Non-ST-elevation acute coronary syndrome in the elderly: treatment strategies and 30-day outcome

Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective

Background

As the elderly represent a substantial proportion of medical care beneficiaries, and there is limited data about age disparity in emerging countries, this study sought to investigate the impact of age on the management in patients with non-ST elevation acute coronary syndromes (NSTE-ACS).

Results

Two hundred patients with NSTE-ACS enrolled prospectively, patients’ data, pharmacotherapy, management strategy as well timing to catheterization were documented. Patients grouped into ≥ 65 years versus < 65 years; 32.5% were ≥ 65-year-old. The older group presented as high GRACE risk (Global Registry of Acute Coronary Events) (67.7% versus 15.6%). Elderly patients were less likely to be referred for catheterization compared with younger counterparts (55.4% versus 76.3%, p = 0.003). Within low risk class patients, none of the elderly versus 9.33% of younger patients were catheterized within 2 h; in the same line, none of the elderly versus 16% of younger patients were catheterized within 24 h. Alternatively, at high risk class, 6.81% of the elderly and none of the younger patients were catheterized within 2 h. On the univariate analysis of variables to predict invasive strategy, presence of history of prior IHD, diabetes, absent in-hospital acute heart failure or atrial fibrillation/flutter, higher haemoglobin and lower creatinine levels predicted the use of invasive strategy, while on multivariate analysis, acute heart failure (95% CI − 0.38 to − 0.41, p = 0.01), lower haemoglobin (95% CI 0.002–0.07, p = 0.03), and atrial fibrillation/flutter (95% CI − 0.48 to − 0.02, p = 0.03) predicted conservative strategy. The elderly were more likely to have acute heart failure (32.3% versus 14.8%, p = 0.004), same as stroke (3.1% versus none, p = 0.04).

Conclusions

Less-invasive strategy used in the elderly with NSTE-ACS compared with younger counterparts, yet age was not a predictor of catheterization underuse on multivariate analysis. It is crucial to bridge the age gap in the healthcare system in setting of ACS management by grasping the attention of decision makers and emphasizing on the adherence of healthcare providers to the guidelines to improve cardiovascular care and outcomes.

Invasive management of acute coronary syndrome: Interaction with competing risks

BACKGROUND

The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS).

METHODS

Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July-December, 2003-2011 with troponin elevation (>30 ng/L) were included. "ACS-specific-risk" was estimated using the GRACE score and "non-ACS-risk" was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard.

RESULTS

In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as 'low-non-ACS risk' (CCI ≤ 1; invasive management 81%; 12-month mortality 5%), 820 as 'medium-non-ACS risk' (CCI 2-3; invasive management 68%; 12-month mortality 13%), and 468 as 'high-non-ACS risk' (CCI ≥ 4; invasive management 47%; 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the 'low-risk' and 'medium-risk' groups (HR = 0.38, 95%CI:0.26-0.56; HR = 0.46, 95%CI:0.32-0.67); but not in the 'high-risk' group (HR = 1.02, 95%CI:0.67-1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk.

CONCLUSIONS

There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in individuals with numerous comorbidities.

Single and dual antiplatelet therapy in elderly patients of medically managed myocardial infarction

Backgrounds

To examine the comparative effectiveness between dual and single antiplatelet therapies in real-world, medically managed elderly patients with acute myocardial infarction (AMI).

Methods

This retrospective study identified very elderly (> 85 years) patients, who were medically managed, with their first AMI from the Taiwan National Health Insurance claims database from 2007 to 2010. Patients were classified as dual antiplatelet therapy (DAPT) group, aspirin only group and clopidogrel only group. Study outcomes included all-cause death, cardiovascular death and gastrointestinal bleeding. Treating DAPT group as the reference, we employed a multivariable Cox regression model to compare the relative risks of outcomes between 3 groups using pairwise comparison approach.

Results

Among 1469 patients with incident ST-elevation myocardial infarction (STEMI, 14%) or non-STEMI (86%), 390 patients were prescribed DAPT, 549 aspirin only, and 530 clopidogrel only. After 9 months of follow-up, aspirin only group had similar risks of all-cause death (adjusted HR 1.21, 95% CI 0.77–1.89, p = 0.41), cardiovascular death (adjusted HR 1.16, 95% CI 0.66–2.04, p = 0.60) and gastrointestinal bleeding (adjusted HR 1.66, 95% CI 0.77–3.57, p = 0.20) in comparison with DAPT group. Clopidogrel users had a higher risk of all-cause death (adjusted HR 1.50, 95% CI 1.00–2.25, p = 0.049) but similar risks of cardiovascular death and gastrointestinal bleeding when compared with DAPT.

Conclusions

Among very elderly patients who were medically managed after AMI, single antiplatelet therapy had comparable protective effect as DAPT. But clopidogrel only strategy was associated with a higher risk of all-cause death.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0777-4) contains supplementary material, which is available to authorized users.

Acute Myocardial Infarction Population Incidence and Mortality Rates, and 28-day Case-fatality in Older Adults. The REGICOR Study

INTRODUCTION AND OBJECTIVES

Our aims were to determine acute myocardial infarction (AMI) incidence and mortality rates, and population and in-hospital case-fatality in the population older than 74 years; variability in clinical characteristics and AMI management of hospitalized patients, and changes in the incidence and mortality rates, case-fatality, and management by age groups from 1996 to 1997 and 2007 to 2008.

METHODS

A population-based AMI registry in Girona (Catalonia, Spain) including individuals with suspected AMI older than 34 years.

RESULTS

The incidence rate increased with age from 169 and 28 cases/100 000 per year in the group aged 35 to 64 years to 2306 and 1384 cases/100 000 per year in the group aged 85 to 94 years, in men and women, respectively. Population case-fatality also increased with age, from 19% in the group aged 35 to 64 years to 84% in the group aged 85 to 94 years. A lower population case-fatality was observed in the second period, mainly explained by a lower in-hospital case-fatality. The use of invasive procedures and effective drugs decreased with age but increased in the second period in all ages up to 84 years.

CONCLUSIONS

Acute myocardial infarction incidence, mortality, and case-fatality increased exponentially with age. There is still a gap in the use of invasive procedures and effective drugs between younger and older patients.

Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis

BACKGROUND

Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld.

METHODS

We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy.

RESULTS

Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies.

CONCLUSION

Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.

Randomized comparison between the invasive and conservative strategies in comorbid elderly patients with non-ST elevation myocardial infarction

BACKGROUND

Comorbid elderly patients with non-ST-elevation myocardial infarction (non-STEMI) are underrepresented in randomized trials and undergo fewer cardiac catheterizations according to registries. Our aim was to compare the conservative and invasive strategies in these patients.

METHODS

Randomized multicenter study, including 106 patients (January 2012-March 2014) with non-STEMI, over 70years and with comorbidities defined by at least two of the following: peripheral artery disease, cerebral vascular disease, dementia, chronic pulmonary disease, chronic renal failure or anemia. Patients were randomized to invasive (routine coronary angiogram, n=52) or conservative (coronary angiogram only if recurrent ischemia or heart failure, n=54) strategy. Medical treatment was identical. The main endpoint was the composite of all-cause mortality, reinfarction and readmission for cardiac cause (postdischarge revascularization or heart failure), at long-term (2.5-year follow-up). Analysis of cumulative event rate (incidence rate ratio=IRR) and time to first event (hazard ratio=HR), were performed.

RESULTS

Cardiac catheterization/revascularization rates were 100%/58% in the invasive versus 20%/9% in the conservative arm. There were no differences between groups in the main endpoint (invasive vs conservative: IRR=0.946, 95% CI 0.466-1.918, p=0.877) at long-term. The invasive strategy, however, tended to improve 3-month outcomes in terms of mortality (HR=0.348, 95% CI 0.122-0.991, p=0.048), and of mortality or ischemic events (reinfarction or postdischarge revascularization) (HR=0.432, 95% CI 0.190-0.984, p=0.046). This benefit declined during follow-up.

CONCLUSIONS

Invasive management did not modify long-term outcome in comorbid elderly patients with non-STEMI. The finding of a tendency towards an improvement in the short-term needs confirmation in larger studies (clinicaltrials.govNCT1645943).

Administration of low molecular weight and unfractionated heparin during percutaneous coronary intervention

This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p<0.001), which was associated with similar target vessel revascularization (p=0.6), similar incidence of stroke (p=0.7), and significantly lower incidence of re-myocardial infarction (p<0.001), major bleeding (p=0.02) and mortality (p<0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.

What's Age Got to do with it? A Review of Contemporary Revascularization in the Elderly

Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.

Update: acute coronary syndromes (VI): treatment of acute coronary syndromes in the elderly and in patients with comorbidities

Acute coronary syndromes have a wide spectrum of clinical presentations and risk of adverse outcomes. A distinction should be made between treatable (extent of ischemia, severity of coronary disease and acute hemodynamic deterioration) and untreatable risk (advanced age, prior myocardial damage, chronic kidney dysfunction, other comorbidities). Most of the patients with "untreatable" risk have been excluded from the "guideline-generating" clinical trials. In recent years, despite the paucity of specific randomized trials, major advances have been completed in the management of elderly patients and patients with comorbidities: from therapeutic nihilism to careful titration of antithrombotic agents, a shift toward the radial approach to percutaneous coronary interventions, and also to less-invasive cardiac surgery. Further advances should be expected from the development of drug regimens suitable for use in the elderly and in patients with renal dysfunction, from a systematic multidisciplinary approach to the management of patents with diabetes mellitus and anemia, and from the courage to undertake randomized trials involving these high-risk populations.

Age-related differences in diagnosis, treatment and outcome of acute coronary syndromes: results from the German ALKK registry

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.

Hospital admission time and acute myocardial infarction outcomes in elderly patients from Central Asia

Aim. To identify the specifics of acute myocardial infarction (AMI) clinical course and to study the association between clinical outcomes and hospital admission time among elderly patients from Central Asia. Material and methods. In total, 508 AMI patients were divided into the main group (MG), which included 298 men and women aged over 65 years, and the control group (CG; n=210). The analysed parameters included mean time between AMI onset and hospital admission; percentage of patients hospitalised within first 6 hours; percentage of patients administered streptokinase; streptokinase effectiveness; clinical course of AMI; and in-hospital outcomes. Results. Mean hospital admission time was significantly higher in the MG, compared to the CG: 1220±165 vs. 977±88 minutes (p<0,05). Out of 188 MG patients with ST segment elevation, thrombolytic therapy (TLT) was administered to 14,3 %; in the CG (149 patients with ST segment elevation), the respective percentage was 25,5 %. Clinical course of AMI was similar in both groups. However, the MG was characterised by a significantly higher risk of death (9,4 % vs. 2,86 %; F=0,001; OR 3,53, 95 % CI 1,43—8,67), acute heart failure (33,89 % vs. 21,9 %; F=0,001; OR 1,83, 95 % CI 1,22—2,74), or chronic heart failure (41,31 % vs. 24,76 %; F=0,000; OR 2,62, 95 % CI 1,78—3,86). Conclusion. Elderly patients faced a lower chance of myocardial reperfusion, due to later hospital admission and lower TLT effectiveness, and, as a result, had a higher risk of heart failure.

Pathological ankle-brachial index is equivalent of advanced age in acute coronary syndromes

BACKGROUND

Age is one the factors associated with poor prognosis in acute coronary syndromes (ACS) and elderly patients are a high-risk collective with few parameters for mid-term cardiovascular stratification. We aimed to assess the predictive value of ankle-brachial index (ABI) in patients (> 75 years) for 1-year mortality after an ACS.

MATERIALS AND METHODS

Prospective, observational and multicentre study of ACS patients in whom ABI was assessed during hospitalization.

RESULTS

A total of 1·054 patients were included, mean age 66·6 (11·7) years from whom 26·6% were > 75 years. Elderly patients showed more history of cardiovascular disease and higher prevalence of all risk factors, except current smoking. Angiography and revascularization were performed less frequently in the elderly. Patients > 75 years showed higher presence of three vessel coronary disease and received fewer guideline-recommended treatments. Patients who died through the follow-up, mean time 387·9 ± 7·2 days, had lower ABI (0·73 ± 0·24 vs. 0·92 ± 0·22; P < 0·01), also in the elderly patients (0·73 ± 0·24 vs. 0·86 ± 0·23; P < 0·01). Cox regression analysis identified age > 75 years (HR: 2·30; IC 95% 1·26-4·18; P < 0·01) and ABI < 0·90 (HR: 3·58; IC 95% 1·80-7·15; P < 0·01) as risk factors for to 1-year mortality. Mortality was similar in elderly patients with ABI > 0·90 and young patients with ABI < 0·90; the worst prognosis was observed in elderly patients with ABI < 0·90 (HR: 10·01; 95% CI 3·74-27·15).

CONCLUSIONS

Elderly patients represent a relevant collective of patients with ACS and are treated less optimally. ABI predicts 1-year mortality after an ACS in elderly patients.

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry

BACKGROUND

There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI).

METHODS

We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years).

RESULTS

963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH.

CONCLUSIONS

The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

Antiplatelet drugs in the elderly: prescriptions often inappropriate and reduced tolerance by associated diseases and drugs

To assess the conditions of prescriptions and tolerance of antiplatelet drugs (APD) in the elderly and to detail the parameters that influence the tolerance of these drugs. Prospective survey in a Department of Geriatric Medicine. Two hundred nineteen patients 70 years and older treated with one or two APD prior to admission were included during 7 months in 2008. We recorded the type of APD, associated diseases, main associated or co-prescribed drugs which could interact with APD and the bleeding adverse events including cutaneous bleeding. The mean age of the 219 patients was 84.5 ± 6.7 years (70-101 years), women 59.4%. Among patients 64.8% received aspirin (mainly 75 mg), 28.3% received clopidogrel and 6.8% received their combination; 16.9% of prescriptions were off-label; 51.6% of patients had an associated disease and/or an associated drug which could have increased risk of bleeding event. Among the patients who received a gastric-protective drug, the prescription followed the recommendations of the French Health Authority in 38.9%. We recorded bleeding events in 24.2% of patients at admission and in 18.3% of patients during the hospitalization. Bleeding events were significantly more frequent in patients treated with aspirin than clopidogrel (40.8 vs. 24.2%, P < 0.05) and/or with an associated drug (OR = 2.36, 95% CI 1.34-4.14, P < 0.01) and/or an associated disease (OR = 1.22, 95% CI 1.01-3.42, P < 0.05). APD treatment was stopped in 28.8% of patients, mainly because lack of indication or bleeding adverse events. Off-label prescriptions of APD were not rare in the elderly, and adverse events are frequent. The results of this preliminary study evoke that medical situations at increased risk of bleeding are perhaps insufficiently evaluated, either in case of prescription of associated drugs with increased bleeding risk or during the follow-up of patients with associated diseases. Cutaneous bleeding events should be more taken into account in prospective studies.

Survival and changes in physical ability after coronary revascularization for octa-nonagenerian patients with acute coronary syndrome

Elderly populations are increasingly represented among patients with acute coronary syndrome (ACS), and advanced age has been identified as an important risk factor for death and adverse outcome in patients with ACS treated invasively. Although considerable data have demonstrated a prognostic benefit of early revascularization in ACS particularly in high-risk patients, elderly patients with ACS are treated invasively less often than younger patients because older age is thought to be an independent predictor of mortality after percutaneous coronary intervention (PCI) in ACS. Over the past 5 years, a total of 54 ACS patients over 85 years old were treated. The 6-month survival rate was around 50% in the non-PCI group (n = 12) and around 80% in the PCI group (n = 42) (P < 0.05). Cardiac death occurred in 6 patients in the PCI group and in 6 patients in the non-PCI group. The rates of both cardiac death and all-cause death were significantly lower in the PCI group. The change in ADL score before and 6 months after the procedure was from 1.57 to 1.59 in the PCI group and from 2.25 to 2.20 in the non-PCI group. PCI for elderly patients with ACS is safe and life saving, and does not reduce the ability to perform activities of daily living. PCI should be recommended even for octo-nonagenerians with ACS.

[Are very old patients good candidates for percutaneous coronary intervention? A monocentric retrospective study]

AIM

To determine the feasibility of percutaneous coronary intervention (PCI) in very old patients.

BACKGROUND

The elderly are a growing population with a high prevalence of ischemic heart disease and then subsequent possibility to benefit from coronary interventions.

METHOD

We have conducted a retrospective study using our PCI database since January 2000. Population characteristics, clinical presentation, type of lesions, technical procedure, immediate results and in hospital outcome are compare between patients older than 85 and the other.

RESULTS

Between January 2008 and March 2009, 3130 patients benefit from coronary angioplasty. Among them, 85 patients were older than 85. There were more female in this group (24.7 vs. 14.3%, P=0.007), but no difference in cardiovascular risk profile. The older was more symptomatic (acute coronary syndrome: 59.52 vs. 44%, P=0.004; silent ischemia: 3.6 vs. 25.7%, P=0.000003). The ejection fraction was worse (EF<55%: 29.4 vs. 14.5%, P=0.0001). The lesion was more complex (B2 and C: 67.2 vs. 57.1% P=0.027) and concern more often the left descending artery (85.9 vs. 57.1%, P=0.000001). The technical success was similar in the two groups (93.28 vs. 94.32%, P=0.34) with similar rate of per procedure complications (2.35 vs. 1.5%, P=0.37). Nevertheless, the in-hospital rate mortality was higher in the older patients (7 vs 1.38%, P=0.0014).

CONCLUSION

PCI is safe and safety in very old patients despite significant but acceptable increasing in-hospital mortality due to more severe disease and co morbidities. Further evaluations are necessary in order to edict specific recommendations.

Prediction of myocardial infarction risk in older patients with acute coronary syndrome

PURPOSES

To identify bedside variables that aid in diagnosis of acute coronary syndrome (ACS) and might facilitate rapid triage of patients aged > or = 65 years.

BASIC PROCEDURES

Prospective, observational study of consecutive patients aged > or = 65 years with suspicion of ACS presenting to our emergency department (ED). Patients' medical characteristics were collected at baseline and during a 1-month follow-up period. We identified variables independently associated with ACS by multivariate analyses and bootstrapping techniques.

MAIN FINDINGS

Among 399 patients, 124 (31.1%) received a diagnosis of ACS (61 acute myocardial infarction, 63 unstable angina). We surveyed multiple clinical and ECG variables to develop a predictive model which included the following variables: male sex, history of coronary artery disease, typical chest pain, dyspnea, epigastric pain, pathological Q-wave, ST-segment elevation (area under the receiver operating characteristic curve (AUC) 0.79, 95% confidence interval 0.71 to 0.82). With the addition of cardiac troponin I to the model the AUC increased to 0.83 (0.79 to 0.88). We used these findings to create the Heart Attack Risk for aged Patient (HARP) scale. Our data suggest that patients with a low HARP score might be safely managed without further testing.

PRINCIPAL CONCLUSIONS

A model based on variables easily available at ED presentation from history, physical examination, and electrocardiography, can help ED physicians to identify seniors at very low risk of ACS.

Target populations and relevant therapeutic end points to further improve outcomes in NSTEACS patients

An aggressive pharmaco-interventional approach has been shown to improve long-term outcome among high-risk patients with acute coronary syndromes without ST-segment elevation (NSTEACS). However, these patients continue to represent a minority among those enrolled in clinical trials, thus precluding the possibility to further improve therapeutic efficacy. Target populations that are not adequately addressed by the majority of therapeutic trials are mainly the elderly and those with reduced renal function, who all show unfavorable outcome after an episode of NSTEACS. In order to allow comparison among different studies, a prerequisite for the planning of meaningful trials should be a uniform definition of the study end points besides mortality, particularly with reference to recurrent myocardial infarction, and rehospitalization owing to cardiovascular instability or severe bleeding. In addition to trial design issues, improvements in the regulatory rules for drug development and in hospital networking conceal significant opportunities to improve treatment of NSTEACS.

[Coronary angioplasty in octogenarians]

Coronary angioplasty is the most frequent method used for coronary revascularisation. Recommendations about its application are well-established. The elderly are a growing population with a high prevalence of ischaemic heart disease, especially with unstable presentation. Despite the worse prognostic reliable to these patients, aggressive treatments are often lacking, particularly the achievement of percutaneous coronary interventions. Most of the time excluded from the largest clinical trials, subject to more complications, bleeding and renal failure for example, the recommendations seem more difficult to implement. The authors propose an update about angioplasty over 80 years. The results of many important registries suggest that octogenarians are potential good candidates for angioplasty, without underestimating the complications inherent with the procedure. However, the selection of patients, improved materials, the choice of the route approach and the development of new molecules can significantly reduce this morbidity. In addition, largest inclusion of elderly in clinical trials and specific studies should allow for more focused recommendations.

Hospital and long-term prognosis of patients with non-ST-segment elevation myocardial infarction

A szerzők 139, nem ST-elevációs infarktus miatt kezelt betegük adatait elemzik. Vizsgálják a betegek kórházi és késői prognózisát, egyes echokardiográfiás adatok prognózissal való összefüggését, valamint a kórházból elbocsátott betegek esetén a szekunder prevenció szempontjából ajánlott gyógyszeres kezelés gyakoriságát. Az utánkövetés a betegek 98%-ában sikeres volt, a bekövetkezett eseményekről, illetve az utánkövetés idején alkalmazott gyógyszeres kezelésről postai kérdőív útján szereztek adatokat. A nők átlagéletkora 78,6, a férfiaké 71,4 év volt. A kezelt betegeknél gyakori volt a társbetegségek (hypertonia, diabetes mellitus, korábbi ischaemiás szívbetegség) előfordulása. A kórházi kezelés időszakában 30 betegnél (22%) történt koronarográfia, és 29 betegnél revascularisatiós beavatkozásra is sor került. A kórházi halálozás 15% volt, az utánkövetés háromnegyed éve alatt 17%-os halálozást észleltek. A kórházban, illetve az utánkövetési idő alatt meghalt betegek szignifikánsan idősebbek voltak azoknál, akik életben maradtak. Egyes echokardiográfiás adatok (ejekciós frakció, végszisztolés átmérő, szegmentális falmozgászavar és a mitralis insufficientia nagysága) prognosztikus jelentőségűnek bizonyultak, mivel szignifikánsan különböztek az életben maradt és a meghalt betegek esetén. A kórházból elbocsátott betegek igen magas arányban részesültek a másodlagos prevenció szempontjából fontosnak ítélt gyógyszeres kezelésben (aszpirin, béta-blokkoló, ACE-gátló, statin). Az utánkövetés idején sem csökkent ezen gyógyszerek használatának aránya, ami a betegek jó compliance-ét igazolja.

Abciximab in elderly with acute coronary syndrome invasively treated: effect on outcome

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77+/-1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77+/-2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p=0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p=0.0001), and pre-PCI (5.7% vs 13.4%; p=0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394-0.976, p=0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

The elder patient with suspected acute coronary syndromes in the emergency department

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.

Management of non-ST-Segment Elevation Myocardial Infarction

Non-ST-segment elevation myocardial infarction (NSTEMI) is a major cause of cardiovascular morbidity and mortality in the United States. It represents the highest risk category of non-ST-segment elevation acute coronary syndromes (NSTEACS), for which timely diagnosis and appropriate therapy are paramount to improve outcomes. Evidence-based treatment, with combination of antiplatelet and anticoagulant therapy, and with serious consideration of early coronary angiography and revascularization along with anti-ischemic medical therapy, is the mainstay of management for NSTEMI. Aggressive risk-factor control after the acute event is imperative for secondary prevention of cardiovascular events. Applying in practice the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations results in improved outcomes.

Results of percutaneous coronary interventions in patients ≥90 years of age

BACKGROUND

There are few data about percutaneous coronary interventions (PCI) in nonagenarians (patients aged > or =90 years). This study aimed to assess acute and intermediate term clinical outcomes among nonagenarian patients undergoing PCI.

METHODS

The study included 65 consecutive patients, age > or =90 years undergoing PCI between January 2001 and August 2006. Fourteen patients were admitted with acute ST elevation acute myocardial infarction (STEAMI), one had cardiogenic shock, 39 patients sustained non-STEAMI, and 12 patients were with severe stable angina pectoris. Procedural data, in-hospital, and six-month clinical outcomes were obtained and adjudicated for all patients.

RESULTS

Coronary angiography documented multivessel disease in 86% of patients with relatively complex lesions (type B or C) in 94% treated using stent deployment in 92% of patients. In 7% of cases IABP was needed. Immediate procedural success was achieved in 92% patients. Cumulative mortality at hospital discharge and by 30-days was 14% and increased to 18% at 6-months follow-up. Total major adverse cardiac events (MACE: death, AMI, TVR, stroke) was 17% at hospital discharge and increased to 21% by 6-months. Stroke was documented in one patient (1.5%) at hospital discharge. Cumulative mortality at 6 month was 0% in patients with stable angina and 23% in emergent PCI scenario (AMI or NSTEAMI or ACS). Univariate analysis revealed that emergent PCI, systolic blood pressure, left ventricular ejection fraction, diabetes mellitus, renal failure, TIMI flow at baseline, and procedural success, are all correlative with 6-months mortality.

CONCLUSION

We conclude that clinically stable nonagenarian patients with coronary artery disease undergoing PCI have excellent PCI related prognosis while clinically unstable patients have a worse outcome. Thus, careful attention to background medical history and clinical presentation should dictate the prognosis and/or management among nonagenarian patients.

Use of glycoprotein IIb/IIIa inhibitors in invasively-treated patients with non-ST elevation acute coronary syndrome

Background In patients with non-ST elevation acute coronary syndrome (NST-ACS) that is treated invasively, glycoprotein (GP) IIb/IIIa inhibitors can be used either as upstream treatment in a coronary care unit or as downstream provisional treatment in selected patients who are undergoing percutaneous coronary intervention (PCI). The relative advantage of either strategy is unknown. The purpose of this study was to assess 30-day outcome of patients enrolled in a prospective NST-ACS registry and treated invasively with either of these two therapeutic strategies. Methods Patients treated invasively (coronary arteriography within 4 days of admission), in the prospective registry ROSAI-2, were divided into two groups according to the upstream use of GPIIb/IIIa inhibitors (n = 241), or not (n = 548). In the latter group, 76 (14%) patients received GPIIb/IIIa in association with a PCI procedure. Clinical and angiographic characteristics as well as in-hospital and 30-day outcome of these two groups of patients were compared. Results The two groups were similar with respect to age, sex, presence of hypertension, diabetes, number of PCI procedures. However, patients treated with upstream GPllb/llla blockers had more frequently ST-segment depression (P = 0.002), a high TIMI risk score (P = 0.01) and were more frequently admitted to centres with Cath Lab facilities (P = 0.001). At 30-day follow-up, the composite of death, acute myocardial infarction and stroke, as well as major bleeding, was not significantly different between the two groups, although it occurred more frequently in patients who received upstream GPIIb/IIIa blockers (9.5% versus 5.7% and 1.7% versus 0.2%, respectively). By multivariate analysis, diabetes [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.2-4.09] and a diagnosis on admission of non-Q-wave myocardial infarction (OR = 2.0, 95% Cl = 1.10-3.6) were independently related to outcome. No additional risk or benefit was related to upstream GPIIb/IIIa inhibitor treatment (OR = 1.5, 95% Cl = 0.84-2.68). Conclusions Among invasively-treated patients with NST-ACS, upstream treatment with GPIIb/IIIa inhibitors was used in those with a higher clinical risk profile, whereas downstream treatment was reserved for a limited number of patients undergoing PCI. Thirty-day outcome was similar in the two groups, irrespective of the treatment strategy used.

End-of-life issues in elderly patients with acute coronary syndrome: the role of the cardiovascular nurse

End-of-life care and cardiovascular disease are concepts that do not have the same synergy as end-of-life care and cancer. Cardiovascular care is predominantly perceived by patients and practitioners as a curative discipline. However, with the aging of the population and the prevalence of cardiovascular heart disease, it will continue to be the leading cause of death for adults in the United States. Clinical treatment options and issues surrounding end-of-life care need to be addressed with elderly patients and their families. The purpose of this article is to discuss the role of the cardiovascular nurse in the care of the elderly patient with acute coronary syndrome.

Appropriate invasive and conservative strategies for patients with non-ST elevation acute coronary syndromes

PURPOSE OF REVIEW

This review focuses on recent developments in three controversial areas of management of acute coronary syndromes.

RECENT FINDINGS

There are potential benefits of an early invasive treatment strategy (routine cardiac catheterization and revascularization when appropriate) in the elderly, who are at high risk for adverse outcomes and treatment-related complications following acute coronary syndromes. There are developments in the role of low-molecular-weight heparin agents in management of acute coronary syndromes in the modern treatment era, in which early coronary revascularization and use of other potent antiplatelet and antithrombin agents are common. Finally, this review looks at emerging data and controversy regarding the effects of intensive lipid-lowering treatment early after acute coronary syndrome. Recent clinical trials have yielded contradictory results.

SUMMARY

This paper evaluates recent evidence in acute coronary syndromes regarding early invasive revascularization strategies in high risk elderly patients, and also discusses controversies regarding the role of low molecular weight heparin and intensive statin regimens.

Epidemiology of non-ST elevation acute coronary syndromes in the Italian cardiology network: the BLITZ-2 study

AIMS

Acute coronary syndromes without ST-segment elevation (NSTEACS) represent an increasingly frequent cause of hospital admission. The BLITZ-2 study was planned to survey the epidemiology and management strategies of NSTEACS in the Italian cardiological network.

METHODS AND RESULTS

The study included 1888 patients with NSTEACS in 275 hospitals in 3 weeks. At admission, almost 20% of patients showed clinical signs of heart failure, half showed ST-segment depression, and half showed any positive biochemical myocardial necrosis marker. Patients admitted to hospitals without CathLab (n=973) were older (P=0.0005) and with higher Killip class on admission (P<0.0001) when compared with those admitted to hospitals with CathLab (n=915). During index hospitalization, 76% of the patients initially admitted to hospitals with invasive capability underwent coronary angiography and 39% percutaneous coronary intervention when compared with 39 and 17.2% of those admitted to hospitals without CathLab (P<0.001). Overall, 30-day mortality was 2.4% (2.0% in patients with invasive capability vs. 2.9% in hospitals without CathLab, P=0.2). Cardiac ischaemic events at 30 days (recurrent MI, recurrent angina, and re-hospitalization for ACS) were significantly higher in the group of patients admitted to hospitals without CathLab (OR 1.71, 95% CI 1.24-2.35). However, after multivariable adjustment, only advanced age (OR 1.043, 95% CI 1.021-1.065, P<0.0001) and Killip class >1 (OR 1.633, 95% CI 1.020-2.614, P=0.04) resulted in independent predictors of death, in-hospital MI, and re-admission for ACS, whereas the absence of an on-site CathLab did not predict an adverse outcome (OR 1.104, 95% CI 0.734-1.660).

CONCLUSION

According to this, the nationwide registry outcome is only marginally influenced by invasive procedures. Contemporary management of patients with NSTEACS in Italy is primarily driven by resource availability.

Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.

Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome

OBJECTIVES

To evaluate an early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome (ACS).

METHODS

All consecutive patients admitted with a diagnosis of non-ST elevation ACS from June 2002 to February 2004 were enrolled in this registry. Clinical outcome was assessed at 30 days and in long term follow up.

RESULTS

An early invasive strategy was followed for 439 patients, of whom 159 (36%) were elderly and had a higher clinical risk profile and greater extent of coronary artery disease (CAD) than the younger patients. Coronary revascularisation was conducted in 133 (83%) elderly patients and 239 (85%) younger patients (not significant). At a mean (SD) follow up time of 10.7 (5.2) months overall mortality, cardiac death, and death plus myocardial infarction were significantly higher among elderly patients than among younger patients (9.4% v 2.1%, p < 0.001; 6.8% v 1.8%, p < 0.01; 11.3% v 5%, p = 0.02, respectively). The significant difference in cardiac death between the two groups was related more to elderly patients being treated by coronary artery bypass grafting (19.3% v 4.9%, p = 0.05) than by percutaneous coronary intervention (PCI) (2.9% v 1.1%, p = 0.3). Cox regression analysis showed age, serum creatinine > 115 micromol/l, no previous history of CAD, left ventricular ejection fraction > 45%, and the absence of diabetes to be independent predictors of the occurrence of major adverse cardiac events.

CONCLUSIONS

In unselected elderly patients presenting with non-ST elevation ACS an early invasive strategy is feasible and leads to coronary revascularisation in the majority of cases, resulting in encouraging immediate and long term clinical results, particularly among PCI treated patients.