Age-related differences in treatment strategies and clinical outcomes in unselected cohort of patients with ST-segment elevation myocardial infarction transferred for primary angioplasty

Age-associated declined function of endothelial progenitor cells and its correlation with plasma IL-18 or IL-23 concentrations in patients with ST-segment elevation myocardial infarction

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) persists to be prevalent in the elderly with a dismal prognosis. The capacity of endothelial progenitor cells (EPCs) is reduced with aging. Nevertheless, the influence of aging on the functionality of EPCs in STEMI is not fully understood.

METHOD

This study enrolled 20 younger STEMI patients and 21 older STEMI patients. We assessed the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events Risk (GRACE) scores in two groups. Then, we detected EPC migration, proliferation, adhesion, and plasma interleukin (IL)-18 and IL-23 concentrations in two groups. In addition, we analyzed the interconnection between age, EPC function, plasma IL-18 and IL-23 concentrations, and GRACE or TIMI scores in STEMI patients.

RESULT

GRACE and TIMI scores in older STEMI patients were higher than in younger STEMI patients, whereas EPC function declined. GRACE and TIMI scores were found to have an inverse relationship with the EPC function. In older STEMI patients, plasma concentrations of IL-18 and IL-23 increased. Plasma IL-18 and IL-23 concentrations were adversely connected to EPC capacity and positively related to GRACE and TIMI scores. Moreover, age was positively correlated with plasma IL-18 or IL-23 concentrations, as well as GRACE or TIMI scores. However, age was adversely correlated with EPC function.

CONCLUSION

In patients with STEMI, aging results in declined EPC function, which may be associated with inflammatory cytokines. The current investigation may offer new perception about mechanism and therapeutic targets of aging STEMI.

Invasive versus Conservative Treatment Approach among Older Adult Patients Admitted with Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the preferred treatment strategy for patients with ST-elevation myocardial infarction (STEMI); however, its efficacy remains unclear in very older adult patients with STEMI.

METHODS

This retrospective single-center observational study included 530 patients aged >75 years admitted to Tel Aviv Sourasky Medical Center with a diagnosis of acute STEMI. Primary PCI was performed for patients with symptoms ≤12 hours in duration, while the other patients were conservatively treated. We evaluated 30-day mortality and complications occurring during hospitalization based on data from patient records.

RESULTS

Among the study patients, only 28/530 (5%) were conservatively treated. In-hospital complications, including the use of inotropes or intra-aortic balloon counterpulsation and the need for mechanical ventilation, did not differ significantly between the groups. The only parameter that showed a trend toward significance was the incidence of heart failure during hospitalization (p=0.042). The risk for 30-day mortality was substantially higher in the conservative treatment group than in the invasive treatment group (27% vs. 10%; p = 0.02).

CONCLUSION

Our data suggested that despite concerns regarding the safety of the primary PCI strategy in the older adult STEMI population, this treatment strategy was associated with a survival benefit.

Management of acute coronary syndromes in older adults

Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.

Effect of Age on Clinical Outcomes in Elderly Patients (>80 Years) Undergoing Percutaneous Coronary Intervention: Insights From a Multi-Centre Australian PCI Registry

OBJECTIVES

To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes.

METHODS

We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort).

RESULTS

The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age ≥80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001).

CONCLUSION

The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.

Percutaneous coronary intervention of unprotected left main and bifurcation in octogenarians: Subanalysis from RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life)

OBJECTIVE

Outcomes of complex percutaneous coronary interventions (PCIs) in older patients are still debated. The aim of the study was to evaluate clinical outcomes of Octogenarian patients treated with ultrathinstents on left main or on coronary bifurcations, compared with younger patients.

METHODS

All consecutive patients presenting a critical lesion of an unprotected left main (ULM) or a bifurcation and treated with very thin stents were included in the RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry and divided into octogenarians group (OG, 551 patients) and nonoctogenarians (NOGs, 2,453 patients). Major adverse cardiovascular event (MACE), a composite end point of all-cause death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST), was the primary endpoint, while MACE components, cardiovascular (CV) death, and target vessel revascularization (TVR) were the secondary ones.

RESULTS

Indication for PCI was acute coronary syndrome in 64.7% of the OG versus 53.1% of the NOG. Severe calcifications and a diffuse disease were significantly more in OG. After a follow-up of 15.2 ± 10.3 months, MACEs were higher in the OG than in the NOG patients (OG 19.1% vs. NOG 11.2%, p < .001), along with MI (OG 6% vs. NOG 3.4%, p = .002) and all-cause death (OG 14% vs. NOG 4.3%, p < .001). In contrast, no significant difference was detected in CV-death (OG 5.1% vs. NOG 4%, p = .871), TVR/TLR, or ST. At multivariate analysis, age was not an independent predictor of MACE (OR 1.02 CI 95% 0.76-1.38), while it was for all-cause death, along with diabetes, GFR < 60 ml/min, and ULM disease.

DISCUSSION

Midterm outcomes of complex PCI in OG are similar to those of younger patients. However, due to the higher non-CV death rate, accurate patient selection is mandatory.

Clinical outcomes in nonagenarians undergoing a percutaneous coronary intervention: data from the ORPKI Polish National Registry 2014-2016

BACKGROUND

Despite an increase in the proportion of nonagenarians in demographic structure, there is still a paucity of data on the utilization and outcome of percutaneous coronary interventions (PCIs) in this population. Also, very old patients are under-represented in randomized clinical trials and their treatment is still an emerging challenge. Thus, we sought to compare patient profiles and periprocedural outcomes of PCI in nonagenarians and patients younger than 90 years.

PATIENTS AND METHODS

Data were based on the Polish National Registry of PCI (ORPKI). A total of 651 080 consecutive patients with stable angina (SA) (n=260 920) or acute coronary syndrome (ACS) (n=390 160) undergoing PCI with at least one stent implanted were included. Patients were stratified according to age (<90 and ≥90 years).

RESULTS

Of all included patients, 4413 (0.7%) were older than or equal to 90 years. A similar rate of periprocedural complications was observed in both groups. However, cardiac arrest during both angiography and PCI occurred more often in nonagenarians (0.21 vs. 0.83%; 0.42 vs. 1.07%, respectively, for both P=0.001). Similarly, periprocedural mortality was higher in patients older than or equal to 90 years (0.27 vs. 1.88%; P=0.001). There were no differences in periprocedural outcomes between groups in the SA setting. However, a higher rate of periprocedural cardiac arrest [1971 (0.51%) vs. 43 (1.15%); P=0.001] and mortality [1622 (0.42%) vs. 83 (2.2%); P=0.001] were observed in nonagenarians compared with younger counterparts admitted with ACS.

CONCLUSION

Nonagenarians undergoing PCI because of SA may have similar outcomes as patients younger than 90 years. In ACS presentation, they may have worse outcomes than younger counterparts.

Comparison of epidemiology, treatments and outcomes of ST segment elevation myocardial infarction between young and elderly patients

BACKGROUND

With an ageing population, there is a need to understand the relative risk/benefit of interventions for elderly ST segment elevation myocardial infarction (STEMI) patients. The primary aim of this study was to compare epidemiology, treatments and outcomes between young and elderly STEMI patients. Our secondary aim was to determine the cut-off age when the benefits of primary percutaneous coronary intervention (PCI) were less pronounced.

METHODS

Data were collected by the Singapore Myocardial Infarction Registry. Patients were categorised into young (age <65 years) and elderly STEMI (age ≥65 years) patients.

RESULTS

We analysed 14 006 STEMI cases collected between January 2007 and December 2014; 33.9% were elderly STEMI patients. Elderly STEMI patients had longer median door to balloon (73 vs 64 min, P<0.001) time and were less likely to receive PCI (proportion difference=-23.6%, 95% CI -25.3 to -22.0). In the absence of PCI, elderly STEMI patients had a higher mortality within 30 days (elderly: HR 1.65, 95% CI 1.36 to 1.99, P<0.001; young: HR 1.10, 95% CI 0.79 to 1.54, P=0.573) and 1 year (elderly: HR 1.83, 95% CI 1.57 to 2.14, P<0.001; young: HR 1.41, 95% CI 1.09 to 1.83, P=0.009) of admission. The 1 year survival benefit of PCI started to decline after the age of 65 years.

CONCLUSION

Elderly STEMI patients were less likely to receive PCI and had longer door to balloon times. Survival benefit of PCI decreased after the age of 65 years, with the decline most evident from age 85 years onwards. The risks of PCI need to be weighed carefully against its benefits, especially in very elderly patients.

Second-generation drug-eluting stents in the elderly patients with acute coronary syndrome: the in-hospital and 12-month follow-up of the all-comer registry

Background

Katowice–Zabrze registry provides data that can be used to evaluate clinical outcomes of percutaneous coronary interventions in elderly patients (≥70 y/o) treated with either first- (DES-I) or second-generation (DES-II) drug-eluting stents (DES).

Methods

The registry consisted of data from 1916 patients treated with coronary interventions using either DES-I or DES-II stents. For our study, we defined patients ≥70 years of age as elderly. We evaluated any major adverse cardiac and cerebral events (MACCE) at 12-month follow-up.

Results

Coronary angiography revealed a higher incidence of multivessel coronary artery disease in this elderly patient population. There were no differences in acute and subacute stent thrombosis (0.4 vs. 0.6%, p = 0.760; 0.4 vs. 0.4%; p = 0.712). Elderly patients experienced more in-hospital bleeding complications requiring blood transfusion (2.0 vs. 0.9%; p = 0.003). Resuscitated cardiac arrests (2.0 vs. 0.9%; p = 0.084) were observed more often in this elderly patients during hospitalization. The composite in-hospital MACCE rates did not differ statistically between both groups (1.4 vs. 1.1%; p = 0.567). Data from a twelve-month follow-up disclosed that mortality was higher (7.1 vs. 1.8%; p < 0.001) in the elderly, with no difference in TVR (7.2 vs. 9.9%, p = 0.075), MI (6.0 vs. 4.8%, p = 0.300), stroke (0.8 vs. 0.6%, p = 0.600) and composite MACCE (15.0 vs. 13.4%, p = 0.324). The age of 70 years or over was an independent predictor of death [HR = 2.55 (95% CI 1.49–4.37); p < 0.001]. The use of DES-II reduced the risk of MI [HR = 0.40 (95% CI 0.19–0.82); p = 0.012] in the elderly.

Conclusion

This elderly patient population had an increased risk of in-hospital bleeding complications requiring blood transfusion and a higher risk of death at 12-month follow-up. The use of new-generation DES reduced the risk of MI in the elderly population.

Primary Angioplasty in Patients Older Than 75 Years. Profile of Patients and Procedures, Outcomes, and Predictors of Prognosis in the ESTROFA IM+75 Registry

INTRODUCTION AND OBJECTIVES

The proportion of elderly patients undergoing primary angioplasty is growing. The present study describes the clinical profile, procedural characteristics, outcomes, and predictors of outcome.

METHODS

A 31-center registry of consecutive patients older than 75 years treated with primary angioplasty. Clinical and procedural data were collected, and the patients underwent clinical follow-up.

RESULTS

The study included 3576 patients (39.3% women, 48.5% with renal failure, 11.5% in Killip III or IV, and 29.8% with>6hours of chest pain). Multivessel disease was present in 55.4% and nonculprit lesions were additionally treated in 24.8%. Radial access was used in 56.4%, bivalirudin in 11.8%, thromboaspiration in 55.9%, and drug-eluting stents in 26.6%. The 1-month and 2-year incidences of cardiovascular death were 10.1% and 14.7%, respectively. The 2-year rates of definite or probable thrombosis, repeat revascularization, and BARC bleeding>2 were 3.1%, 2.3%, and 4.2%, respectively. Predictive factors were diabetes mellitus, renal failure, atrial fibrillation, delay to reperfusion>6hours, ejection fraction<45%, Killip class III-IV, radial access, bivalirudin, drug-eluting stents, final TIMI flow of III, and incomplete revascularization at discharge.

CONCLUSIONS

Notable registry findings include frequently delayed presentation and a high prevalence of adverse factors such as renal failure and multivessel disease. Positive procedure-related predictors include shorter delay, use of radial access, bivalirudin, drug-eluting stents, and complete revascularization before discharge.

Primary percutaneous coronary intervention for ST elevation myocardial infarction in nonagenarians

Objective

To assess outcomes following primary percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (STEMI) in nonagenarian patients.

Methods

We conducted a multicentre retrospective study between 2006 and 2013 in five international high-volume centres and included consecutive all-comer nonagenarians treated with primary PCI for STEMI. There were no exclusion criteria. We enrolled 145 patients and collected demographic, clinical and procedural data. Severe clinical events and mortality at 6 months and 1 year were assessed.

Results

Cardiogenic shock was present at admission in 21%. Median (IQR) delay between symptom onset and balloon was 3.7 (2.4–5.6) hours and 60% of procedures were performed through the transradial approach. Successful revascularisation of the culprit vessel was obtained in 86% of the cases (thrombolysis in myocardial infarction flow of 2 or 3). Major or clinically relevant bleeding was observed in 4% of patients. Median left ventricular ejection fraction post PCI was 41.5% (32.0–50.0). The in-hospital mortality was 24%, with 6 months and 1-year survival rates of 61% and 53%, respectively.

Conclusions

In our study, primary PCI in nonagenarians with STEMI was achieved and feasible through a transradial approach. It is associated with a high rate of reperfusion of the infarct-related artery and 53% survival at 1 year. These results suggest that primary PCI may be offered in selected nonagenarians with acute myocardial infarction.

Characteristics of ST Elevation Myocardial Infarction Patients Who Do Not Undergo Percutaneous Coronary Intervention After Prehospital Cardiac Catheterization Laboratory Activation

OBJECTIVES

To assess the clinical and electrocardiographic characteristics of patients diagnosed with ST elevation myocardial infarction (STEMI) that are associated with an increased likelihood of not undergoing percutaneous coronary intervention (PCI) after prehospital Cardiac Catheterization Laboratory activation in a regional STEMI system.

METHODS

We performed a retrospective analysis of prehospital Cardiac Catheterization Laboratory activations in Mecklenburg County, North Carolina, between May 2008 and March 2011. Data were extracted from the prehospital patient record, the prehospital electrocardiogram, and the regional STEMI database. The independent variables of interest included objective patient characteristics as well as documented cardiac history and risk factors. Analysis was performed using descriptive statistics and logistic regression.

RESULTS

Two hundred thirty-one prehospital activations were included in the analysis. Five independent variables were found to be associated with an increased likelihood of not undergoing PCI: increasing age, bundle branch block, elevated heart rate, left ventricular hypertrophy, and non-white race. The variables with the most significance were any type of bundle branch block [adjusted odds ratios (AOR), 5.66; 95% confidence interval (CI), 1.91-16.76], left ventricular hypertrophy (AOR, 4.63; 95% CI, 2.03-10.53), and non-white race (AOR, 3.53; 95% CI, 1.76-7.08). Conversely, the only variable associated with a higher likelihood of undergoing PCI was the presence of arm pain (AOR, 2.94; 95% CI, 1.36-6.25).

CONCLUSIONS

Several of the above variables are expected electrocardiogram mimics; however, the decreased rate of PCI in non-white patients highlights an area for investigation and process improvement. This may guide the development of prehospital STEMI protocols, although avoiding false positive and inappropriate activations.

Prehospital and in-hospital use of healthcare resources in patients surviving acute coronary syndromes: an analysis of the EPICOR registry

Objective

The aim of this report is to provide insight into real-world healthcare resource use (HCRU) during the critical management of patients surviving acute coronary syndromes (ACS), using data from EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) (NCT01171404).

Methods

EPICOR was a prospective, multinational, observational study that enrolled 10 568 ACS survivors from 555 hospitals in 20 countries in Europe and Latin America, between September 2010 and March 2011. HCRU was evaluated in patients with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation ACS (NSTE-ACS), with or without a history of cardiovascular disease (CVD). Multivariable analysis was performed to determine factors that affected resource use.

Results

Before hospitalisation, more patients with STEMI than with NSTE-ACS had their first ECG (44.1% vs 36.4%, p<0.0001) and received antithrombotic medication (26.6% vs 15.2%, p<0.0001). Patients with NSTE-ACS with prior CVD were less likely than those without to be catheterised (73.1% vs 82.8%, p<0.0001). More patients with STEMI than with NSTE-ACS had percutaneous coronary intervention (77.1% vs 54.9%, p<0.0001), but fewer underwent coronary artery bypass grafting (1.2% vs 3.7%, p<0.0001). Multivariable analysis showed that resource use, including length of hospital stay and coronary revascularisation, was significantly influenced by multiple factors, including ACS type, site characteristics and region (all p≤0.05).

Conclusions

In this large-scale, real-life study, findings were generally in line with clinical logic, although site characteristics and region still significantly affected resource use. Moreover, and unexpectedly, resource use tended to be slightly higher in patients without a history of CVD.

Trial registration number

NCT01171404 (ClinicalTrials.gov).

Temporal trends and in-hospital outcomes of primary percutaneous coronary intervention in nonagenarians with ST-segment elevation myocardial infarction

BACKGROUND/AIMS

Data regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in nonagenarians are very limited. The aim of the present study was to evaluate the temporal trends and in-hospital outcomes of primary PCI in nonagenarian STEMI patients.

METHODS

We retrospectively reviewed data from the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008, and from the Korea Working Group on Myocardial Infarction (KorMI) from February 2008 to May 2010.

RESULTS

During this period, the proportion of nonagenarians among STEMI patients more than doubled (0.59% in KAMIR vs. 1.35% in KorMI), and the rate of use of primary PCI also increased (from 62.5% in KAMIR to 81.0% in KorMI). We identified 84 eligible study patients for which the overall in-hospital mortality rate was 21.4% (25.0% in KAMIR vs. 20.3% in KorMI, p = 0.919). Multivariate analysis identified two independent predictors of in-hospital mortality, namely a final Thrombolysis in Myocardial Infarction (TIMI) flow < 3 (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.2 to 59.0; p < 0.001) and cardiogenic shock during hospitalization (OR, 6.7; 95% CI, 1.5 to 30.3; p = 0.013).

CONCLUSIONS

The number of nonagenarian STEMI patients who have undergone primary PCI has increased. Although a final TIMI flow < 3 and cardiogenic shock are independent predictors of in-hospital mortality, primary PCI can be performed with a high success rate and an acceptable in-hospital mortality rate.

Safety and efficacy of abciximab in older adults undergoing percutaneous coronary intervention

BACKGROUND

As a result of increased cost and bleeding concerns, older patients receive abciximab during percutaneous coronary intervention (PCI) less often than younger patients.

OBJECTIVE

The aim of this was to evaluate the safety and efficacy of abciximab in older adults undergoing PCI.

DESIGN

Retrospective, observational single centre cohort study.

METHODS

The British Cardiovascular Intervention Society (BCIS) database was used to establish the impact of abciximab in people with advanced age (≥ 75 years) on in-hospital bleeding and ischaemic events and all-cause mortality in 5727 consecutive patients undergoing PCI between January 2008 and June 2014.

RESULTS

Older patients represented 23% of the study population (n = 1298). Abciximab was used in 198 (15%) older patients and 970 (22%) younger patients (p < 0.001). Unadjusted bleeding and mortality rates were 1.2% and 5.6%, respectively, vs. 0.4% and 1.7% in younger patients (p = 0.001 and p < 0.001 respectively). On multivariate analysis older subjects were at higher risk of bleeding [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.26-6.04, p = 0.011] and had higher in-hospital mortality (OR 2.36, 95% CI 1.48-3.74, p < 0.001). The use of abciximab in older patients was not significantly associated with excess bleeding (adjusted OR 1.86, 95% CI 0.58-5.93, p = 0.3), ischaemic outcomes (adjusted OR, 95% CI, p = 0.12) or in-hospital mortality (adjusted OR, 95% CI, p = 0.11). Older patients having primary PCI had higher risk of bleeding irrespective of abciximab use (adjusted p = 0.042).

CONCLUSION

Abciximab may not be associated with excess bleeding complications in older patients compared with younger individuals and may be safe to use in older people if indicated.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

In-hospital outcomes after primary percutaneous coronary intervention according to left ventricular ejection fraction

BACKGROUND

The primary objective of primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is not only to restore the blood flow in the infarct-related artery, but also to save the patients' quality and duration of their life. Since left ventricular ejection fraction (LVEF) is a known predictor of clinical outcomes in STEMI patients, the possible association between characteristics of a large group of patients who undergo pPCI with LVEF and death was evaluated.

METHODS

This prospective cohort study included 304 patients who had undergone pPCI between 2009 and 2011. The association between LVEF and in-hospital outcomes of patients was assessed.

RESULTS

LVEF ≤ 25%, 25% < LVEF < 50%, and LVEF ≥ 50% were presented in 23 (7.6%), 150 (49.3%), and 128 (42.1%) of the patients, respectively. Three patients (0.01%) died before echocardiography. There was no significant difference among aforementioned three groups regarding baseline characteristics, except age (P = 0.012) and sex (P = 0.016). Cumulative number of cardiogenic shock and death were 7 (2.3%) and 22 (7.2%), respectively; with significant differences between three LVEF groups. Age more than 70 years old, pulmonary edema, systolic blood pressure < 100 mm Hg, shock, post-PCI thrombolysis in myocardial infarction (MI) flow grade, corrected thrombolysis in MI frame count, angiographic success and ST-segment resolution showed significant association with death (P < 0.050).

CONCLUSION

This study not only demonstrates that LVEF ≤ 50% is associated with a higher incidence of in-hospital adverse events, but also identifies characteristics that are strongly correlated with the risk of LVEF ≤ 50% and death after pPCI.

Management and decision-making process leading to coronary angiography and revascularization in octogenarians with coronary artery disease: Insights from a large single-center registry

AIMS

Cardiovascular diseases remain the most common cause of death in older adults. Guidelines state that advanced age alone should not limit the use of invasive therapy. However, coronary angiograms and subsequent revascularization are often not carried out in octogenarians. The benefit/risk balance of an invasive strategy and the decision-making process are not clearly defined. The aim of the present study was to assess the decision-making process, and the in-hospital and long-term mortality based on the clinical presentation, the diagnostic approach (coronary angiogram or conservative) and the therapeutic management (revascularization or not).

METHODS

The present study was a single-center retrospective analysis.

RESULTS

A total of 522 patients aged ≥80 years, with a diagnosis of coronary disease were included from 2003 to 2009. The mean age was 82 ± 2.6 years. A total of 195 of 522 (37%) presented with a ST segment elevation myocardial infarction (STEMI). A coronary angiogram was carried out in 316 patients (60.5%) and 71% were treated by percutaneous coronary revascularization. A total of 39.5% were considered ineligible for a coronary angiogram due to cardiological reasons or comorbidities. Excluding cardiogenic shock, overall in-hospital mortality was 4.9%. Clinical presentation strongly influenced both in-hospital and 6-month mortality rates (cardiogenic shock 20% and 28.7%, stable angina 1% and 4.1%, respectively, P < 0.001). Long-term mortality was reduced in the coronary angiography arm compared with the conservative group (14.3% vs 20.9%, P = 0.04) whether or not revascularization was carried out.

CONCLUSION

In the present study, in octogenarians, long-term mortality was lower in the group of patients who underwent a coronary angiogram, regardless of revascularization. The selection process for coronary angiography and angioplasty was mostly influenced by the existence of age-associated comorbidities. Risk prediction models are required to reduce age-dependent biases.