1
|
Cha JJ, Park JH, Joo HJ, Hong SJ, Ahn TH, Kim BK, Shin W, Ahn SG, Yoon J, Kim YH, Cho YH, Kang WC, Kim W, Lim YH, Gwon HC, Choi WG, Lim DS. Impact of genetic variants on clinical outcome after percutaneous coronary intervention in elderly patients. Aging (Albany NY) 2021; 13:6506-6524. [PMID: 33707344 PMCID: PMC7993709 DOI: 10.18632/aging.202799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/16/2021] [Indexed: 12/02/2022]
Abstract
Elderly patients treated with percutaneous coronary intervention (PCI) have a higher risk of both ischemic and bleeding complications than younger patients. However, few studies have reported how genetic information of elderly patients treated with PCI affects clinical outcomes. We investigated the impact of genetic variants on clinical outcomes in elderly patients. Correlations between single-nucleotide polymorphisms (CYP2C19 and P2Y12 receptor gene G52T polymorphism) and clinical outcomes were analyzed in 811 elderly patients (≥75 years of age) from a prospective multicenter registry. The primary endpoint was a composite of myocardial infarction and death. Secondary endpoints were an individual event of death, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, stroke, and major bleeding (Bleeding Academic Research Consortium ≥3). Regarding CYP2C19, patients with poor metabolizers had a significantly higher risk for the primary endpoint (hazard ratio [HR] 2.43; 95% confidence interval [95% CI] 1.12–5.24; p=0.024) and secondary endpoints (death and cardiac death). Regarding P2Y12 G52T, the TT group had a significantly higher occurrence of major bleeding than the other groups (HR 3.87; 95% CI 1.41–10.68; p=0.009). In conclusion, poor metabolizers of CYP2C19 and TT groups of P2Y12 G52T may be significant predictors of poor clinical outcomes in elderly patients.
Collapse
Affiliation(s)
- Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Tae Hoon Ahn
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - WonYong Shin
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - JungHan Yoon
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Yun-Hyeong Cho
- Department of Internal Medicine, Hanyang University Myongji Hospital, Goyang, South Korea
| | - Woong Chol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Weon Kim
- Department of Internal Medicine, Division of Cardiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Young-Hyo Lim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woong Gil Choi
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| |
Collapse
|
2
|
Quan N, Sun W, Wang L, Chen X, Bogan JS, Zhou X, Cates C, Liu Q, Zheng Y, Li J. Sestrin2 prevents age-related intolerance to ischemia and reperfusion injury by modulating substrate metabolism. FASEB J 2017; 31:4153-4167. [PMID: 28592638 PMCID: PMC5572689 DOI: 10.1096/fj.201700063r] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 05/22/2017] [Indexed: 12/24/2022]
Abstract
A novel stress-inducible protein, Sestrin2 (Sesn2), declines in the heart with aging. AMPK has emerged as a pertinent stress-activated kinase that has been shown to have cardioprotective capabilities against myocardial ischemic injury. We identified the interaction between Sesn2 and AMPK in the ischemic heart. To determine whether ischemic AMPK activation-modulated by the Sesn2-AMPK complex in the heart-is impaired in aging that sensitizes the heart to ischemic insults, young C57BL/6 mice (age 3-4 mo), middle-aged mice (age 10-12 mo), and aged mice (age 24-26 mo) were subjected to left anterior descending coronary artery occlusion for in vivo regional ischemia. The ex vivo working heart system was used for measuring substrate metabolism. The protein level of Sesn2 in hearts was gradually decreased with aging. Of interest, ischemic AMPK activation was blunted in aged hearts compared with young hearts (P < 0.05); the AMPK downstream glucose uptake and the rate of glucose oxidation were significantly impaired in aged hearts during ischemia and reperfusion (P < 0.05 vs. young hearts). Myocardial infarction size was larger in aged hearts (P < 0.05 vs. young hearts). Immunoprecipitation with Sesn2 Ab revealed that cardiac Sesn2 forms a complex with AMPK and upstream liver kinase B1 (LKB1) during ischemia. Of interest, the binding affinity between Sesn2 and AMPK upstream LKB1 is impaired in aged hearts during ischemia (P < 0.05 vs. young hearts). Furthermore, Sesn2-knockout hearts demonstrate a cardiac phenotype and response to ischemic stress that is similar to wild-type aged hearts (i.e., impaired ischemic AMPK activation and higher sensitivity to ischemia- and reperfusion- induced injury). Adeno-associated virus-Sesn2 was delivered to aged hearts via a coronary delivery approach and significantly rescued the protein level of Sesn2 and the ischemic tolerance of aged hearts; therefore, Sesn2 is a scaffold protein that mediates AMPK activation in the ischemic myocardium via an interaction with AMPK upstream LKB1. Decreased Sesn2 levels in aging lead to a blunted ischemic AMPK activation, alterations in substrate metabolism, and an increased sensitivity to ischemic insults-Quan, N., Sun, W., Wang, L., Chen, X., Bogan, J. S., Zhou, X., Cates, C., Liu, Q., Zheng, Y., Li J. Sestrin2 prevents age-related intolerance to ischemia and reperfusion injury by modulating substrate metabolism.
Collapse
Affiliation(s)
- Nanhu Quan
- Cardiovascular Center, First Hospital of Jilin University, Changchun, China
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Wanqing Sun
- Cardiovascular Center, First Hospital of Jilin University, Changchun, China
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lin Wang
- Cardiovascular Center, First Hospital of Jilin University, Changchun, China
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Xu Chen
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jonathan S Bogan
- Section of Endocrinology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; and
- Department of Cell Biology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xinchun Zhou
- Department of Pathology, Cancer Institute, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Courtney Cates
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Quan Liu
- Cardiovascular Center, First Hospital of Jilin University, Changchun, China
| | - Yang Zheng
- Cardiovascular Center, First Hospital of Jilin University, Changchun, China;
| | - Ji Li
- Department of Physiology and Biophysics, Mississippi Center for Heart Research, University of Mississippi Medical Center, Jackson, Mississippi, USA;
| |
Collapse
|
3
|
Ilic I, Stankovic I, Ilisic B, Cerovic M, Aleksic A, Nikolajevic I, Kafedzic S, Cuellas Ramon C, Sokolov M, El Setecha M, Putnikovic B, Neskovic AN. Favorable outcomes in octogenarians treated with bioresorbable polymer drug-eluting stent. Geriatr Gerontol Int 2016; 16:1246-1253. [PMID: 26735289 DOI: 10.1111/ggi.12619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/30/2022]
Abstract
AIM As a result of a higher prevalence of comorbidities, elderly adults are often underrepresented in clinical trials, and more often experience complications during percutaneous coronary intervention. Our aim was to evaluate clinical outcomes of patients older than 80 years, compared with their younger counterparts, when bioresorbable polymer biolimus A9 drug-eluting stent is used for their treatment. METHODS The prospective, observational e-Nobori registry was created to validate the safety and efficacy of bioresorbable polymer drug-eluting stent in unselected patients. The primary end-point of the study was freedom from target lesion failure defined as a composite of cardiac death, target vessel-related myocardial infarction and clinically-driven target lesion revascularization at 1 year. RESULTS There were 781 (7.8%) octogenarians, they were less frequently male (62% vs 77%; P < 0.0001) and more often presented as acute coronary syndrome (44% vs 39%; P = 0.0182). The index percutaneous coronary intervention success was lower in the elderly patients (98% vs 99%; P = 0.0398). One-year follow up was completed for 97% of the elderly patients and 99% of the younger patients. The difference in target lesion failure (3.33% vs 2.83%; log-rank P = 0.0114) was mainly driven by increased mortality in octogenarians (3.73% vs 1.47%; P < 0.0001). Elderly patients had more bleeding and vascular complications (2.67% vs 1.05%; P = 0.0001). CONCLUSIONS Despite advanced age, multiple comorbidities and complexity of treated lesions, clinical outcomes are favorable in octogenarians treated by bioresorbable polymer biolimus A9 drug-eluting stent. Geriatr Gerontol Int 2016; 16: 1246-1253.
Collapse
Affiliation(s)
- Ivan Ilic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Stankovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bojan Ilisic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milivoje Cerovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Aleksic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivica Nikolajevic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Kafedzic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Maxim Sokolov
- Cardiology, Ukrainian Institute of Cardiology, Kiev, Ukraine
| | | | - Biljana Putnikovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Aleksandar N Neskovic
- Department of Cardiology, Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
4
|
Rodriguez-Menocal L, Faridi MH, Martinez L, Shehadeh LA, Duque JC, Wei Y, Mesa A, Pena A, Gupta V, Pham SM, Vazquez-Padron RI. Macrophage-derived IL-18 and increased fibrinogen deposition are age-related inflammatory signatures of vascular remodeling. Am J Physiol Heart Circ Physiol 2014; 306:H641-53. [PMID: 24414074 DOI: 10.1152/ajpheart.00641.2013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Aging has been associated with pathological vascular remodeling and increased neointimal hyperplasia. The understanding of how aging exacerbates this process is fundamental to prevent cardiovascular complications in the elderly. This study proposes a mechanism by which aging sustains leukocyte adhesion, vascular inflammation, and increased neointimal thickness after injury. The effect of aging on vascular remodeling was assessed in the rat balloon injury model using microarray analysis, immunohistochemistry, and LINCOplex assays. The injured arteries in aging rats developed thicker neointimas than those in younger animals, and this significantly correlated with a higher number of tissue macrophages and increased vascular IL-18. Indeed, IL-18 was 23-fold more abundant in the injured vasculature of aged animals compared with young rats, while circulating levels were similar in both groups of animals. The depletion of macrophages in aged rats with clodronate liposomes ameliorated vascular accumulation of IL-18 and significantly decreased neointimal formation. IL-18 was found to inhibit apoptosis of vascular smooth muscle cells (VSMC) and macrophages, thus favoring both the formation and inflammation of the neointima. In addition, injured arteries of aged rats accumulated 18-fold more fibrinogen-γ than those of young animals. Incubation of rat peritoneal macrophages with immobilized IL-18 increased leukocyte adhesion to fibrinogen and suggested a proinflammatory positive feedback loop among macrophages, VSMC, and the deposition of fibrinogen during neointimal hyperplasia. In conclusion, our data reveal that concentration changes in vascular cytokine and fibrinogen following injury in aging rats contribute to local inflammation and postinjury neointima formation.
Collapse
Affiliation(s)
- Luis Rodriguez-Menocal
- Department of Surgery and Vascular Biology Institute, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Yamanaka F, Jeong MH, Saito S, Ahn Y, Chae SC, Hur SH, Hong TJ, Kim YJ, Seong IW, Chae JK, Rhew JY, Chae IH, Cho MC, Bae JH, Rha SW, Kim CJ, Choi D, Jang YS, Yoon J, Chung WS, Cho JG, Seung KB, Park SJ. Comparison of clinical outcomes between octogenarians and non-octogenarians with acute myocardial infarction in the drug-eluting stent era: analysis of the Korean Acute Myocardial Infarction Registry. J Cardiol 2013; 62:210-6. [PMID: 23731919 DOI: 10.1016/j.jjcc.2013.04.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 11/18/2012] [Accepted: 04/13/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Octogenarians (age ≥ 80 years) with coronary artery disease constitute a high-risk group. However, octogenarian patients with acute myocardial infarction (AMI) in the drug-eluting stents (DES) era have not been widely reported. We aimed to identify clinical outcomes in octogenarian compared with non-octogenarian AMI patients. METHODS AND SUBJECTS We retrospectively analyzed 9877 patients who underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and who were enrolled in the Korean Acute Myocardial Infarction Registry (KAMIR). They were divided into 2 groups, octogenarians (n=1494) and non-octogenarians (n=8383), in order to compare the incidence of 1-year all-cause death and 1-year major adverse cardiac events (MACE), where MACE included all-cause death, recurrent myocardial infarction, target vessel revascularization (TVR), target lesion revascularization (TLR), and coronary artery bypass grafting (CABG). RESULTS The clinical status was significantly inferior in octogenarians compared to non-octogenarians: Killip class ≥ II (34.8% vs. 22.5%, p<0.001), multivessel disease (65.8% vs. 53.7%, p<0.001). Rates of 1-year all-cause death were significantly higher in octogenarians than in non-octogenarians (22.3% vs. 6.5%, p<0.001). However, the rates of 1-year recurrent myocardial infarction (1.3% vs. 0.9%, p=0.68), TLR (2.4% vs. 3.1%, p=0.69), TVR (3.6% vs. 4.3%, p=0.96), and CABG (0.9% vs. 0.9%, p=0.76) did not differ significantly between the 2 groups. CONCLUSIONS Octogenarian AMI patients have higher rates of mortality and MACE even in the DES era. According to KAMIR subgroup analysis, the TLR/TVR rates in octogenarians were comparable to those in non-octogenarian AMI patients.
Collapse
Affiliation(s)
- Futoshi Yamanaka
- Chonnam National University Hospital, Gwangju, Republic of Korea; Shonan Kamakura Hospital, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Rittger H, Hochadel M, Behrens S, Hauptmann KE, Zahn R, Mudra H, Brachmann J, Senges J, Zeymer U. Age-related differences in diagnosis, treatment and outcome of acute coronary syndromes: results from the German ALKK registry. EUROINTERVENTION 2012; 7:1197-205. [PMID: 22334318 DOI: 10.4244/eijv7i10a191] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The elderly constitute an increasing proportion of all patients with acute coronary syndromes (ACS). However, increased age has been identified as an important risk factor for adverse events and complications of ACS and treatment. The purpose of this study was to investigate age-related differences in presentation and diagnostics, as well as contemporary treatment and outcome in a large series of elderly patients receiving an invasive strategy for ACS. METHODS AND RESULTS The present study is an analysis of all patients, who were enrolled in the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK) registry in 2008. To assess age-related differences, subjects were divided into three groups: (<75 yrs, 75 to 85 yrs and >85 yrs). Out of 19,708 consecutive patients who were admitted for the treatment of ACS and enrolled in the ALKK registry, 14,174 (71.9%) were <75 yrs, 4,685 (23.8%) were between 75 and 84 yrs and 849 (4.3%) patients were >85 yrs. Therapy recommendation after diagnostic angiography was conservative in 24.6% of the youngest, in 25.1% of the elderly, and in 25.3% of the very elderly patients. Interventional success rates were 95.2% in the youngest vs. 93.1% in the elderly and very elderly patient group (p<0.001). Overall in-hospital event rate increased significantly with age (3.4% vs. 7.4% vs. 8.3%, respectively; p<0.001). CONCLUSIONS Our analysis shows that there is a high success rate among the large proportion of elderly patients who are treated for ACS by an intervention. Complication rates increased significantly, however, with age.
Collapse
Affiliation(s)
- Harald Rittger
- Medizinische Klinik 2, Universitätsklinikum Erlangen, Erlangen, Germany. harald.rittger@arcor
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Hermiller JB, Nikolsky E, Lansky AJ, Applegate RJ, Sanz M, Yaqub M, Sood P, Cao S, Sudhir K, Stone GW. Clinical and angiographic outcomes of elderly patients treated with everolimus-eluting versus paclitaxel-eluting stents: three-year results from the SPIRIT III randomised trial. EUROINTERVENTION 2011; 7:307-13. [PMID: 21729832 DOI: 10.4244/eijv7i3a54] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Age is an important determinant of outcomes in patients treated with percutaneous coronary intervention (PCI). This report from the randomised multicentre SPIRIT III trial compares the outcomes in elderly and younger patients treated with everolimus-eluting stent (EES) versus paclitaxel-eluting stent (PES). METHODS AND RESULTS A total of 1,002 patients with stable or unstable angina or inducible ischaemia undergoing PCI were randomised in a 2:1 ratio to receive EES or PES. Outcomes were examined across the randomised groups as a function of age and stent type. Patients ≥65 years of age (elderly) treated with EES vs. PES had lower in-segment late lumen loss (0.11±0.32 mm vs. 0.38±0.55 mm, respectively, p=0.0002) and lower rates of binary in-segment restenosis (3.4% vs. 15.5%, p = 0.004) at eight months, along with a 48% lower incidence of 3-year target vessel failure (TVF=cardiac death, myocardial infarction and ischaemia-driven target vessel revascularisation [TVR]; 10.8% vs. 20.8%, p=0.009), mainly due to a lower incidence of TVR (5.4% vs. 9.2%, p=0.20). Among EES patients, elderly compared to younger patients had comparable rates of binary in-segment restenosis (3.4% vs. 5.6%, p=0.44) at eight months but paradoxically lower rates of TVF (10.8% vs. 17.1%, p=0.03) at three years. Among PES patients, elderly compared to younger patients had a higher rate of binary in-segment restenosis (15.5% vs. 3.4%, p=0.01) at eight months and no difference in the rate of 3-year TVF (20.8% vs. 19.4%, p=0.77) .There was a significant interaction between stent assignment, age ≥65 years and 8-month angiographic in-segment late loss (p=0.001). CONCLUSIONS Implantation of both EES and PES appeared to be safe in elderly patients, however EES compared to PES was more effective due to enhanced 3-year MACE- and TVF-free outcomes. Further research should clarify age-specific mechanisms of neointimal response after treatment with drug-eluting stents.
Collapse
Affiliation(s)
- James B Hermiller
- The Care Group, LLC, St. Vincent Heart Center of IN, LLC, Indianapolis, IN 46290, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Hong YJ, Jeong MH, Abizaid A, Banning A, Bartorelli A, Dzavik V, Ellis SG, Gao R, Holmes DR, Legrand V, Neumann FJ, Spaulding C, Worthley S, Urban P. Sirolimus-Eluting Coronary Stents in Octogenarians. JACC Cardiovasc Interv 2011; 4:982-91. [DOI: 10.1016/j.jcin.2011.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 01/16/2023]
|
9
|
Abstract
Coronary artery disease is the leading cause of death in developed countries and its incidence and severity is greater among older patients. So, because of the ageing of the population, clinicians will be increasingly confronted in daily practice with managing acute coronary syndrome in extreme old age and high-risk patients. Despite this demographic reality, several large randomized controlled trials evaluating the benefit-risk ratio of invasive versus conservative approach have systematically excluded elderly patients. The extrapolation of evidence-based medicine, initially focused on younger patients, is often contentious in this population and because of the lack of clear and specific recommendations in the elderly, the optimal management of STEMI in octogenarians remains a topic of debate. Elderly patients present unique issues related to the ageing process and multiple comorbid diseases making difficult the extrapolation of evidence obtained on younger demographics. Data from registries seem to support, nevertheless, the benefit of primary revascularization by PCI of the culprit lesion in "selected" octogenarians with a high technical success rate, few complications, acceptable short and long-term mortality rate and quality of life. Obviously, the "ideal octogenarian" doesn't exist and all the old patients are not suitable for an invasive approach. Managing elderly patients requires not only cardiological skills but also geriatric acknowledges and the individualized geriatric assessment is the corner store of the decision process. The aim is to screen for the presence of comorbidities (cognitive disorders, functional decline, anemia, renal insufficiency…), social isolation and existence of an underlying frailty. To conclude, the optimal strategy for the management of STEMI in octogenarians is not univocal: the best approach is the one that offers the greater benefits regard considerations of general health.
Collapse
|
10
|
Hong YJ, Jeong MH, Choi YH, Ma EH, Ko JS, Lee MG, Park KH, Sim DS, Yoon NS, Youn HJ, Kim KH, Park HW, Kim JH, Ahn Y, Cho JG, Park JC, Kang JC. Age-related differences in virtual histology-intravascular ultrasound findings in patients with coronary artery disease. J Cardiol 2010; 55:224-31. [DOI: 10.1016/j.jjcc.2009.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 10/31/2009] [Accepted: 11/04/2009] [Indexed: 10/20/2022]
|
11
|
Lymbury R, Tinggi U, Griffiths L, Rosenfeldt F, Perkins AV. Selenium status of the Australian population: effect of age, gender and cardiovascular disease. Biol Trace Elem Res 2008; 126 Suppl 1:S1-10. [PMID: 18797826 DOI: 10.1007/s12011-008-8208-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 07/30/2008] [Indexed: 10/21/2022]
Abstract
Selenium (Se) is an essential trace element and the clinical consequences of Se deficiency have been well-documented. Se is primarily obtained through the diet and recent studies have suggested that the level of Se in Australian foods is declining. Currently there is limited data on the Se status of the Australian population so the aim of this study was to determine the plasma concentration of Se and glutathione peroxidase (GSH-Px), a well-established biomarker of Se status. Furthermore, the effect of gender, age and presence of cardiovascular disease (CVD) was also examined. Blood plasma samples from healthy subjects (140 samples, mean age = 54 years; range, 20-86 years) and CVD patients (112 samples, mean age = 67 years; range, 40-87 years) were analysed for Se concentration and GSH-Px activity. The results revealed that the healthy Australian cohort had a mean plasma Se level of 100.2 +/- 1.3 microg Se/L and a mean GSH-Px activity of 108.8 +/- 1.7 U/L. Although the mean value for plasma Se reached the level required for optimal GSH-Px activity (i.e. 100 microg Se/L), 47% of the healthy individuals tested fell below this level. Further evaluation revealed that certain age groups were more at risk of a lowered Se status, in particular, the oldest age group of over 81 years (females = 97.6 +/- 6.1 microg Se/L; males = 89.4 +/- 3.8 microg Se/L). The difference in Se status between males and females was not found to be significant. The presence of CVD did not appear to influence Se status, with the exception of the over 81 age group, which showed a trend for a further decline in Se status with disease (plasma Se, 93.5 +/- 3.6 microg Se/L for healthy versus 88.2 +/- 5.3 microg Se/L for CVD; plasma GSH-Px, 98.3 +/- 3.9 U/L for healthy versus 87.0 +/- 6.5 U/L for CVD). These findings emphasise the importance of an adequate dietary intake of Se for the maintenance of a healthy ageing population, especially in terms of cardiovascular health.
Collapse
Affiliation(s)
- Robyn Lymbury
- Heart Foundation Research Centre, School of Medical Science, Griffith University Gold Coast Campus, Parklands Drive, Southport, QLD 9726, Australia
| | | | | | | | | |
Collapse
|
12
|
Hong YJ, Jeong MH, Ahn Y, Sim DS, Chung JW, Cho JS, Yoon NS, Yoon HJ, Moon JY, Kim KH, Park HW, Kim JH, Cho JG, Park JC, Kang JC. Age-Related Differences in Intravascular Ultrasound Findings in 1,009 Coronary Artery Disease Patients. Circ J 2008; 72:1270-5. [DOI: 10.1253/circj.72.1270] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Myung Ho Jeong
- The Heart Center of Chonnam National University Hospital
| | - Youngkeun Ahn
- The Heart Center of Chonnam National University Hospital
| | - Doo Sun Sim
- The Heart Center of Chonnam National University Hospital
| | - Jong Won Chung
- The Heart Center of Chonnam National University Hospital
| | - Jung Sun Cho
- The Heart Center of Chonnam National University Hospital
| | - Nam Sik Yoon
- The Heart Center of Chonnam National University Hospital
| | - Hyun Ju Yoon
- The Heart Center of Chonnam National University Hospital
| | - Jae Youn Moon
- The Heart Center of Chonnam National University Hospital
| | - Kye Hun Kim
- The Heart Center of Chonnam National University Hospital
| | | | - Ju Han Kim
- The Heart Center of Chonnam National University Hospital
| | - Jeong Gwan Cho
- The Heart Center of Chonnam National University Hospital
| | - Jong Chun Park
- The Heart Center of Chonnam National University Hospital
| | | |
Collapse
|
13
|
Wu X, Zhou Q, Huang L, Sun A, Wang K, Zou Y, Ge J. Ageing-exaggerated proliferation of vascular smooth muscle cells is related to attenuation of Jagged1 expression in endothelial cells. Cardiovasc Res 2007; 77:800-8. [PMID: 18079106 DOI: 10.1093/cvr/cvm105] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIMS Ageing has been shown to enhance neointima formation due to abnormal growth of vascular smooth muscular cells (VSMC), which is regulated by endothelial functions. The mechanism of how endothelium affects the growth of VSMC in the process remains unclear. We here examined the role of Jagged1, a regulator of cell growth. METHODS AND RESULTS Male Sprague-Dawley rats at 3 (young) and 22 (old) months of age were subjected to a balloon catheter injury in the thoracic aorta. After 4 weeks, the neointima formation in the injured artery of old rats was more than that of young rats. Compared with the young rats, the increase in Jagged1 expression in the endothelium of old rats after the injury was delayed, weakened, and shortened, suggesting an impaired response of Jagged1 to the injury. In contrast, the increase in the expression of proliferating cell nuclear antigen in the neointima was more significant and maintained longer in old rats than in the young ones. Moreover, the expression of Jagged1 in the cultured arterial endothelial cells (EC) of old animals was less than those of the young ones, which promoted the Platelet-derived growth factor (PDGF)-induced growth and migration of the co-cultured VSMC. Furthermore, suppression of Jagged1 expression by a small interfering RNA in the EC of young rats reduced alpha-smooth muscle actin and calponin expression and also intensified the PDGF-increased growth and migration of the co-cultured VSMC. CONCLUSION Ageing enhanced VSMC proliferation, at least in part, through impairing Jagged1 expression in the EC after vascular injury.
Collapse
Affiliation(s)
- Xiaojing Wu
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, PR China
| | | | | | | | | | | | | |
Collapse
|
14
|
Han JH, Lindsell CJ, Hornung RW, Lewis T, Storrow AB, Hoekstra JW, Hollander JE, Miller CD, Peacock WF, Pollack CV, Gibler WB. The elder patient with suspected acute coronary syndromes in the emergency department. Acad Emerg Med 2007; 14:732-9. [PMID: 17567963 DOI: 10.1197/j.aem.2007.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED). METHODS This was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients. RESULTS A total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients. CONCLUSIONS Elder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.
Collapse
Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Sardella G, De Luca L, De Persio G, Colantonio R, Petrolini A, Conti G, Fedele F. Benefits on coronary restenosis from elective paclitaxel-eluting stent implantation in patients aged 75 years and older. J Cardiovasc Med (Hagerstown) 2007; 8:494-8. [PMID: 17568281 DOI: 10.2459/01.jcm.0000278442.81741.d2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Elderly patients are increasingly referred for revascularisation yet have been underrepresented in some large clinical trials. Although the advent of drug-eluting stents has dramatically reduced clinical events related to restenosis, older age remains one of the most important correlates of adverse outcome, even after an elective percutaneous coronary intervention (PCI). We sought to evaluate the impact of paclitaxel-eluting stents on coronary restenosis in elderly patients undergoing elective PCI. METHODS Patients undergoing successful elective PCI with stenting of de novo coronary artery lesions were identified and screened for participation in this study. All patients included in our analysis were divided into two cohort groups: patients aged <75 years (younger cohort) and patients aged >or=75 years (elderly cohort). We evaluated the six-month incidence of target lesion revascularisation (TLR) and major adverse cardiac events, which included TLR, death and myocardial infarction. RESULTS A total of 171 (58 aged >or=75 years) consecutive patients were enrolled in the study. At six months, TLR rate was similar in both groups [1.77 vs. 1.72%, odds ratio (OR) 0.97, 95% confidence interval (CI) 0.08-10.9, P = 0.98, in the younger and elderly group, respectively]. Even the rate of major adverse cardiac events was comparable between the two groups (7.96 vs. 8.62%, OR 1.09, 95% CI 0.34-3.41, P = 0.88, in the younger and elderly group, respectively). Also the angiographic restenosis rates were comparable between patients <75 or >or=75 years (4.42 vs. 3.46%, P = 0.76). CONCLUSIONS After elective paclitaxel-eluting stent implantation, there is no difference in coronary restenosis in younger and elderly patients, suggesting an age-independent efficacy.
Collapse
Affiliation(s)
- Gennaro Sardella
- Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy.
| | | | | | | | | | | | | |
Collapse
|
16
|
Torella D, Leosco D, Indolfi C, Curcio A, Coppola C, Ellison GM, Russo VG, Torella M, Li Volti G, Rengo F, Chiariello M. Aging exacerbates negative remodeling and impairs endothelial regeneration after balloon injury. Am J Physiol Heart Circ Physiol 2004; 287:H2850-60. [PMID: 15231505 DOI: 10.1152/ajpheart.01119.2003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Many older patients, because of their high prevalence of coronary artery disease, are candidates for percutaneous coronary interventions (PCI), but the effects of vascular aging on restenosis after PCI are not yet well understood. Balloon injury to the right carotid artery was performed in adult and old rats. Vascular smooth muscle cell (VSMC) proliferation, apoptotic cell death, together with Akt induction, telomerase activity, p27kip1, and endothelial nitric oxide synthase (eNOS) expression was assessed in isolated arteries. Neointima hyperplasia and vascular remodeling along with endothelial cell regeneration were also measured after balloon injury. Arteries isolated from old rats exhibited a significant reduction of VSMC proliferation and an increase in apoptotic death after balloon injury when compared with adult rats. In the vascular wall of adult rats, balloon dilation induced Akt phosphorylation, and this was barely present in old rats. In arteries from old rats, Akt-modulated cell cycle check points like telomerase activity and p27kip1 expression were decreased and increased, respectively, compared with adults. After balloon injury, old rats showed a significant reduction of neointima formation and an increased vascular negative remodeling compared with adults. These results were coupled by a marked delay in endothelial regeneration in aged rats, partially mediated by a decreased eNOS expression and phosphorylation. Interestingly, chronic administration of l-arginine prevented negative remodeling and improved reendothelialization after balloon injury in aged animals. A decreased neointimal proliferation, an impaired endothelial regeneration, and an increase in vascular remodeling after balloon injury were observed in aged animals. The molecular mechanisms underlying these responses seem to be a reduced Akt and eNOS activity.
Collapse
Affiliation(s)
- Daniele Torella
- Div. of Cardiology, Magna Graecia Univ., Via Tommaso Campanella, 115, 88100 Catanzaro, Italy
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Rosenfeldt F, Miller F, Nagley P, Hadj A, Marasco S, Quick D, Sheeran F, Wowk M, Pepe S. Response of the Senescent Heart to Stress: Clinical Therapeutic Strategies and Quest for Mitochondrial Predictors of Biological Age. Ann N Y Acad Sci 2004; 1019:78-84. [PMID: 15246998 DOI: 10.1196/annals.1297.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aging heart has an impaired response to many kinds of stress. In clinical practice, there is a need for senescence-specific therapies to protect against stress and for biochemical markers of senescence to identify those patients most in need of therapy. In isolated rat hearts, in human tissues, and in a clinical trial, we have shown previously that coenzyme Q(10) has the ability to protect the heart against stress especially in senescence. We recently have devised a regimen of therapy to protect the senescent heart against stress, combining metabolic therapy (coenzyme Q(10), alpha lipoic acid, magnesium orotate, and omega 3 polyunsaturated fatty acids) with physical exercise and mental stress reduction. The preliminary results of this program are promising. In an endeavor to predict the likely response of individual senescent hearts to stress, we correlated the tissue load of mitochondrial DNA deletions and total cellular mitochondrial DNA copy number in human cardiac tissue with recovery of the same tissue from ischemia/reperfusion stress. We found that these mitochondrial markers actually were less predictive of impaired response to stress than age alone. We conclude that the aging heart has a diminished capacity to recover from stress that is not readily predictable by cardiac content of intact mitochondrial DNA and that this recovery can be improved by metabolic therapy combined with physical exercise and mental stress reduction.
Collapse
Affiliation(s)
- Franklin Rosenfeldt
- Cardiac Surgical Research Unit, Alfred Hospital and Baker Heart Research Institute (Wynn Domain), Melbourne, Prahran Victoria 3181, Australia.
| | | | | | | | | | | | | | | | | |
Collapse
|
18
|
De Servi S, Cavallini C, Dellavalle A, Santoro GM, Bonizzoni E, Marzocchi A, Politi A, Pesaresi A, Mariani M, Chierchia S. Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome. Am Heart J 2004; 147:830-6. [PMID: 15131538 DOI: 10.1016/j.ahj.2003.12.016] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The purpose of this study was to assess the current care of elderly patients with non-ST-elevation acute coronary syndrome (ACS), with particular regard to the rate of use of antiplatelet drugs and the type of strategy, aggressive or conservative, in a population of consecutive patients admitted to 76 Coronary Care Units in Italy. METHODS Prospective registry of patients admitted to Coronary Care Units with a diagnosis of non-ST-elevation ACS during a 2-month period. Thirty-day follow-up was available in all patients. RESULTS Of 1581 patients enrolled in the registry, 564 were 75 years or older. As compared with the 1017 younger patients, elderly patients had a greater prevalence of female sex (42% vs 27%, P <.001), hypertension (70% vs 59%, P <.001), prior myocardial infarction (MI) (41% vs 29%, P <.001), prior angina (18% vs 13%, P <.01), prior use of aspirin (49% vs 39%, P <.001), ST-segment depression (54% vs 43%, P <.001), and troponin positivity (66% vs 59%, P <.05). The higher-risk profile of elderly patients was confirmed by the greater number of patients with a high TIMI risk score (37% vs 22%, P <.001). GPIIb/IIIa inhibitors were less frequently used in elderly patients (P <.05). An aggressive strategy (coronary arteriography within 4 days of admission, followed by revascularization, if feasible) was adopted in 39% elderly patients and in 56% younger patients (P <.001). An interventional procedure within 30 days was performed in 30% of elderly patients and 48% of younger patients (P <.001). Elderly patients had a more unfavorable 30-day outcome compared with younger ones, as shown by the higher rates of death (6.4% vs 1.7%), acute myocardial infarction (7.1% vs 5%), and stroke (1.3% vs 0.5%). Multivariate analysis of the elderly group identified a conservative strategy (OR, 2.31; 95% CI, 1.20 to 4.48) and a diagnosis of non-Q-wave MI (OR, 2.27; 95% CI, 1.32 to 3.93) as independent predictors of 30-day events. CONCLUSIONS The elderly represent a very high-risk subgroup among patients with non-ST-elevation ACS, with a nearly 4-fold as high 30-day death rate as that of younger patients. These data call for a greater attention to such population, both in terms of an improved representation in clinical research and of the assessment of the outcome of different strategies in appropriately designed randomized trials.
Collapse
Affiliation(s)
- Stefano De Servi
- Unita' Operativa di Cardiologia, Ospedale Civile di Legnano, Legnano, Milan, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Assali AR, Moustapha A, Sdringola S, Salloum J, Awadalla H, Saikia S, Ghani M, Hale S, Schroth G, Rosales O, Anderson HV, Smalling RW. The dilemma of success: percutaneous coronary interventions in patients > or = 75 years of age-successful but associated with higher vascular complications and cardiac mortality. Catheter Cardiovasc Interv 2003; 59:195-9. [PMID: 12772238 DOI: 10.1002/ccd.10532] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Elderly patients are increasingly referred to percutaneous coronary interventions (PCIs). Recent reports suggest complications rates are declining in the elderly. We sought to determine whether procedural and in-hospital outcomes are different in patients aged > or = 75 years undergoing nonemergent PCI as compared to patients age < 75 years. The outcome of 266 consecutive patients age > or = 75 years undergoing nonemergent PCI was compared to that of 1,681 consecutive patients age < 75 years. Compared with younger patients, greater proportions of elderly patients were women and had a history of hypertension, peripheral vascular disease, and cerebral vascular events. Elderly patients had more extensive coronary involvement. Procedural success was similar in both groups (94%). The in-hospital cardiac death rate was significantly higher in the elderly patients (2.3% vs. 0.7%; P = 0.03). Aged patients also had a significantly higher incidence of vascular and bleeding complications. Blood transfusion was required more often in the elderly group (4.5% vs. 2.6%; P = 0.07). The hospitalization length was significantly higher in the elderly group (4.1 +/- 6.0 vs. 2.5 +/- 4.3 day; P = 0.0004). By multivariate logistic regression (adjusted for baseline clinical and angiographic variables), age > or = 75 years was found to be an independent predictor of in-hospital cardiac death (odds ratio = 3.9; 95% CI = 1.3-11.5; P = 0.015). Although PCI is technically successful in patients aged > or = 75 years; it is associated with more acute cardiac and vascular complications and higher in-hospital cardiac mortality.
Collapse
Affiliation(s)
- Abid R Assali
- Cardiac Catheterization Laboratory, Rabin Medical Center, Petach-Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Dynina O, Vakili BA, Slater JN, Sherman W, Ravi KL, Green SJ, Sanborn TA, Brown DL. In-hospital outcomes of contemporary percutaneous coronary interventions in the very elderly. Catheter Cardiovasc Interv 2003; 58:351-7. [PMID: 12594701 DOI: 10.1002/ccd.10437] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Coronary heart disease is the leading cause of death among the elderly (> 65 years) and the very elderly (> 85 years). Little information is available regarding the outcome of very elderly patients referred for PCI in the current era of improved techniques, devices, and pharmacotherapy. The objective of the current study was to evaluate the clinical characteristics and outcomes of very elderly patients > or = 85 years of age in a large, contemporary, multi-institutional PCI database. Five hospitals in the New York City metropolitan area contributed these prospectively defined data elements on consecutive patients undergoing PCI from 1 January 1998 to 1 October 1999. Of 10,847 patients, 5,341 (49%) were younger than 65 years, 3,342 (31%) were 65-74 years, 1,885 (17%) were 75-84 years, and 279 (2.6%) were at least 85 years of age. Following PCI, the very elderly developed stroke (P < 0.001) and renal failure requiring dialysis (P = 0.002) more commonly than younger patients following PCI. The very elderly had a significantly increased in-hospital mortality rate at 2.5% (P < 0.001). However, on multivariate analysis, age > or = 85 years was not an independent predictor of in-hospital mortality (OR = 1.22; 95% CI = 0.37-4.07). The very elderly should not be refused PCI on the basis of advanced age alone.
Collapse
Affiliation(s)
- Olga Dynina
- Department of Medicine (Cardiology), Albert Einstein College of Medicine, Bronx, New York 10003, USA
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Voudris VA, Skoularigis JS, Malakos JS, Kourgianides GC, Pavlides GS, Manginas AN, Kolovou GD, Cokkinos DV. Long-term clinical outcome of coronary artery stenting in elderly patients. Coron Artery Dis 2002; 13:323-9. [PMID: 12436027 DOI: 10.1097/00019501-200209000-00004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The elderly constitute a rapidly expanding segment of our population and cardiovascular disease becomes more prevalent with increasing age. Existing data have shown that percutaneous coronary interventions in the elderly are associated with an increase risk of in-hospital complications compared to younger patients. In the present study we retrospectively assessed the long-term clinical outcome of coronary artery stenting in an elderly population and compared them with the cohort of younger patients. METHODS The study population included 402 consecutive patients with coronary artery disease who underwent coronary artery stenting; of these 69 were elderly (age > 70 years, group I) and 333 were younger (age <or= 70 years, group II). Percutaneous coronary intervention combined with stent implantation was performed using standard techniques. Clinical outcomes during follow-up (24 +/- 13 months, range 7-56 months) were obtained in all patients without major in-hospital complications. Survival curves and multivariate Cox proportional hazard models for any late clinical event were reported. RESULTS No difference in in-hospital complications or clinical success rate was observed between the two groups of patients. Complete revascularization was obtained more frequently in younger compared to elderly patients (P < 0.05). At 2 years, event-free survival was 62% in the elderly and 76% in younger patients (P < 0.001); this difference was mostly made-up by recurrence of angina in the elderly. Impaired left ventricular systolic function (ejection fraction < 40%) was an independent predictor of late death. CONCLUSIONS Coronary artery stenting is an effective therapeutic strategy in elderly with coronary artery disease and is associated with good short- and long-term results. Age per se should not preclude patients from undergoing coronary stenting.
Collapse
Affiliation(s)
- Vassilis A Voudris
- First Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece.
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Kroll CR, Ohman EM. Should reperfusion strategies in myocardial infarction be modified for the very elderly? Am Heart J 2002; 143:373-6. [PMID: 11868038 DOI: 10.1067/mhj.2002.120779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
23
|
Brorsson B, Bernstein SJ, Brook RH, Werkö L. Quality of life of patients with chronic stable angina before and four years after coronary revascularisation compared with a normal population. Heart 2002; 87:140-5. [PMID: 11796552 PMCID: PMC1766984 DOI: 10.1136/heart.87.2.140] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the impact of coronary revascularisation on the health related quality of life (HRQOL) of patients with chronic stable angina compared with data from "community" norms four years following revascularisation. DESIGN Prospective survey and review of medical records. SETTING Seven of the eight public Swedish heart centres that performed coronary artery interventions. SUBJECTS 827 patients aged 55-79 years with chronic stable angina who underwent coronary artery revascularisation in 1994 or 1995 and completed the four year HRQOL survey. MAIN OUTCOME MEASURES Five components of the Swedish quality of life survey. RESULTS Compared with age and sex adjusted population norms, patients at baseline had significantly lower mean scores on all five functioning and wellbeing scales (p < 0.001). Four years after revascularisation, the mean levels of functioning and wellbeing were similar to those in the normative population (p > 0.05) except for quality of sleep (p < 0.001). The improvements were the same across age groups and for men and women. However, 36% of men and 55% of women were not completely free from angina by four years (p < 0.001). Men without angina after four years had better HRQOL than their community norms (p < 0.001) on all dimensions except quality of sleep (p > 0.05). Women without angina had less pain (p < 0.01) and better general health perception (p < 0.05) but similar physical functioning, quality of sleep, and emotional wellbeing compared with their community counterparts. Both men and women who had suffered at least one anginal attack during the preceding four weeks had significantly worse HRQOL by four years than their community norms (p < 0.01). CONCLUSIONS By four years following revascularisation, three fifths of patients with chronic stable angina were free of angina and their HRQOL was the same as or better than that of the general Swedish population. However, fewer than half of all women and two thirds of men who underwent revascularisation were angina-free after four years. Among patients with new or persistent angina, the HRQOL was worse than that in community norms.
Collapse
Affiliation(s)
- B Brorsson
- The Swedish Council on Technology Assessment in Health Care, Stockholm, Sweden.
| | | | | | | |
Collapse
|
24
|
Chauhan MS, Kuntz RE, Ho KL, Cohen DJ, Popma JJ, Carrozza JP, Baim DS, Cutlip DE. Coronary artery stenting in the aged. J Am Coll Cardiol 2001; 37:856-62. [PMID: 11693762 DOI: 10.1016/s0735-1097(00)01170-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The study compared the safety and efficacy of coronary artery stenting in aged and nonaged patients and identified predictors of adverse clinical outcomes. BACKGROUND Limited data are available on the outcomes of stenting in the aged (> or = 80 years) compared to nonaged patients. METHODS The study was a pooled analysis of 6,186 patients who underwent coronary artery stenting in six recent multicenter trials. A clinical events committee adjudicated clinical end points, and quantitative angiography was performed by an independent core laboratory. RESULTS There were 301 (4.9%) aged patients (> or = 80 years). Compared to nonaged patients, aged patients had a higher prevalence of multivessel disease (16.5% vs. 9.6%, p = 0.001), unstable angina (50.8% vs. 42.1%, p = 0.003), moderate to severe target lesion calcification (30.4% vs. 15.3%, p = 0.001) and smaller reference vessel diameter (2.90 mm vs. 2.98 mm, p = 0.004). Procedural success rate (97.4% vs. 98.5%, p = 0.14) was similar in the two groups. In-hospital mortality (1.33% vs. 0.10%, p = 0.001), bleeding complications (4.98% vs. 1.00%, p < 0.001) and one-year mortality (5.65% vs. 1.41%, p < 0.001) were significantly higher for the aged patients. Clinical restenosis was similar for the two groups (11.19% vs. 11.93%, p = 0.78). Advanced age, diabetes, prior myocardial infarction and presence of three-vessel disease were independent predictors of long-term mortality. CONCLUSIONS Coronary artery stenting can be performed safely in patients > or = 80 years of age, with excellent acute results and a low rate of clinical restenosis, albeit with higher incidences of in-hospital and long-term mortality, and vascular and bleeding complications compared to nonaged patients.
Collapse
Affiliation(s)
- M S Chauhan
- Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Torre Hernández JMDL, Fernández-Valls M, Royuela N, Gómez González I, Enríquez SG, Zueco J, Figueroa Á, Colman T. Angina inestable en el paciente octogenario: ¿es factible y eficaz el abordaje invasivo? Rev Esp Cardiol (Engl Ed) 2001. [DOI: 10.1016/s0300-8932(01)76382-8] [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]
|
26
|
Bermejo García J, López de Sá E, López-Sendón JL, Pabón Osuna P, García-Morán E, Bethencourt A, Bosch Genover X, Roldán Rabadán I, Calviño Santos R, Valle Tudela V. [Unstable angina in the elderly: clinical, profile, management and mortality at three months. The PEPA Registry Data]. Rev Esp Cardiol 2000; 53:1564-72. [PMID: 11171478 DOI: 10.1016/s0300-8932(00)75281-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION AND OBJECTIVES Few reports in the literature have studied the characteristics and management of unstable angina in the elderly in Spain. The aim of this study was to analyze the clinical characteristics and the use of diagnostic and therapeutic resources in patients > or = 70 years of age. PATIENTS AND METHODS A total of 1,551 patients > or = 70 years of age were included out of 4,115 included in the PEPA registry with a follow up of 90 days. These patients were compared with 2,564 < 70 years. RESULTS In comparison, the elderly (76 +/- 5 years) versus the younger group (58 +/- 8.5 years) included a higher proportion of women (43 vs 27%), diabetics (30 vs 23%)and hypertensive patients (60 vs 49%) with a lower proportion (p < 0.001) of hypercholesterolemia (33 vs 43%), smoking (40 vs 60%) or family history (9 vs 17%). A previous history of angina (49 vs 35%) or infarction (38 vs31%) and comorbidity was found to be significantly more frequent in the elderly, with a worse previous functional class (NYHA > 2 out of 34 vs 15%). The elderly were treated with fewer invasive procedures (25 vs 44%) or catheterization (26 vs 36%) and they were more frequently controlled with medical treatment (86 vs 83%) although with a lower use of beta blockers (45 vs 53%). The mortality at 3 months was greater in the elderly (7.4 vs 3.0%;p < 0.005) with age being an independent predictor of bad prognosis. Cox multivariate analysis showed the age, ST segment depression, diabetes and heart failure on admission to be predictors of bad prognosis in the elderly. CONCLUSIONS A different pattern is observed in cardiovascular risk factors with a more unfavorable clinical profile in elderly patients with unstable angina. The management of these patients is less aggressive and the mortality is greater. Diabetes, heart failure and ST segment depression on admission are independent predictors of bad prognosis in elderly patients.
Collapse
|
27
|
Abizaid AS, Mintz GS, Abizaid A, Saucedo JF, Mehran R, Pichard AD, Kent KM, Satler LF, Leon MB. Influence of patient age on acute and late clinical outcomes following Palmaz-Schatz coronary stent implantation. Am J Cardiol 2000; 85:338-43. [PMID: 11078303 DOI: 10.1016/s0002-9149(99)00743-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Procedural success may be lower and complication rates higher after balloon angioplasty in older patients. Elective stent implantation improves procedural outcome in younger patients; however, few series have specifically analyzed the octogenarian population. Therefore, we studied 2,534 consecutive patients (3,965 native coronary artery stenoses) who were treated electively with Palmaz-Schatz stents and divided them into 3 groups: (1) < or = 70 years old (n = 1,805), (2) 71 to 80 years old (elderly, n = 607), and (3) > 80 years old (octogenarian, n = 122). Major in-hospital complications (death, myocardial infarction, and urgent bypass surgery) were significantly higher in the octogenarians than in the elderly and patients < or = 70 years of age (4.5% vs 2.0% and 1.5%; p = 0.001). At 1-year follow-up, cardiac events (death, nonfatal myocardial infarction, and need for any revascularization) did not differ among groups; however, there was a stepwise increase in late death in octogenarians (5%) compared with elderly patients (2%) and patients aged < or = 70 years (1%) (p = 0.001). Target lesion revascularization was similar among the groups (11% in octogenarian vs 14% in elderly and 15% in patients < or = 70 years, p = 0.791). By multivariate logistic regression analysis, age was an independent predictor of late mortality (odds ratio 1.05, p = 0.0001), but not a predictor of target lesion revascularization. Stent implantation in octogenarians is associated with (1) more acute complications, (2) a higher in-hospital mortality, (3) a higher late mortality, and (4) a target lesion revascularization similar to younger patients.
Collapse
Affiliation(s)
- A S Abizaid
- Cardiac Catheterization Laboratories, Washington Hospital Center, DC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Moreno R, García E, Cantalapiedra JL, Ortega A, López de Sá E, López-Sendón JL, Delcán JL. Manejo de la angina inestable: la edad avanzada continúa siendo un predictor independiente de manejo más conservador tras la estratificación pronóstica mediante prueba de esfuerzo. Rev Esp Cardiol (Engl Ed) 2000. [DOI: 10.1016/s0300-8932(00)75175-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
29
|
Alfonso F, Azcona L, Perez-Vizcayno MJ, Hernandez R, Goicolea J, Fernandez-Ortiz A, Bañuelos C, Escaned J, Ribera JM, Fernandez C, Macaya C. Initial results and long-term clinical and angiographic implications of coronary stenting in elderly patients. Am J Cardiol 1999; 83:1483-7, A7. [PMID: 10335767 DOI: 10.1016/s0002-9149(99)00128-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Results of 378 consecutive elderly patients (> or = 65 years) undergoing coronary stenting were compared with those of 601 younger patients. Although the restenosis rate was similar in the 2 groups, age > or = 65 years was an independent predictor of in-hospital mortality (relative risk 5.4, 95% confidence interval 1.2 to 20.1) and follow-up mortality (relative risk 2.8, 95% confidence interval 1.3 to 6.1).
Collapse
Affiliation(s)
- F Alfonso
- Department of Clinical Epidemiology, San Carlos University Hospital, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Rosenfeldt FL, Pepe S, Ou R, Mariani JA, Rowland MA, Nagley P, Linnane AW. Coenzyme Q10 improves the tolerance of the senescent myocardium to aerobic and ischemic stress: studies in rats and in human atrial tissue. Biofactors 1999; 9:291-9. [PMID: 10416043 DOI: 10.1002/biof.5520090226] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The inferior recovery of cardiac function after interventional cardiac procedures in elderly patients compared to younger patients suggests that the aged myocardium is more sensitive to stress. We report two studies that demonstrate an age-related deficit in myocardial performance after aerobic and ischemic stress and the capacity of CoQ10 treatment to correct age-specific diminished recovery of function. In Study 1 the functional recovery of young (4 mo) and senescent (35 mo) isolated working rat hearts after aerobic stress produced by rapid electrical pacing was examined. After pacing, the senescent hearts, compared to young, showed reduced recovery of pre-stress work performance. CoQ10 pretreatment (daily intraperitoneal injections of 4 mg/kg CoQ10 for 6 weeks) in senescent hearts improved their recovery to match that of young hearts. Study 2 tested whether the capacity of human atrial trabeculae (obtained during surgery) to recover contractile function, following ischemic stress in vitro (60 min), is decreased with age and whether this decrease can be reversed by CoQ10. Trabeculae from older individuals (> or = 70 yr) showed reduced recovery of developed force after simulated ischemia compared to younger counterparts (< 70 yr). Notably, this age-associated effect was prevented in trabeculae pretreated in vitro (30 min at 24 degrees C) with CoQ10 (400 MicroM). We measured significantly lower CoQ10 content in trabeculae from > or = 70 yr patients. In vitro pretreatment raised trabecular CoQ10 content to similar levels in all groups. We conclude that, compared to younger counterparts, the senescent myocardium of rats and humans has a reduced capacity to tolerate ischemic or aerobic stress and recover pre-stress contractile performance, however, this reduction is attenuated by CoQ10 pretreatment.
Collapse
Affiliation(s)
- F L Rosenfeldt
- Cardiac Surgical Research Unit, Baker Medical Research Institute, Prahran, Vic., Australia
| | | | | | | | | | | | | |
Collapse
|
31
|
Rowland MA, Nagley P, Linnane AW, Rosenfeldt FL. Coenzyme Q10 treatment improves the tolerance of the senescent myocardium to pacing stress in the rat. Cardiovasc Res 1998; 40:165-73. [PMID: 9876329 DOI: 10.1016/s0008-6363(98)00132-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE In elderly patients the results of cardiac interventions are inferior to those in the young. A possible contributing factor is an age-related reduction in cellular energy transduction during the intervention which may induce aerobic or ischemic stress. To investigate whether coenzyme Q10 (CoQ10) improves the response to aerobic stress, functional recoveries of senescent and young rat hearts after rapid pacing were compared with or without CoQ10. METHODS Young (4.8 +/- 0.1 months) and senescent (35.3 +/- 0.2 months) rats were given daily intraperitoneal injections of CoQ10 (4 mg/kg) or vehicle for 6 weeks. Their isolated hearts were rapidly paced at 510 beats per minute for 120 min to induce aerobic stress without ischemia. RESULTS In senescent hearts pre-pacing cardiac work was 74% and oxygen consumption (MVO2) 66% of that in young hearts. CoQ10 treatment abolished these differences. After pacing, the untreated senescent hearts, compared to young, showed reduced recovery of pre-pacing work, (16.8 +/- 4.3 vs. 44.5 +/- 7.4%; P < 0.01). CoQ10 treatment in senescent hearts improved recovery of work, (48.1 +/- 4.1 vs. 16.8 +/- 4.3%; P < 0.0001) and MVO2 (82.1 +/- 2.8 vs. 61.3 +/- 4.0%; P < 0.01) in treated versus untreated hearts respectively. Post-pacing levels of these parameters in CoQ10 treated senescent hearts were as high as in young hearts. CONCLUSIONS (1) Senescent rat hearts have reduced baseline function and reduced tolerance to aerobic stress compared to young hearts. (2) Pre-treatment with CoQ10 improves baseline function of the senescent myocardium and its tolerance to aerobic stress.
Collapse
Affiliation(s)
- M A Rowland
- Cardiac Surgical Research Unit, Baker Medical Research Institute, Prahran, Victoria, Australia
| | | | | | | |
Collapse
|
32
|
De Gregorio J, Kobayashi Y, Albiero R, Reimers B, Di Mario C, Finci L, Colombo A. Coronary artery stenting in the elderly: short-term outcome and long-term angiographic and clinical follow-up. J Am Coll Cardiol 1998; 32:577-83. [PMID: 9741496 DOI: 10.1016/s0735-1097(98)00287-3] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study sought to compare the short- and long-term outcomes of elderly patients undergoing coronary artery stenting with those of younger patients and to determine the long-term clinical outcome and survival of elderly patients post stent implantation. BACKGROUND Elderly patients undergoing coronary revascularization are considered a high-risk group. Few data exist that relate the results of stenting in treating coronary artery disease in the elderly population. METHODS All elderly patients >75 years of age who underwent coronary artery stenting between March 1993 and July 1997 (n=137) at our center were compared to the patients <75 who underwent coronary artery stenting during the same time period (n=2,551). Long-term clinical follow-up and survival were determined for the elderly group. RESULTS Elderly patients presented with lower ejection fractions (54% vs. 58%, p=0.0001), more unstable angina (47% vs. 28%, p=0.0001), and more multivessel disease (78% vs. 62%, p= 0.0001) than younger patients. These older patients had higher rates of procedure related complications including procedural myocardial infarction (MI) (2.9% vs. 1.7%, p=0.2), emergency CABG (3.7% vs. 1.4%, p=0.04), and death (2.2% vs. 0.12%, p=0.0001). Angiographic follow-up, obtained in both groups, demonstrated significantly higher restenosis rates in the elderly versus younger patients (47% vs. 28%, p=0.0007). Longer term clinical follow-up, which was obtained only in the elderly group, showed that at a mean follow-up period of 12 months post coronary stenting, elderly survival free from death, MI, revascularization and angina was 54% and that their overall survival was 91%. Subanalysis of the elderly patients who died showed much higher incidence of combined unstable angina (80%), prior MI (60%), lower ejection fraction (46%), multivessel disease (100%) and complex lesions (100%) than the overall group. CONCLUSIONS Elderly patients who undergo coronary artery stenting have significantly higher rates of procedural complications and worse six month outcomes than younger patients, especially those who present with combined unstable angina, history of MI, EF < 50%, multivessel disease and complex lesions. Overall survival in the elderly population at 12 months postcoronary artery stenting was 91% and event-free survival was 54%.
Collapse
|
33
|
Lefèvre T, Morice MC, Eltchaninoff H, Chabrillat Y, Amor M, Juliard JM, Gommeaux A, Cattan S, Dumas P, Benveniste E. One-month results of coronary stenting in patients > or = 75 years of age. Am J Cardiol 1998; 82:17-21. [PMID: 9671002 DOI: 10.1016/s0002-9149(98)00236-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Coronary artery bypass operations are associated with increased morbidity and mortality in the elderly. Similarly, it has been shown that coronary angioplasty is associated with a higher risk of complications in the elderly than in younger patients. The purpose of this study was to evaluate the 1-month outcome of elderly patients (>75 years old) who were included in the Stenting without Coumadin French Registry. From December 1992 to March 1995, 2,900 patients (mean age 61+/-11 years) were included in this registry. All patients were treated with ticlopidine (250 to 500 mg/day) for 1 month from the day of percutaneous transluminal angioplasty, aspirin (100 to 250 mg/day) for >6 months, and low-molecular-weight heparin (antiXa 0.5 to 1 IU/ml) for 1 month in phase II, 15 days in phase III, and 7 days in phase IV. No heparin was given in phase V. The study group included 233 patients (8.0%) > 75 years old (mean age 79+/-4), 44 (18%) of whom were women. All patients underwent dilatation of a native coronary vessel. One hundred seventeen had unstable angina (50.2%), 20 had postmyocardial infarction ischemia (8.6%), and 6 had acute myocardial infarction (2.6%). Indications for stenting were de novo lesion in 63 patients (27.0%), restenosis in 38 (16.3%), suboptimal result in 48 (20.6%), nonocclusive dissection in 56 (24.0%), and occlusive dissection in 28 (12.0%), respectively. Stented coronary arteries were the left anterior descending in 109 (46.8%), the right in 80 (34.3%), the left circumflex in 40 (17.2%), and the left main in 4 (1.7%). Palmaz-Schatz stents were used in 228 patients (82.0%), AVE microstents in 38 (13.7%), and other stents in 12 (4.3%). More than 1 stent was used in 48 patients (17.3%). The mean diameter of the balloon used for stenting was 3.31+/-0.38 mm and maximal inflation pressure was 12.2+/-2.9 atm. At one-month follow-up, vascular complications occurred in 5 patients, requiring surgery in 2 (1.3%), acute closure occurred in 1 (0.4%), subacute closure in 3 (1.3%), emergency or planned coronary artery bypass graft surgery in none, acute myocardial infarction in 4 (1.7%), stroke in 1 (0.4%), and death in 8 (3.4%). The composite end point of a major cardiac event was observed in 13 cases (5.6%). Coronary stenting using ticlopidine and aspirin appears to be a particularly safe approach in this high-risk subset.
Collapse
Affiliation(s)
- T Lefèvre
- Institut Cardiovasculaire Paris Sud, Institut Hospitalier Jacques Cartier, Massy, France
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Mandak JS, Blankenship JC, Gardner LH, Berkowitz SD, Aguirre FV, Sigmon KN, Timmis GC, Gilchrist IC, McIvor M, Resar J, Weiner BH, George BS, Talley JD, Lincoff AM, Tcheng JE, Califf RM, Topol EJ. Modifiable risk factors for vascular access site complications in the IMPACT II Trial of angioplasty with versus without eptifibatide. Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis. J Am Coll Cardiol 1998; 31:1518-24. [PMID: 9626829 DOI: 10.1016/s0735-1097(98)00130-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study was designed to identify potential predictors of vascular access site (VAS) complications in the large-scale Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis (IMPACT) II trial, which studied angioplasty with versus without a new glycoprotein (GP) IIb/IIIa receptor inhibitor (eptifibatide). BACKGROUND GP IIb/IIIa receptor inhibition during coronary interventions has been associated with excess VAS complications. If other predictors of VAS complications could be identified, they might be manipulated to reduce complications. METHODS A total of 4,010 patients undergoing percutaneous transluminal coronary revascularization (PTCR) were randomized into one of three bolus/20- to 24-h infusion arms: placebo bolus/placebo infusion; 135-microg/kg body weight eptifibatide bolus/0.5-microg/kg per min eptifibatide infusion; or 135-microg/kg eptifibatide bolus/0.75-microg/kg per min eptifibatide infusion. Heparin during the procedure was weight adjusted and stopped 4 h before sheaths were removed. Logistic regression modeling was used to identify independent predictors of VAS complications. RESULTS VAS complications were more common in patients treated with eptifibatide (9.9% vs. 5.9% placebo-treated patients, p < 0.001). Multivariate analysis identified eptifibatide therapy (p < 0.0001), advanced age (p = 0.0001), longer time to sheath removal (p = 0.0002), stent placement (with intense post-stent anticoagulation) (p = 0.0004), female gender (p = 0.0006), PTCR within 24 h of thrombolytic therapy (p = 0.002), larger heparin doses during PTCR (p = 0.009), major coronary dissection (p = 0.03) and placement of a venous sheath (p = 0.04) as independent predictors of VAS complications. CONCLUSIONS VAS complications may be reduced by early sheath removal, by avoiding placement of venous sheaths and by limiting heparin dosing to avoid excessive activated clotting times. Early sheath removal during inhibition of platelet aggregation by eptifibatide is feasible.
Collapse
Affiliation(s)
- J S Mandak
- Geisinger Medical Center, Danville, Pennsylvania 17822-2160, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Blake-Inada LM, Goldschlager N. Unstable angina. Strategies to minimize myocardial injury. Postgrad Med 1996; 100:139-42, 147-9, 153-4. [PMID: 8700813 DOI: 10.3810/pgm.1996.08.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The primary goals in treatment of unstable angina are to relieve pain and prevent or limit myocardial infarction or ischemia. Patients with distinct, rapid progression of their usual angina pattern should be admitted to a coronary care unit and given heparin and intravenous nitrates as well as aspirin. Cardioselective beta blockers should also be administered when there are no contraindications. Intravenous thrombolytic agents are indicated in patients with objective evidence of ischemia who fit criteria for this therapy. However, thrombolysis is not advocated for routine treatment of unstable angina. Percutaneous transluminal coronary angioplasty or coronary artery bypass grafting should be considered--depending on the location, age, and morphology of the culprit lesion and the degree of left ventricular dysfunction--in patients who have refractory or recurrent ischemia despite aggressive medical therapy. However, in general, high-technology interventions are not a substitute for long-term regimens, such as risk-factor and lifestyle modification, daily aspirin, and pharmacologic therapies aimed at maximizing cardiac function.
Collapse
Affiliation(s)
- L M Blake-Inada
- Department of Medicine, University of California, San Francisco, School of Medicine, USA
| | | |
Collapse
|
36
|
Abstract
The elderly represent an increasingly important and challenging subset of the population of patients with ischemic heart disease. They are more likely to have comorbid conditions, atypical presentations, and unfavorable outcomes than their younger counterparts. Some of these findings are undoubtedly related to the structural and functional changes in the cardiovascular system associated with aging. The available data suggest that standard pharmacologic, thrombolytic, and definitive revascularization techniques have important roles in the therapy of geriatric patients but have been underused.
Collapse
Affiliation(s)
- N M Keller
- New York University School of Medicine, Tisch Hospital, Cardiac Catheterization Laboratory, NY 10016, USA
| | | |
Collapse
|
37
|
|