who did not, this was significant only for younger patients (< 75 years old, odds ratio 0.58, confidence interval 0.40 to 0.84). In conclusion, > 42% of the oldest old have reported contraindications to reperfusion, with neither mortality benefit nor harm in those who receive it. Disparities in process of care and co-morbidity may explain these observational findings. Whether efforts to optimize patient selection and initiate reperfusion therapy can improve outcomes in the oldest old with STEMI is unknown.
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Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, García EJ, López-Sendón JL, Macaya C, Hernández-Antolín R. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2010; 32:51-60. [PMID: 20971744 PMCID: PMC3013200 DOI: 10.1093/eurheartj/ehq375] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims To compare primary percutaneous coronary intervention (pPCI) and fibrinolysis in very old patients with ST-segment elevation myocardial infarction (STEMI), in whom head-to-head comparisons between both strategies are scarce. Methods and results Patients ≥75 years old with STEMI <6 h were randomized to pPCI or fibrinolysis. The primary endpoint was a composite of all-cause mortality, re-infarction, or disabling stroke at 30 days. The trial was prematurely stopped due to slow recruitment after enroling 266 patients (134 allocated to pPCI and 132 to fibrinolysis). Both groups were well balanced in baseline characteristics. Mean age was 81 years. The primary endpoint was reached in 25 patients in the pPCI group (18.9%) and 34 (25.4%) in the fibrinolysis arm [odds ratio (OR), 0.69; 95% confidence interval (CI) 0.38–1.23; P = 0.21]. Similarly, non-significant reductions were found in death (13.6 vs. 17.2%, P = 0.43), re-infarction (5.3 vs. 8.2%, P = 0.35), or disabling stroke (0.8 vs. 3.0%, P = 0.18). Recurrent ischaemia was less common in pPCI-treated patients (0.8 vs. 9.7%, P< 0.001). No differences were found in major bleeds. A pooled analysis with the two previous reperfusion trials performed in older patients showed an advantage of pPCI over fibrinolysis in reducing death, re-infarction, or stroke at 30 days (OR, 0.64; 95% CI 0.45–0.91). Conclusion Primary PCI seems to be the best reperfusion therapy for STEMI even for the oldest patients. Early contemporary fibrinolytic therapy may be a safe alternative to pPCI in the elderly when this is not available. Clinicaltrials.gov # NCT00257309.
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Affiliation(s)
- Héctor Bueno
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Dr Esquerdo 46, Madrid, Spain.
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Danzi GB, Centola M, Pomidossi GA, Consonni D, De Matteis S, Stabile A, Sesana M, Anzuini A, Sganzerla P, Cortese B, Migliorini A, Antoniucci D. Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction. Am J Cardiol 2010; 106:770-3. [PMID: 20816115 DOI: 10.1016/j.amjcard.2010.04.041] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2010] [Revised: 04/26/2010] [Accepted: 04/26/2010] [Indexed: 11/29/2022]
Abstract
The optimal reperfusion strategy in very elderly patients with ST-segment elevation myocardial infarction is still a subject of debate. The aim of this multicenter study was to determine the medium-term outcomes of nonagenarians after primary percutaneous intervention for ST-segment elevation myocardial infarction. A systematic review of the databases of 7 Italian centers showed that these had performed 5,023 primary angioplasties over the previous 5 years, 100 of which (2%) involved patients > or =90 years old. Thirty-five subjects were in Killip class III or IV at time of presentation, 78 had multivessel coronary artery disease, and mean ejection fraction was 0.40 +/- 0.12%. In-hospital mortality was 19% and was significantly higher in patients with shock (58% vs 10%, p <0.001). Survival rate after 6 months was 68%: 16% in those with Killip class IV at admission and 81% in the remaining patients (p <0.001). Cox regression analysis identified 3 independent predictors of 6-month mortality: cardiogenic shock at presentation (hazard ratio [HR] 10.82, 95% confidence interval [CI] 4.51 to 25.93, p <0.001), Thrombolysis In Myocardial Infarction myocardial flow after percutaneous coronary intervention (HR 0.19, 95% CI 0.07 to 0.50, p = 0.001), and abciximab administration (HR 0.32, 95% CI 0.13 to 0.78, p = 0.01). In conclusion, the results of this multicenter study suggest that selected nonagenarians with acute myocardial infarction benefit from successful primary angioplasty. The treatment does not affect the poor prognosis of patients presenting with cardiogenic shock, but the administration of abciximab seems to have a positive effect on 6-month mortality.
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Affiliation(s)
- Gian Battista Danzi
- Divisione di Cardiologia, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy.
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73
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Sung LC, Wang JH. A Very Elderly Woman Experiencing Two Episodes of Acute Myocardial Infarction Treated by Percutaneous Coronary Intervention: A Case Report and Literature Review. INT J GERONTOL 2010. [DOI: 10.1016/s1873-9598(10)70039-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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74
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Abstract
The elderly population (age > or =65 years) is increasing, and with it the prevalence of heart failure and associated morbidity, hospitalizations and costs. Despite advances, clinical trial data on heart failure therapy exclusively for elderly patients are lacking. However, trials of therapy for heart failure with left ventricular systolic dysfunction or low ejection fraction in primarily non-elderly patients showed mortality benefit in elderly patients. By contrast, trials for heart failure with normal left ventricular systolic function or preserved ejection fraction have not shown mortality benefit in elderly or non-elderly patients. Heart failure pharmacotherapy in the elderly is challenging; it needs to be individualized and consider aging-specific changes in physiology, drug metabolism, drug pharmacokinetics and tolerance, comorbidities, polypharmacy and drug-drug interactions that can contribute to adverse effects. More research into the biology of aging and clinical trials in elderly patients may lead to the discovery of new therapies for heart failure in the elderly.
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Affiliation(s)
- Bodh I Jugdutt
- 2C2 W.C. Mackenzie Health Sciences Centre, Division of Cardiology, Department of Medicine, University of Alberta and Hospitals, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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Pagé M, Doucet M, Eisenberg MJ, Behlouli H, Pilote L. Temporal trends in revascularization and outcomes after acute myocardial infarction among the very elderly. CMAJ 2010; 182:1415-20. [PMID: 20682731 DOI: 10.1503/cmaj.092053] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Few data are available on time-related changes in use and outcomes of invasive procedures after acute myocardial infarction in very elderly patients. Our objective was to describe trends in revascularization procedures and outcomes in a provincial cohort of very elderly patients who had experienced acute myocardial infarction. METHODS We used a database of hospital discharge summaries to identify all patients aged 80 years or older admitted for acute myocardial infarction in Quebec. We used the provincial database of physicians' services and medication claims to assess treatment and obtain data on survival. RESULTS Between March 1996 and March 2007, 29 750 patients aged 80 years or older were admitted to hospital for acute myocardial infarction. During this period, use of percutaneous coronary interventions increased from 2.2% to 24.9%, and use of coronary artery bypass graft surgery increased from 0.8% to 3.1%. Evidence-based prescriptions of medication increased over time (p < 0.001). The prevalence of reported comorbidities was higher during the period of 2003-2006 than during the 1996-1999 period. One-year mortality improved over time (46.5% for 1996-1999 v. 40.9% for 2003-2006, p < 0.001) but remained unchanged in the subgroup of patients who did not undergo revascularization. INTERPRETATION The use of revascularization, especially percutaneous coronary interventions, in the very elderly after acute myocardial infarction has been growing at a rapid pace, while the prevalence of reported comorbidities has been increasing in this population. Revascularization procedures are no longer restricted to younger patients. In the context of an aging population, it is imperative to determine whether these changes in practice are cost-effective.
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Affiliation(s)
- Maude Pagé
- Division of Cardiology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Que.
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76
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de Boer SPM, Westerhout CM, Simes RJ, Granger CB, Zijlstra F, Boersma E. Mortality and morbidity reduction by primary percutaneous coronary intervention is independent of the patient's age. JACC Cardiovasc Interv 2010; 3:324-31. [PMID: 20298993 DOI: 10.1016/j.jcin.2009.11.022] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 11/30/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to obtain a valid estimate of the clinical effects of primary percutaneous coronary intervention (PPCI) in relation to age. BACKGROUND Treatment with PPCI is most beneficial in high-risk myocardial infarction patients. Paradoxically, elderly patients, who are at increased risk of adverse outcome, are often withheld PPCI. METHODS Individual patient data were obtained from 22 randomized trials (n = 6,763) evaluating the clinical effects of PPCI versus fibrinolysis (FL). Differences in 30-day death, repeat myocardial infarction, and stroke between patients randomized to FL and PPCI were determined in 5 age-strata: < or =50, >50 to 60, >60 to 70, >70 to 80, and >80 years. Treatment effects are reported as odds ratios (ORs) and 95% confidence intervals (CI). Multivariable logistic regression analyses, which included age x treatment interaction, were applied to examine evidence of heterogeneity in age-specific ORs. RESULTS Thirty-day death increased with increasing age and ranged from 1.1% (FL) and 1.8% (PPCI) in patients < or =50 years to 26.4% and 18.3% in patients >80 years of age. The point estimate of treatment effect (overall adjusted OR: 0.65; 95% CI: 0.52 to 0.79) was compatible with a mortality reduction favoring PPCI in all age-strata (except in patients < or =50 years of age), and 95% CIs were largely overlapping. There was no evidence of heterogeneity in ORs between age categories. Similar results were observed for repeat myocardial infarction and stroke. CONCLUSIONS In this analysis of randomized trials, the reduction in clinical end points by PPCI was not influenced by age. Hence, age per se should not be considered an exclusion criterion for the application of PPCI.
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Affiliation(s)
- Sanneke P M de Boer
- Clinical Epidemiology Unit, Thoraxcenter Cardiology, Erasmus Medical Center, 's Gravendijkwal 230, Rotterdam, the Netherlands
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78
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Shelton RJ, Crean AM, Somers K, Priestley C, Hague C, Blaxill JM, Wheatcroft SB, McLenachan JM, Greenwood JP, Blackman DJ. Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service. Am Heart J 2010; 159:956-63. [PMID: 20569706 DOI: 10.1016/j.ahj.2010.02.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 02/24/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged > or =80 before and after the introduction of routine 24/7 PPCI. METHODS Retrospective observational analysis of all patients aged > or =80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis. RESULTS Two hundred fifty-six STEMI patients aged > or =80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis. CONCLUSIONS Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.
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79
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Lee CH, Tai BC, Low AF, Teo SG, Lim YT, Tan HC. Angiographic no-reflow and six-month mortality in elderly (>/= 75 years old) Asian patients undergoing primary percutaneous coronary intervention: A single center experience from 1998 to 2007. ACUTE CARDIAC CARE 2010; 12:63-9. [PMID: 20443652 DOI: 10.3109/17482941003732733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND We sought to report the incidence of angiographic no-reflow and clinical outcomes of elderly patients who have undergone primary percutaneous coronary intervention at a tertiary institution in Singapore over a period of 10 years. METHODS A total of 141 patients (60% male) aged 75 or above underwent primary PCI between 1998 and 2007. Their average age was 80+/-5 years. Cardiogenic shock complicating STEMI on presentation accounted for 15% of the patients. RESULTS At baseline, 103 (73%) patients have impaired TIMI flow grade (TIMI 0-2), and 38 (27%) have normal flow (TIMI 3). At the end of the procedure, 44 (31.2%) patients had no-reflow phenomenon (TIMI 0-2), whereas 97 (68.8%) achieved normal antegrade flow. Post-procedure corrected TIMI frame count was analyzable in 66% (n=93) of the patients. Post-procedure corrected TIMI frame count was>28 in 37.6% (n=35) of patients. In-hospital, 30-day and six-month mortalities were 20.6, 25.5% and 27.7%, respectively. Multivariable analysis showed that age 80 or above, low systolic blood pressure and final TIMI 0-2 flow independently predicted six-month mortality. CONCLUSIONS We found that one-third of the treated patients developed no-reflow phenomenon. Six-month mortality was 27.7%, most were cardiac deaths that occurred during index hospitalization.
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Affiliation(s)
- Chi-Hang Lee
- Department of Medicine, National University of Singapore, Singapore.
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80
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de Boer MJ, Ottervanger JP, Suryapranata H, Hoorntje JCA, Dambrink JHE, Gosselink ATM, van't Hof AWJ, Zijlstra F. Old age and outcome after primary angioplasty for acute myocardial infarction. J Am Geriatr Soc 2010; 58:867-72. [PMID: 20406318 DOI: 10.1111/j.1532-5415.2010.02821.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the influence of age as an independent factor determining the prognosis and outcome of patients with acute myocardial infarction (AMI) treated using primary percutaneous coronary intervention (PCI). DESIGN A retrospective analysis from a dedicated database. SETTING A high-volume interventional cardiology center in the Netherlands. PARTICIPANTS Four thousand nine hundred thirty-three consecutive patients with AMI. MEASUREMENTS Baseline characteristics and clinical outcomes after 30 days and 1 year were compared according to age categorized in three groups: younger than 65, 65 to 74, and 75 and older. A more-detailed analysis was performed with six age groups, from younger than 40 to 80 and older. RESULTS Of the 4,933 consecutive patients with AMI treated with PCI between 1992 and 2004, 643 were aged 75 and older. Multivariate analysis revealed that patients aged 65 to 75 had a greater risk of 1-year mortality than those younger than 65 (adjusted odds ratio (AOR)=1.57, 95% confidence interval (CI)=1.15-2.16) and that those aged 75 and older had a greater risk of 1-year mortality than those younger than 65 (AOR=3.03, 95% CI=2.14-4.29). CONCLUSION In this retrospective analysis, older age was independently associated with greater mortality after PCI for AMI. Patients aged 65 and older had a higher risk of mortality than younger patients, and those aged 75 and older had the highest risk of mortality.
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Affiliation(s)
- Menko-Jan de Boer
- Department of Cardiology, Isala Klinieken, Locatie Weezenlanden, Zwolle, the Netherlands.
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81
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Tratamiento de revascularización en fase aguda del infarto de miocardio con elevación del segmento ST en mujeres ancianas: eficacia en la reducción de su mortalidad. Med Clin (Barc) 2010; 134:333-9. [DOI: 10.1016/j.medcli.2009.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 07/08/2009] [Indexed: 11/21/2022]
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Jokhadar M, Wenger NK. Review of the treatment of acute coronary syndrome in elderly patients. Clin Interv Aging 2009; 4:435-44. [PMID: 19966912 PMCID: PMC2785867 DOI: 10.2147/cia.s3035] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2009] [Indexed: 11/23/2022] Open
Abstract
Advances in treatment and early revascularization have led to improved outcomes for patients with acute coronary syndrome (ACS). However, elderly ACS patients are less likely to receive evidence-based treatment, including revascularization therapy, due to uncertainty of the associated benefits and risks in this population. This article addresses key issues regarding medical and revascularization therapy in elderly ACS patients based on a review of the medical literature and in concordance with clinical practice guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).
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Affiliation(s)
- Maan Jokhadar
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
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83
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De Luca G, Cassetti E, Marino P. Percutaneous coronary intervention–related time delay, patient's risk profile, and survival benefits of primary angioplasty vs lytic therapy in ST-segment elevation myocardial infarction. Am J Emerg Med 2009; 27:712-9. [DOI: 10.1016/j.ajem.2008.04.026] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Revised: 04/09/2008] [Accepted: 04/20/2008] [Indexed: 11/25/2022] Open
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Huynh T, Perron S, O'Loughlin J, Joseph L, Labrecque M, Tu JV, Théroux P. Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction. Circulation 2009; 119:3101-9. [PMID: 19506117 DOI: 10.1161/circulationaha.108.793745] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.
Methods and Results—
We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.
Conclusions—
Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.
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Affiliation(s)
- Thao Huynh
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Stephane Perron
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jennifer O'Loughlin
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Lawrence Joseph
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Michel Labrecque
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Jack V. Tu
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
| | - Pierre Théroux
- From the McGill Health University Center (T.H.) and Department of Epidemiology and Biostatistics (L.J.), McGill University, Montreal; Direction of Public Health of Montreal (S.P.), Department of Social and Preventive Medicine (J.O.), and Montreal Heart Institute (P.T.), University of Montreal, Montreal; Department of Family Medicine, Laval University, Quebec (M.L.); and Institute for Clinical Evaluative Sciences, University of Toronto, Toronto (J.V.T.), Canada
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Luo Y, Li GL, Pan YZ, Zhou SF. Determinants and prognostic implications of reperfusion injury during primary percutaneous coronary intervention in Chinese patients with acute myocardial infarction. Clin Cardiol 2009; 32:148-53. [PMID: 19301290 DOI: 10.1002/clc.20294] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The poor clinical outcome in acute myocardial infarction (AMI) patients undergoing primary percutaneous coronary intervention (PCI) has been attributed to myocardial ischemia-reperfusion injury (MIRI). OBJECTIVE This study aimed to identify the predictive factors of MIRI during PCI in Chinese AMI patients with or without ST-segment elevation. METHODS Clinical and angiographic data of 228 patients in whom the infarct-related artery (IRA) was successfully recanalized by primary PCI were retrospectively analyzed. Multiple logistic regressions were used. RESULTS Compared with non-MIRI group (n=109), patients with MIRI (n=119) were characterized by more inferior infarct location, shorter ischemic duration, more frequently right coronary artery as IRA, more lesion vessels, more often thrombolysis in myocardial infarction (TIMI) 0 flow in IRA prior to PCI, less preinfarction angina, and more renal insufficiency. Ischemic time<or=6 hours (p=0.014), inferior infarct location (p=0.006), and initial antegrade flow in IRA<or=TIMI grade 1 (p=0.028) were independent risk factors for MIRI. Other risk factors included multivessel lesions (p=0.063) and renal insufficiency (p=0.067). Only preinfarction angina was a protective factor (p=0.005). CONCLUSIONS The factors promoting MIRI during primary PCI includes short ischemic time from AMI onset to IRA recanalization, inferior infarct location, low IRA antegrade flow prior to PCI, multivessel lesions, and renal insufficiency, whereas preinfarction angina is a protective factor attenuating MIRI.
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Affiliation(s)
- Yi Luo
- Department of Cardiology, Guangzhou First People's Hospital Affiliated to Guangzhou Medical College, Guangdong, China.
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86
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Rasoul S, Ottervanger JP, de Boer MJ, Dambrink JHE, Hoorntje JC, Gosselink AM, Zijlstra F, Suryapranata H, van 't Hof AW. Primary percutaneous coronary intervention for ST-elevation myocardial infarction: From clinical trial to clinical practice. Int J Cardiol 2009; 134:104-9. [DOI: 10.1016/j.ijcard.2008.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 01/07/2008] [Accepted: 01/20/2008] [Indexed: 11/30/2022]
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87
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In-hospital outcomes of emergent and elective percutaneous coronary intervention in octogenarians. Coron Artery Dis 2009; 20:118-23. [DOI: 10.1097/mca.0b013e3283292ae1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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88
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Multidecade-long trends (1986-2005) in the utilization of coronary reperfusion and revascularization treatment strategies in patients hospitalized with acute myocardial infarction: a community-wide perspective. Coron Artery Dis 2009; 20:71-80. [PMID: 19050597 DOI: 10.1097/mca.0b013e32831bb4aa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of our community-wide investigation were to describe multidecade-long trends (1986-2005) in the utilization of thrombolytic therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery in patients hospitalized with acute myocardial infarction (AMI). METHODS The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 11 annual periods between 1986 and 2005. RESULTS Increases in the utilization of percutaneous coronary interventions were observed between 1986 (2.0%) and 2005 (50.7%) with the most rapid increases beginning in the late 1990s. Utilization of coronary artery bypass graft surgery during hospitalization for AMI increased moderately in the 1990s, remained stable thereafter, and declined to being performed in 3.8% of hospitalized patients in 2005. The use of thrombolytic therapy increased between 1986 and 1995 (9.3-25.2%) and decreased markedly thereafter through 2005 (<1%). Demographic and clinical characteristics of several patients were associated with the receipt of these treatment regimens. CONCLUSION The results of this study in residents of a large Central New England community suggest an increasingly invasive approach to the management of patients hospitalized with AMI.
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90
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De Luca L, Bolognese L, Casella G, Savonitto S, Gonzini L, Di Chiara A, De Servi S, Notaristefano S, Valagussa L, Maggioni AP, Chiarella F. Modalities of treatment and 30-day outcomes of unselected patients older than 75 years with acute ST-elevation myocardial infarction: data from the BLITZ study. J Cardiovasc Med (Hagerstown) 2008; 9:1045-51. [DOI: 10.2459/jcm.0b013e32830eb6eb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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91
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Effect of time to treatment and age on one year mortality in acute STEMI: difference between thrombolysis and primary percutaneous coronary intervention. Arch Cardiovasc Dis 2008; 101:48-54. [PMID: 18391873 DOI: 10.1016/s1875-2136(08)70255-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
CONTEXT Although thrombolysis (THL) and primary percutaneous coronary intervention (PPCI) are two validated options in reperfusion algorithms for ST-elevation myocardial infarction (STEMI), recent papers seems to show that PPCI could be the best therapeutic option irrespective of the time to treatment (TT) and of the cardiovascular risk profile of the patient. The impact of TT and age on reperfusion strategies requires elucidation. The aim of this study was to analyze the effect of time to treatment and age on the 1-year mortality of patients presenting with STEMI, for each reperfusion strategy. MATERIALS AND METHODS The study population consisted in 794 patients directly admitted to the cardiological intensive care unit for STEMI < or =12 hours. The relationship between TT and 1-year mortality was studied using logistic regression models. The models were implemented on the overall population and on 3 different age groups: [<65 years]; [> or =65 and <75 years]; [> or =75 years] for patients undergoing THL (n=299) and for patients undergoing PPCI (n=495). There was no significant between-group difference in all-cause 1-year mortality for the patients [<65 years] and those [> or =65 and <75 years]. In contrast, the 1-year mortality was significantly higher in the patients [> or =75 years] undergoing THL (51.4 vs. 15.3%; p<0.001). The analysis of the curves of mortality suggests that 1- year mortality of patients with STEMI depend not only on reperfusion strategy but so on the time to treatment and on the age of the patients. CONCLUSION In STEMI, on a 1-year mortality criteria, PPCI is not always upper than THL, particularly for patients<65 years treated within the first two hours after symptoms onset. TT and age affects the results of the reperfusion strategies and must be still incorporated in the reperfusion algorithms of STEMI.
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Reperfusion Strategies in Acute ST-Elevation Myocardial Infarction: An Overview of Current Status. Prog Cardiovasc Dis 2008; 50:352-82. [DOI: 10.1016/j.pcad.2007.11.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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93
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Liistro F, Angioli P, Ducci K, Falsini G, Baldassarre S, Brandini R, Bolognese L. Transfer for primary angioplasty in elderly patients with acute myocardial infarction. ACUTE CARDIAC CARE 2008; 10:152-158. [PMID: 18608033 DOI: 10.1080/17482940802084986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION The aim of this study was the evaluation of an immediate transfer for primary angioplasty (PPCI) in elderly (age > or = 75 years) patients with ST elevation acute myocardial infarction (STEMI). METHODS AND MATERIALS All elderly patients with STEMI admitted for PPCI from June 2002 to October 2005, were enrolled. Major Adverse Cardiac Events (MACE) were collected at 6 months. RESULTS 133 patients (group 1) were admitted directly and 154 patients (group 2) were transferred from peripheral hospitals. Ischemia time was 248 +/- 146 min in group 1 and 276 +/- 169 min in group two (P<0.001); door-to-balloon time was 60+/-30 min in group 1 and 90+/-45 min in group two (P<0.0001). At 6 months cardiac death occurred in 15 (11%) and 16 (10%) patients in group 1 and 2 respectively (P=NS), MI in 3(2%) and 2(1%) respectively (P=NS), clinically driven target lesion revascularization in 6(4%) and 5(3%) respectively, for an overall event-free survival rate of 82% in group 1 and 83% in group 2 (P=NS). Logistic regression analysis showed age (OR: 1.04.1; 95% CI: 1.0-1.2; P=0.049) Killip class > or = 2 (OR: 4.6; 95% CI: 1.3-16.4; P=0.01) to be the only independent predictors of 6-month cardiac mortality. CONCLUSION Systematic transfer of elderly STEMI patients for PPCI, with a door-to-balloon time <1 h, leads to clinical results similar to those achievable in patients who present directly in hospital with cath.-lab. facilities.
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Affiliation(s)
- Francesco Liistro
- Department of Cardiovascular Disease, San Donato Hospital, Arezzo, Italy.
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94
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Acute Coronary Syndromes and Acute Myocardial Infarction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50033-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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95
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Jacquemin L, Dezfouli MH, El Belghiti R, Roth O, Calatan A, Levy J, Monassier JP. [Acute myocardial infarction in octogenarians treated by primary coronary angioplasty: in hospital outcome, social evolution and long-term mortality. About a forty-seven consecutive patients study]. Ann Cardiol Angeiol (Paris) 2007; 56:194-200. [PMID: 17920560 DOI: 10.1016/j.ancard.2007.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Accepted: 08/27/2007] [Indexed: 10/22/2022]
Abstract
This study evaluated the hospital outcome of octogenarian patients treated by primary angioplasty for acute myocardial infarction less than 12 hours. The long-term mortality and social outcome were evaluated, social outcome was based on IADL and IADL-E scales corresponding to physical autonomy and level of dependence. We included from 1999 to 2005 47 old patients of 83.5+/-3.2 years. The reperfusion of the obstructed coronary artery was obtained in 45 patients (95.7%) with TIMI 3 flow. Hospital mortality was 25.5% and 4.2% without hemodynamic complication. A multivariate analysis identified a Killip score>1 as predictive factor of hospital mortality (OR=8.9 and p=0.05). The long-term survival without death with a follow-up of 26.3+/-18.3 months was 82.2% at 24 months and 70.6% at 48 months according to the Kaplan-Meier method. In an multivariate analysis, hospitalization exit without aspirine was associated with a higher long term mortality (OR=34.8 and p=0.04). According to the evolution of scores of IADL and IADL-E scales, patients had an excellent autonomy and good capacities before the infarction and they kept them on the long term. Thus octogenarians with acute myocardial infarction treated by primary angioplasty have a high in hospital and long term mortality but the survivors preserve an excellent daily autonomy.
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Affiliation(s)
- L Jacquemin
- Service de cardiologie, centre hospitalier Emile-Muller, 20, rue du Docteur-Laennec, BP 1370, 68070 Mulhouse, France.
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96
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Asseburg C, Vergel YB, Palmer S, Fenwick E, de Belder M, Abrams KR, Sculpher M. Assessing the effectiveness of primary angioplasty compared with thrombolysis and its relationship to time delay: a Bayesian evidence synthesis. Heart 2007; 93:1244-50. [PMID: 17277350 PMCID: PMC2000960 DOI: 10.1136/hrt.2006.093336] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2006] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Meta-analyses of trials have shown greater benefits from angioplasty than thrombolysis after an acute myocardial infarction, but the time delay in initiating angioplasty needs to be considered. OBJECTIVE To extend earlier meta-analyses by considering 1- and 6-month outcome data for both forms of reperfusion. To use Bayesian statistical methods to quantify the uncertainty associated with the estimated relationships. METHODS A systematic review and meta-analysis published in 2003 was updated. Data on key clinical outcomes and the difference between time-to-balloon and time-to-needle were independently extracted by two researchers. Bayesian statistical methods were used to synthesise evidence despite differences between reported follow-up times and outcomes. Outcomes are presented as absolute probabilities of specific events and odds ratios (ORs; with 95% credible intervals (CrI)) as a function of the additional time delay associated with angioplasty. RESULTS 22 studies were included in the meta-analysis, with 3760 and 3758 patients randomised to primary angioplasty and thrombolysis, respectively. The mean (SE) angioplasty-related time delay (over and above time to thrombolysis) was 54.3 (2.2) minutes. For this delay, mean event probabilities were lower for primary angioplasty for all outcomes. Mortality within 1 month was 4.5% after angioplasty and 6.4% after thrombolysis (OR = 0.68 (95% CrI 0.46 to 1.01)). For non-fatal reinfarction, OR = 0.32 (95% CrI 0.20 to 0.51); for non-fatal stroke OR = 0.24 (95% CrI 0.11 to 0.50). For all outcomes, the benefit of angioplasty decreased with longer delay from initiation. CONCLUSIONS The benefit of primary angioplasty, over thrombolysis, depends on the former's additional time delay. For delays of 30-90 minutes, angioplasty is superior for 1-month fatal and non-fatal outcomes. For delays of around 90 minutes thrombolysis may be the preferred option as assessed by 6-month mortality; there is considerable uncertainty for longer time delays.
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97
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de Labriolle A, Giraudeau B, Pacouret G, Desveaux B, Quilliet L, Charbonnier B, Fauchier L. Revascularization algorithm in acute STEMI should take into account age. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:90-3. [PMID: 17574166 DOI: 10.1016/j.carrev.2006.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 12/12/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the elderly patients, the optimal reperfusion strategy of acute ST-segment elevation myocardial infarction (STEMI) remains a topic of debate. Moreover, there is a lack of data regarding the effect of time to treatment (TT) on prognosis of STEMI in elderly patients. PURPOSE The goal of our work was to analyze, in real life, the link between TT and 1-year mortality in patients with STEMI (> or =75 years) who were treated with thrombolysis (THL) or primary percutaneous coronary intervention (PCI). METHODS AND MATERIALS Data were extracted from our university hospital prospective registry. Between 1995 and 2005, all patients who met the criteria (> or =75 years old, has had an acute STEMI <12 h, has been admitted directly into our cardiologic care unit, and has had a revascularization procedure) were included in the analysis. Using logistic regression, we studied the relation between TT and 1-year mortality for each strategy of reperfusion in patients with STEMI who were > or =75 years old. RESULTS One hundred fifty-nine consecutive patients with STEMI <12 h were analyzed; 35 were treated with THL and 124 were treated with primary PCI. Mean age (+/-S.D.) was 80+/-4 years, and 56% of patients were men. In logistic regression analysis, TT was not associated to death after THL (P=.81), while it was positively correlated after PCI (P=.03). All-cause 1-year mortality was markedly higher in the THL group than in the PCI group (51.4% vs. 15.3%; P<.001). CONCLUSION Our work suggests that the extrapolation of algorithm of revascularization used in younger patients is not appropriate for elderly patients. Specific algorithm of revascularization and recommendations are needed in elderly patients.
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Affiliation(s)
- Axel de Labriolle
- Département de Cardiologie, Centre Hospitalier Universitaire Tours, Tours, France.
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98
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Klein LW. Optimal revascularization strategies for ST-segment elevation myocardial infarction in the elderly patient. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2007; 16:295-303. [PMID: 17786059 DOI: 10.1111/j.1076-7460.2007.07328.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Patients older than 75 years account for >60% of all deaths from acute myocardial infarction. Although there are accepted guidelines for treatment of acute ST-segment elevation myocardial infarction, elderly patients tend to have a variety of conditions that can complicate decisions about the best therapy. Many elderly patients do not receive potentially lifesaving treatments, such as percutaneous coronary intervention or thrombolytic therapy, for fear of an adverse event. Those who do receive appropriate revascularization therapy often receive it later in the course of the infarct, when irreversible damage has occurred. Yet studies show that patients older than 75 years will benefit substantially from these therapies. Early treatment improves outcomes in this population, as in younger patients, despite a higher risk of complications. In this review, the evidence regarding medical and revascularization therapies in ST-segment elevation myocardial infarction is critically examined.
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99
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Hirakawa Y, Masuda Y, Kuzuya M, Kimata T, Iguchi A, Uemura K. Factors associated with use of percutaneous coronary intervention among very elderly patients with acute myocardial infarction: Lessons from the Tokai Acute Myocardial Infarction Study (TAMIS). Geriatr Gerontol Int 2007. [DOI: 10.1111/j.1447-0594.2007.00408.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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100
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Cucherat M, Bonnefoy E, Tremeau G. WITHDRAWN: Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction. Cochrane Database Syst Rev 2007; 2003:CD001560. [PMID: 17636680 PMCID: PMC6413765 DOI: 10.1002/14651858.cd001560.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous thrombolytic therapy is the standard care for patients with acute myocardial infarction, based upon its widespread availability and ability to reduce patient mortality well demonstrated in randomised trials. Despite its proven efficacy, thrombolytic therapy has limitations. Many patients are ineligible for treatment with thrombolytics. Of those given thrombolytic therapy, 10 to 15 percent have persistent occlusion or reocclusion of the infarct-related artery. Consequently, primary angioplasty (primary PTCA) has been advocated as a better treatment of myocardial infarction. OBJECTIVES To determine whether primary coronary angioplasty is superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction. SEARCH STRATEGY Electronic search of The Cochrane Library (1998; Issue 2). MEDLINE (to January 1998); references from reviews, trials and previously published meta-analyses; and experts. Date of most recent searches January 1998. SELECTION CRITERIA All unconfounded, randomised controlled trials comparing primary angioplasty against intravenous thrombolysis in patients with acute myocardial infarction DATA COLLECTION AND ANALYSIS At least two independent reviewers abstracted data on morbidity and mortality and trial characteristics. The following outcomes were assessed: total mortality at the end of the study, reinfarction, stroke of any type, composite endpoint of death and reinfarction, recurrent ischemia, severe bleeding and coronary artery bypass grafting. MAIN RESULTS Ten trials including 2573 subjects were identified. Compared to thrombolytic therapy, primary angioplasty was associated with a significant reduction in short-term mortality at the end of the studies (relative reduction in risk RRR = 32% 95%CI = 5%;50%). Similar reductions were observed for the rate of reinfarction (RRR = 52%, 95%CI = 30%;67%), recurrent ischemia (RRR = 54%; 95%CI = 39%,66%) and for the combined criteria death or reinfarction (RRR = 46%; 95%CI=30%;58%). The frequency of strokes of any cause was significantly decreased by 66% (95%CI=28%;84%). No significant difference was observed for the incidence of major bleeding (relative risk RR =1.18, 95%CI = 0.73;1.90) but the confidence interval was large. The superiority of the primary angioplasty over thrombolysis in terms of the composite endpoint (mortality and reinfarction) was less with accelerated t-PA (RR=0.70, 95%CI=0.51;0.97) than with streptokinase (RR=0.30, 95%CI=0.17;0.53). The biggest and most recent trial, Gusto 2B (GUSTO-2B 97), which involved general as well as highly specialised centres, obtained less favorable results. AUTHORS' CONCLUSIONS This meta-analysis suggests that angioplasty provides a short-term clinical advantage over thrombolysis which may not be sustained. Primary angioplasty when available promptly at experienced centres, may be considered the preferred strategy for myocardial reperfusion. In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy.
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Affiliation(s)
- M Cucherat
- Cardiovascular Hospital, Dept of Clinical Pharmacology, 162, Av. Lacassagne, Lyon, France, 69003.
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