Prognosis of elderly patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention in 2001 to 2011: A report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) registry

Temporal trends of in-hospital mortality and its determinants following percutaneous coronary intervention in patients with acute coronary syndrome in England and Wales: A population-based study between 2006 and 2021

BACKGROUND

There is limited data around drivers of changes in mortality over time. We aimed to examine the temporal changes in mortality and understand its determinants over time.

METHODS

743,149 PCI procedures for patients from the British Cardiovascular Intervention Society (BCIS) database who were aged between 18 and 100 years and underwent Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS) in England and Wales between 2006 and 2021 were included. We decomposed the contributing factors to the difference in the observed mortality proportions between 2006 and 2021 using Fairlie decomposition method. Multiple imputation was used to address missing data.

RESULTS

Overall, there was an increase in the mortality proportion over time, from 1.7% (95% CI: 1.5% to 1.9%) in 2006 to 3.1% (95% CI: 3.0% to 3.2%) in 2021. 61.2% of this difference was explained by the variables included in the model. ACS subtypes (percentage contribution: 14.67%; 95% CI: 5.76% to 23.59%) and medical history (percentage contribution: 13.50%; 95% CI: 4.33% to 22.67%) were the strongest contributors to the difference in the observed mortality proportions between 2006 and 2021. Also, there were different drivers to mortality changes between different time periods. Specifically, ACS subtypes and severity of presentation were amongst the strongest contributors between 2006 and 2012 while access site and demographics were the strongest contributors between 2012 and 2021.

CONCLUSIONS

Patient factors and the move towards ST-elevated myocardial infarction (STEMI) PCI have driven the short-term mortality changes following PCI for ACS the most.

10-Year Temporal Trends of In-Hospital Mortality and Emergency Percutaneous Coronary Intervention for Acute Myocardial Infarction

Background

The mortality rate of acute myocardial infarction (AMI) has improved dramatically because of reperfusion therapy during the last 40 years; however, recent temporal trends for AMI have not been fully clarified in Japan.

Objectives

The purpose of this study was to elucidate the temporary trend in in-hospital mortality and treatment of AMI for the last decade in the Tokyo Metropolitan area.

Methods

We enrolled 30,553 patients from the Tokyo Cardiovascular Care Unit Network Registry, diagnosed with AMI from 2007 to 2016, as part of an ongoing, multicenter, cohort study. We analyzed the temporal trends in basic characteristics, treatment, and in-hospital mortality of AMI.

Results

The overall emergency percutaneous coronary intervention (PCI) rate significantly increased (P < 0.001). In particular, it remarkably increased in patients older than 80 years of age (58.3% to 70.3%, P < 0.001) and patients with Killip III or IV (Killip III, 46.9% to 65.7%; Killip IV, 65.2% to 76.6%, P < 0.001 for both). The crude and age-adjusted in-hospital mortality remained low (5.2% to 8.2% and 3.4% to 5.5%, respectively) and significantly decreased during the decade (P < 0.001). The in-hospital mortality remarkably decreased in patients older than 80 years of age (17.3% to 12.7%, P < 0.001) and in those with cardiogenic shock (38.5% to 27.3%, P < 0.001).

Conclusions

This large cohort study from Tokyo revealed that in-hospital mortality of AMI significantly decreased with the increase in emergency percutaneous coronary intervention rate over the decade, particularly for high-risk patients such as older patients and those with cardiogenic shock.

One-year outcome after percutaneous coronary intervention in nonagenarians: Insights from the J-PCI OUTCOME registry

BACKGROUND

Nonagenarian patients who undergo percutaneous coronary intervention (PCI) are increasing, and a few previous studies have reported their long-term outcomes. However, differences in their long-term outcomes between generations remain unclear. This study aimed to investigate 1-year all-cause and cardiovascular (CV) mortality, and major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke) of nonagenarian patients who underwent PCI compared with the other elder patients, using a nationwide registration system.

METHODS

The patient-level data registered between January 2017 and December 2017 was extracted from the J-PCI OUTCOME Registry endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT). The one-year all-cause and cardiovascular (CV) mortality, MACE, and major bleeding events were identified.

RESULTS

Out of 40,722 patients over 60 years of age, 880 (2.1%) were nonagenarians. For nonagenarians, the 1-year mortality rate was substantial (13.5%). The MACE and CV death rates were also high (8.1%, and 6.8%, respectively) for nonagenarians, and these event rates were approximately 1.5 times higher in nonagenarians than octogenarians. Multivariate regression analysis showed that presentation with cardiogenic shock [hazard ratio (HR) 2.32; 95 confidence intervals (CI): 1.22-4.41], or cardiac arrest (HR 2.91; 90% CI: 1.28-6.62), and use of oral anticoagulants (HR 2.10; 90% CI: 1.07-4.12) were the predictors of 1-year MACE.

CONCLUSIONS

Even in the contemporary era, nonagenarians who have undergone PCI still face a considerably increased risk for adverse cardiovascular events that reduces long-term survival. In addition to having poorer lesion characteristics, adverse events, including death, MACEs, and major bleeding, occurred 1.5 times more frequently in nonagenarians than in octogenarians.

Acute kidney injury and in-hospital mortality in patients with ST-elevation myocardial infarction of different age groups

BACKGROUND

Acute kidney injury (AKI) is a well-known complication of ST-elevation acute myocardial infarction (STEMI) with an adverse impact on prognosis. Since AKI develops more frequently in elderly patients, we hypothesized that its higher incidence in older STEMI patients might explain their increased in-hospital mortality. We assessed the relationship between AKI and in-hospital mortality in patients with STEMI of different age groups.

METHODS

We retrospectively evaluated 5136 STEMI patients treated with primary percutaneous coronary intervention (pPCI). We defined AKI as ≥0.5 mg/dl creatinine increase in the first 72 h. Patients were grouped according to age (<75 [n = 4040] or ≥ 75 [n = 1096] years). The primary endpoint was in-hospital mortality.

RESULTS

The incidence of AKI was 7%. It was 4.6% in patients <75 years and 15.1% in those ≥75 years (P < 0.0001). The overall in-hospital mortality was 4%. It was 2.6% and 8.5% in patients younger and older than 75 years, respectively (P < 0.0001). It was higher in AKI than in non-AKI patients, both in the overall population (27% vs. 2%) and in the two age groups (25% vs. 2% and 29% vs. 5% in younger and older patients, respectively; P < 0.0001). The adjusted odds ratio of in-hospital mortality associated with AKI progressively decreased in parallel with increasing age decades (from 24.7 [95% CI 11.2-54.1] in patients <65 years to 3.9 [95% CI 1.6-9.7] in those >85 years).

CONCLUSIONS

In STEMI patients treated with pPCI, AKI incidence and in-hospital mortality steadily increase with age. However, the prognostic impact of AKI is progressively reduced as age increases.

The prognostic value of MELD-XI in elderly patients with ST-segment elevation myocardial infarction: an observational study

Background

The model for end-stage liver disease excluding international normalized ratio (MELD-XI) is a simple score for risk assessment. However, the prognostic role of MELD-XI and its additional value to current risk assessment in elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) is uncertain.

Methods

In all, 1029 elderly patients with STEMI undergoing PCI were consecutively included and classified into three groups according to the TIMI risk score: low-risk (≤ 3, n = 251); moderate-risk (4–6, n = 509); and high-risk (≥ 7, n = 269) groups. Multivariate analysis was performed to identify risk factors for adverse events.

Results

The overall in-hospital mortality was 5.3% and was significantly higher in the high-risk group (1.2% vs. 3.3% vs. 13.0%, p < 0.001). The optimal cut-off of the TIMI risk score and MELD-XI for in-hospital death was 7 and 13, respectively. MELD-XI was associated with in-hospital (adjusted odds ratio = 1.09, 95% CI = 1.04–1.14, p = 0.001) and one-year (adjusted hazard ratio = 1.05, 95% CI = 1.01–1.08, p = 0.005) mortality independently of the TIMI risk score. Combining TIMI risk score and MELD-XI exhibited better predictive power for in-hospital death than TIMI risk score (area under the curve [AUC] = 0.810 vs. 0.753, p = 0.008) or MELD-XI alone (AUC = 0.810 vs. 0.750, p = 0.018). Patients with TIMI risk score ≥ 7 and MELD-XI ≥ 13 had the worst prognosis.

Conclusion

MELD-XI could be considered as a risk-stratified tool for elderly patients with STEMI undergoing PCI. It had an additive prognostic value to TIMI risk score.

[Interests and limitations of percutaneous coronary intervention strategy in nonagenarian patients: A single center experience]

AIM

To expose our center results in the angioplasty in nonagenarians and to evaluate its effectiveness but also the MACEs and the mortality in the short and long term.

METHODS

A retrospective study of 98 patients admitted to the Antibes hospital center from November 2013 to September 2018.

RESULTS

The median age was 91.8 [90.8-93.4]. 52.6% was male. 9.7% of the patients had a polyvascular site. 50.6% of patients had moderate renal failure. The radial approach was used in 88.4% of cases. 21.6% of patients had tri-truncal lesions, while 46.4% were monotruncular, LAD artery was the culprit artery in 67% of cases. One stent per lesion was used in the majority of cases. Our successful rate was 90%. After angioplasty, 96% of the patients underwent double antiaggregation platelet therapy, 74.4% under clopidogrel. The presence of arrhythmias before angioplasty, the femoral approach, the coronary dissection and cardiogenic shock after angioplasty were predictors of short- and long-term mortality. Diabetes, history of myocardial infarction, impaired left ventricular ejection fraction, calcified coronary lesions, occurrence of arrhythmias or signs of heart failure on post-procedure were predictors of MACE occurrence.

CONCLUSIONS

This study demonstrates that angioplasty in selected population of nonagenarians is perfectly feasible with a good risk/benefit ratio and specifies the different predictors of MACE, both short- and long-term mortality.

Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

BACKGROUND

Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

OBJECTIVES

The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.

METHODS

We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).

RESULTS

Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).

CONCLUSIONS

This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

Comparison of In-Hospital Clinical Outcomes of Acute Myocardial Infarction Between Nonagenarians and Octogenarians

Acute myocardial infarction (AMI) in the very elderly is associated with high morbidity and mortality. Although there are earlier studies regarding AMI in octogenarians, clinical evidences of AMI in nonagenarians are sparse. The aim of the present study was to compare in-hospital outcomes of AMI between octogenarians and nonagenarians. We included consecutive 415 very elderly (≥ 80 years) with AMI and divided them into the nonagenarian group (n = 38) and the octogenarian group (n = 377). Clinical characteristics and in-hospital outcomes were compared between the two groups. Furthermore, we used propensity score matching to find the matched octogenarian group (n = 38). Percutaneous coronary interventions (PCI) to the culprit of AMI were similarly performed between the nonagenarian (86.8%) and octogenarian (87.0%) groups. The incidence of in-hospital death in the nonagenarian group (10.5%) was similar to that in the octogenarian group (12.5%) (P = 0.487). After using the propensity score matching, the incidence of in-hospital death was less in the nonagenarian group (10.5%) than in the matched octogenarian group (18.4%) without reaching statistical significance (P = 0.328). The length of hospitalization was significantly shorter in the nonagenarian group [7.0 (4.0-9.0)] than in the matched octogenarian group [10.0 (6.5-15.0)] (P = 0.01). In conclusion, the in-hospital mortality of nonagenarians with AMI was comparable to that of octogenarians with AMI. In-hospital outcomes in nonagenarians with AMI may be acceptable as long as acute medical management including PCI to the culprit of AMI is performed.

Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years

Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.

A retrospective study of an invasive versus conservative strategy in patients aged ≥80 years with acute ST-segment elevation myocardial infarction

Objective

To investigate what is the most appropriate strategy for patients with ST-segment elevation myocardial infarction (STEMI) aged ≥80 years in China.

Methods

This cohort study retrospectively enrolled patients with STEMI aged ≥80 years old and grouped them according to the treatment strategy that was used: a conservative treatment strategy or an invasive treatment strategy. Factors associated with whether to perform an invasive intervention, in-hospital death and a good prognosis were investigated using logistic regression analyses.

Results

A total of 232 patients were enrolled: conservative treatment group ( n = 93) and invasive treatment group ( n = 139). Patients in the invasive treatment group had a better prognosis and lower incidence of adverse events compared with the conservative treatment group. Advanced age, creatinine level and a higher Killip class were inversely correlated with whether to perform an invasive intervention, while the use of beta-receptor-blocking agents was a favourable factor for invasive treatment. Hypertension and a higher Killip class were risk factors for in-hospital death, while the use of beta-receptor-blocking agents and diuretics decreased the risk of in-hospital death.

Conclusions

An invasive treatment strategy was superior to a conservative treatment strategy in patients with STEMI aged ≥80 years.

Frailty score for elderly patients is associated with short-term clinical outcomes in patients with ST-segment elevated myocardial infarction treated with primary percutaneous coronary intervention

OBJECTIVE

Consistent with the aging population in the Western world, there is a growing number of elderly patients with ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in elderly patients; risk models to determine which of these patients are prone to have poor clinical outcomes are, however, essential. The purpose of this study was to assess the association between frailty and short-term mortality and PCI-related serious adverse events (SAE) in elderly patients.

METHODS

All STEMI patients (aged ≥70 years) treated with primary PCI in 2013-2015 at the Leiden University Medical Centre were assessed. The Safety Management Programme (VMS) score was used to identify frail elderly patients. The primary endpoint was 30-day all-cause mortality; the secondary endpoint included 30-day clinical death, target vessel failure, major bleeding, contrast induced kidney insufficiency and stroke.

RESULTS

A total of 206 patients were included (79 ± 6.4 years, 119 [58%] male). The VMS score was ≥1 in 28% of all cases. Primary and secondary endpoint rates were 5 and 23% respectively. VMS score ≥1 was an independent predictor for both 30-day mortality (odds ratio [OR] 9.6 [95% confidence interval, CI 1.6-56.9] p-value = 0.013) and 30-day SAE (OR 2.9 [95% CI 1.1-7.9] p-value = 0.038).

CONCLUSIONS

VMS score for frailty is independently associated with short-term mortality and PCI-related SAE in elderly patients with STEMI treated with primary PCI. These results suggest that frailty in elderly patients is an important feature to measure and to be taken into account when developing risk models.

Temporal trends in relative survival following percutaneous coronary intervention

OBJECTIVE

Percutaneous coronary intervention (PCI) has seen substantial shifts in patient selection in recent years that have increased baseline patient mortality risk. It is unclear to what extent observed changes in mortality are attributable to background mortality risk or the indication and selection for PCI itself. PCI-attributable mortality can be estimated using relative survival, which adjusts observed mortality by that seen in a matched control population. We report relative survival ratios and compare these across different time periods.

METHODS

National Health Service PCI activity in England and Wales from 2007 to 2014 is considered using data from the British Cardiovascular Intervention Society PCI Registry. Background mortality is as reported in Office for National Statistics life tables. Relative survival ratios up to 1 year are estimated, matching on patient age, sex and procedure date. Estimates are stratified by indication for PCI, sex and procedure date.

RESULTS

549 305 procedures were studied after exclusions for missing age, sex, indication and mortality status. Comparing from 2007 to 2008 to 2013-2014, differences in crude survival at 1 year were consistently lower in later years across all strata. For relative survival, these differences remained but were smaller, suggesting poorer survival in later years is partly due to demographic characteristics. Relative survival was higher in older patients.

CONCLUSIONS

Changes in patient demographics account for some but not all of the crude survival changes seen during the study period. Relative survival is an under-used methodology in interventional settings like PCI and should be considered wherever survival is compared between populations with different demographic characteristics, such as between countries or time periods.

National Trends and Outcomes of Percutaneous Coronary Intervention in Patients ≥70 Years of Age With Acute Coronary Syndrome (from the National Inpatient Sample Database)

Several randomized trials have demonstrated the benefits of an invasive strategy for older patients with acute coronary syndromes (ACS); however, there are limited real-world data of the temporal trends in the use of percutaneous coronary intervention (PCI) in this population. This was a retrospective observational analysis. We queried the National Inpatient Sample database from 1998 to 2013 for patients aged ≥70 years who had non-ST-elevation acute coronary syndrome (NSTE-ACS) or ST-elevation myocardial infarction (STEMI). We reported the temporal trends of PCI and in-hospital mortality. A total of 6,720,281 hospitalizations with ACS were identified in advanced age patients, 18.3% of whom also underwent PCI. There was an upward trend in the rate of PCI in older adults ≥70 years with any ACS from 9.4% in 1998 to 28.3% in 2013 (p <0.001), as well as in cases of PCI for NSTE-ACS (7.3% in 1998 vs 24.9% in 2013, p <0.001) and PCI for STEMI (11% in 1998 vs 35.7% in 2013, p = 0.002). This upward trend was consistent in all age categories (70 to 79), (80 to 89) and ≥90 years. Despite an increase in the prevalence of comorbidities for ACS hospitalizations aged ≥70 years who received PCI, the in-hospital mortality rate showed a downward trend (p <0.001). Multivariate analysis adjusting for various comorbidities showed that PCI was associated with lower in-hospital mortality and length of hospital stay among elderly with NSTE-ACS and STEMI. In conclusion, in this 16-year analysis there was an increase in the rate of PCI procedures among older adults with ACS. PCI was independently associated with lower mortality in elderly patients with ACS.

Development and Validation of a Novel Risk Score for Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

BACKGROUND

Primary percutaneous coronary intervention (PPCI) is the default treatment for patients with ST elevation myocardial infarction (STEMI) and carries a higher risk of adverse outcomes when compared with elective and urgent PCI. Conventional PCI risk scores tend to be complex and may underestimate the risk associated with PPCI due to under-representation of patients with STEMI in their datasets. This study aimed to develop a simple, practical and contemporary risk model to provide risk stratification in PPCI.

METHODS

Demographic, clinical and outcome data were collected for all patients who underwent PPCI between January 2009 and October 2013 at the Northern General Hospital, Sheffield. Multiple regression analysis was used to identify independent predictors of mortality and to construct a risk model. This model was then separately validated on an internal and external dataset.

RESULTS

The derivation cohort included 2870 patients with a 30-day mortality of 5.1% (145 patients). Only four variables were required to predict 30-day mortality: age [OR:1.047, 95% CI:1.031-1.063], call-to-balloon (CTB) time [OR:1.829, 95% CI:1.198-2.791], cardiogenic shock [OR:13.886, 95% CI:8.284-23.275] and congestive heart failure [OR:3.169, 95% CI:1.420-7.072]. Internal validation was performed in 693 patients and external validation in 660 patients undergoing PPCI. Our model showed excellent discrimination on ROC-curve analysis (C-Stat = 0.87 internal and 0.86, external), and excellent calibration on Hosmer-Lemeshow testing (p = 0.37 internal, 0.55 external).

CONCLUSIONS

We have developed a bedside risk model which can predict 30-day mortality after PPCI using only four variables: age, CTB time, congestive heart failure and shock.

The relationship of Charlson comorbidity index with stent restenosis and extent of coronary artery disease

Objectives

The objective of this study is to investigate the effect of comorbid conditions [Charlson comorbidity index (CCI)] on stent restenosis who underwent coronary angioplasty earlier.

Methods

Patients were divided into two groups; patients with critical restenosis [recurrent diameter stenosis >50% at the stent segment or its edges (5-mm segments adjacent to the stent) (Group 1; n = 53, mean age: 63.8 ± 9.9 years)] and patients with no critical restenosis [<50% obstruction (Group 2; n = 94, mean age: 62.1 ± 9.1 years)]. The CCI and modified CCI were used for the presence of comorbid conditions. The Gensini scoring system was used to assess the extent of coronary artery disease (CAD).

Results

Group 1 had a significantly greater CCI and modified CCI score compared to Group 2 (7.1 ± 3.7 vs. 5.6 ± 1.6, p = 0.006; 6.9 ± 3.6 vs. 4.5 ± 1.5, p = 0.008, respectively). There was a weak correlation, albeit significant, between the modified CCI score and restenosis percentage (r = 0.29, p < 0.001; r = 0.25, p = 0.003, respectively).

Conclusions

In conclusion, the CCI score is greater among patients with stent restenosis than those without. CCI score is higher among patients with a more diffuse CAD than with a milder disease extent.

Changes in Periprocedural Bleeding Complications Following Percutaneous Coronary Intervention in The United Kingdom Between 2006 and 2013 (from the British Cardiovascular Interventional Society)

Major bleeding is a common complication after percutaneous coronary intervention (PCI), although little is known about how bleeding rates have changed over time and what has driven this. We analyzed all patients who underwent PCI in England and Wales from 2006 to 2013. Multivariate analyses using logistic regression models were performed to identify predictors of bleeding to identify potential factors influencing bleeding trends over time. 545,604 participants who had PCI in England and Wales between 2006 and 2013 were included in the analyses. Overall bleeding rates decreased from 7.0 (CI 6.2 to 7.8) per 1,000 procedures in 2006 to 5.5 (CI 4.7 to 6.2) per 1,000 in 2013. Increasing age, female sex, GPIIb/IIIa inhibitors use, and circulatory support were independently associated with increased risk of bleeding complications whereas radial access and vascular closure device use were independently associated with decreases in risk. Decreases in bleeding rates over time were associated with radial access site, and changes in pharmacology, but this was offset by greater proportion of ACS cases and the adverse patient clinical demographics. In conclusion, major bleeding complications after PCI have decreased due to changes in access site practice and decreased usage of GPIIb/IIIa inhibitors, but this is offset by the increase of patients with higher propensity to bleed. Changes in access site practice nationally have the potential to significantly reduce major bleeding after PCI.

Effect of Comorbidity On Unplanned Readmissions After Percutaneous Coronary Intervention (From The Nationwide Readmission Database)

It is unclear how comorbidity influences rates and causes of unplanned readmissions following percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database who were admitted to hospital between 2010 and 2014. The comorbidity burden as defined by the Charlson Comorbidity Index (CCI). Primary outcomes were 30-day readmission rates and causes of readmission according to comorbidity burden. A total of 2,294,346 PCI procedures were included the analysis. The patients in CCI = 0, 1, 2 and ≥3 were 842,272(36.7%), 701,476(30.6%), 347,537(15.1%) and 403,061(17.6%), respectively. 219,227(9.6%) had an unplanned readmission within 30 days and rates by CCI group were 6.6%, 8.6%, 11.4% and 15.9% for CCI groups 0, 1, 2 and ≥3, respectively. The CCI score was also associated with greater cost (cost of index PCI for not readmitted vs readmitted was CCI = 0 $21,257 vs $19,764 and CCI ≥ 3 $26,736 vs $27,723). Compared to patients with CCI = 0, greater CCI score was associated with greater independent odds of readmission (CCI = 1 OR 1.25(1.22–1.28), p < 0.001, CCI ≥ 3 OR 2.08(2.03–2.14), p < 0.001). Rates of non-cardiac causes for readmissions increased with increasing CCI group from 49.4% in CCI = 0 to 57.1% in CCI ≥ 3. Rates of early unplanned readmission increase with greater comorbidity burden and non-cardiac readmissions are higher among more comorbid patients.

Long-Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice

BACKGROUND

There is limited information about the long-term survival of older patients after myocardial infarction (MI).

METHODS AND RESULTS

CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long-term mortality (defined as 8 years post index event). Long-term unadjusted Kaplan-Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post-MI was conducted. We used multivariable Cox regression to compare mortality risks between ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence-based medication use at discharge: aspirin 95%, β-blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight-year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post-MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65-74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight-year mortality was lower among ST-segment-elevation myocardial infarction than non-ST-segment-elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88-1.00).

CONCLUSIONS

Long-term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year.

Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions

BACKGROUND

Nowadays, the majority of patients with myocardial infarction with ST-segment elevation (STEMI) are treated with primary percutaneous coronary interventions (PCI). In recent years, there have been ongoing improvements in PCI techniques, devices and concomitant pharmacotherapy. However, reports on further mortality reduction among PCI-treated STEMI patients remain inconclusive. The aim of this study was to compare changes in management and mortality in PCI-treated STEMI patients between 2005 and 2011 in a real-life setting.

METHODS

Data on 79,522 PCI-treated patients with STEMI from Polish Registry of Acute Coronary Syndromes (PL-ACS) admitted to Polish hospitals between 2005 and 2011 were analyzed. First, temporal trends of in-hospital management in men and women were presented. In the next step, patients from 2005 and 2011 were nearest neighbor matched on their propensity scores to compare in-hospital, 30-day and 1-year mortality rates and in-hospital management strategies and complications.

RESULTS

Some significant changes were noted in hospital management including shortening of median times from admission to PCI, increased use of drug-eluting stents, potent antiplatelet agents but also less frequent use of statin, beta-blockers and angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. There was a strong tendency toward preforming additional PCI of non-infarct related arteries, especially in women. After propensity score adjustment there were significant changes in inhospital but not in 30-day or 1-year mortality rates between 2005 and 2011. The results were similar in men and women.

CONCLUSIONS

There were apparent changes in management and significant in-hospital mortality reductions in PCI-treated STEMI patients between 2005 and 2011. However, it did not result in 30-day or 1-year survival benefit at a population level. There may be room for improvement in the use of guideline-recommended pharmacotherapy.

Temporal Trends, Complications, and Predictors of Outcomes Among Nonagenarians Undergoing Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

OBJECTIVES

The aim of this study was to determine temporal trends, in-laboratory complications, mortality, and predictors of mortality among nonagenarians undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Nonagenarians (patients 90 years of age or older) undergoing PCI are often underrepresented in clinical trials, and their management remains challenging and controversial.

METHODS

All veterans undergoing PCI with data recorded in the Veterans Affairs Clinical Assessment, Reporting, and Tracking program from 2005 to 2014 were evaluated. Temporal trends in the use of PCI, occurrence of in-laboratory complications, and 30-day and 1-year mortality were assessed. Using a frailty model, predictors of 30-day and 1-year mortality in nonagenarians were evaluated.

RESULTS

Among all veterans undergoing PCI (n = 67,148) between 2005 and 2014, 274 (0.4%) were nonagenarians. The proportion of nonagenarians increased from 0.25% in 2008 to 0.58% in 2014. Compared with younger patients, nonagenarians had a greater risk for acute cardiogenic shock post-procedure (0.73% vs. 0.12%; p = 0.04) and no reflow (2.9% vs. 1.0%; p = 0.02). Unadjusted (10.6% vs. 1.4%; p < 0.0001) and adjusted 30-day mortality (odds ratio: 2.14; 95% confidence interval [CI]: 1.42 to 3.22) and unadjusted (16.3% vs. 4.2%; p < 0.0001) and adjusted 1-year mortality (odds ratio: 1.82; 95% CI: 1.27 to 2.62) were higher among PCI patients who were nonagenarians. The National Cardiovascular Data Registry risk score was highly predictive of both 30-day (hazard ratio: 2.29; 95% CI: 1.86 to 2.82) and 1-year (hazard ratio: 1.43; 95% CI: 1.07 to 1.90) mortality among nonagenarians.

CONCLUSIONS

Nonagenarians were a small but growing population with worse 30-day and 1-year mortality. The National Cardiovascular Data Registry risk score was a strong predictor of mortality in these patients.

Prognostic Factors for In-Hospital and Long-Term Survival in Patients with Acute ST-Segment Elevation Myocardial Infarction after Percutaneous Coronary Intervention

Acute ST segment elevation myocardial infarction (STEMI) is one of the causes of death and disability in patients with cardiovascular diseases. This study aimed to investigate the prognostic factors of in-hospital and long-term survival in patients with acute STEMI undergoing percutaneous coronary intervention (PCI). Patients with STEMI undergoing PCI were divided into the death group (n = 54) and the survival group (n = 306) based on the outcomes during hospitalization. The routine blood and biochemistry tests, Killip classes and global registry of acute coronary events (GRACE) risk score were detected. The 1-, 2- and 3-year survival rates after PCI was observed through a 3-year follow-up. The survival factors, survival rates and multivariate analyses were conducted using Logistic regression analysis, Kaplan-Meier survival analysis and Cox proportional hazards regression. The incidence of cardiogenic shock and anterior wall MI (AWMI), the serum levels of γ-glutamyl endopeptidase (γ-GGT) and creatine kinase isoenzyme MB (CK-MB), Killip classes and GRACE risk score were higher in the death group, compared with the survival group. AWMI, cardiogenic shock, high serum levels of γ-GGT and CK-MB, Killip class III-IV and high GRACE risk scores were associated with in-hospital mortality. AWMI, cardiogenic shock, Killip class III-IV and high GRACE risk scores were correlated with a poor long-term survival. Our findings have demonstrated that AWMI, cardiogenic shock, high serum levels of γ-GGT and CK-MB, Killip class III-IV, and high GRACE risk scores are risk factors for in-hospital and long-term prognosis of acute STEMI patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

Short and long-term outcome in very old patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention

BACKGROUND

Although octogenarians constitute a fast-growing portion of cardiovascular patients, few data are available on the outcome of patients aged ≥85 years with ST-Elevation Myocardial Infarction (STEMI).

METHODS AND RESULTS

We analyzed 126 consecutive patients aged ≥85 years (age 88±2 years) with STEMI, undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from symptoms onset. Long-term follow-up (median 898 days) was obtained for the 102 patients surviving the index-hospitalization. In-hospital mortality rate was 19%. Nonagenarians, diabetes mellitus, severe left ventricular systolic dysfunction and intra-aortic balloon pumping were significantly and independently correlated to in-hospital mortality at the multivariate analysis. A low rate of complications was detected. Among patients surviving the index hospitalization, 32 (31%) patients died during follow-up. 55 patients (54%) had re-hospitalization due to cardiovascular causes. The univariate analysis identified chronic renal failure, Killip class ≥ 3, TIMI Risk Score >8 and very high risk of bleeding as predictors of long-term overall mortality. At the multivariate analysis only chronic renal failure and very high risk of bleeding were significantly and independently correlated to long-term all-cause mortality. Renal function and anterior myocardial infarction were significantly and independently associated with the combined end-point of cardiac mortality and re-hospitalization due to cardiovascular disease at the multivariate analysis.

CONCLUSIONS

PPCI in patients ≥85 years old is relatively safe. In this population, pPCI is associated with a good long-term survival, although still worse than in younger patients, despite a considerable incidence of re-hospitalization due to cardiovascular events.

Educational attainment and differences in relative survival after acute myocardial infarction in Norway: a registry-based population study

BACKGROUND

Although there is a broad societal interest in socioeconomic differences in survival after an acute myocardial infarction, only a few studies have investigated how such differences relate to the survival in general population groups. We aimed to investigate education-specific survival after acute myocardial infarction and to compare this with the survival of corresponding groups in the general population.

METHODS

Our study included the entire population of Norwegian patients admitted to hospitals for acute myocardial infarction during 2008-2010, with a 6- year follow-up period. Patient survival was measured relative to the expected survival in the general population for three educational groups: primary, secondary and tertiary. Education, sex, age and calendar year-specific expected survival were obtained from population life tables and adjusted for the presence of infarction-related mortality.

RESULTS

Six-year patient survivals were 56.3% (55.3-57.2) and 65.5% (65.6-69.3) for the primary and tertiary educational groups (95% CIs), respectively. Also 6-year relative survival was markedly lower for the primary educational group: 70.2% (68.6-71.8) versus 81.2% (77.4-84.4). Throughout the follow-up period, patient survival tended to remain lower than the survival in the general population with the same educational background.

CONCLUSION

Both patient survival and relative survival after acute myocardial infarction are positively associated with educational level. Our findings may suggest that secondary prevention has been more effective for the highly educated.

Survival and neurological outcome in the elderly after in-hospital cardiac arrest

BACKGROUND

There have been few studies of the outcome in elderly patients who have suffered in-hospital cardiac arrest (IHCA) and the association between cardiac arrest characteristics and survival.

AIM

The aim of this large observational study was to investigate the survival and neurological outcome in the elderly after IHCA, and to identify which factors were associated with survival.

METHODS

We investigated elderly IHCA patients (≥70years of age) who were registered in the Swedish Cardiopulmonary Resuscitation Registry 2007-2015. For descriptive purposes, the patients were grouped according to age (70-79, 80-89, and ≥90years). Predictors of 30-day survival were identified using multivariable analysis.

RESULTS

Altogether, 11,396 patients were included in the study. Thirty-day survival was 28% for patients aged 70-79 years, 20% for patients aged 80-89 years, and 14% for patients aged ≥90years. Factors associated with higher survival were: patients with an initially shockable rhythm, IHCA at an ECG-monitored location, IHCA was witnessed, IHCA during daytime (8 a.m.-8 p.m.), and an etiology of arrhythmia. A lower survival was associated with a history of heart failure, respiratory insufficiency, renal dysfunction and with an etiology of acute pulmonary oedema. Patients over 90 years of age with VF/VT as initial rhythm had a 41% survival rate. We found a trend indicating a less aggressive care with increasing age during cardiac arrest (fewer intubations, and less use of adrenalin and anti-arrhythmic drugs) but there was no association between age and delay in starting cardiopulmonary resuscitation (CPR). In survivors, there was no significant association between age and a favourable neurological outcome (CPC score: 1-2) (92%, 93%, and 88% in the three age groups, respectively).

CONCLUSIONS

Increasing age among the elderly is associated with a lower 30-day survival after IHCA. Less aggressive treatment and a worse risk profile might contribute to these findings. Relatively high survival rates among certain subgroups suggest that discussions about advanced directives should be individualized. Most survivors have good neurological outcome, even patients over 90 years of age.

Prognostic Impact of Age and Hemoglobin in Acute ST-Segment Elevation Myocardial Infarction Treated With Reperfusion Therapy

Advanced age and low hemoglobin levels have been associated with a poor prognosis in ST-segment elevation myocardial infarction (STEMI). We studied 1,111 patients with STEMI who received reperfusion treatment (1,032 [92.9%] primary angioplasty and 79 [7.1%] fibrinolysis without rescue percutaneous coronary intervention). Mean age was 64.1 ± 14.0 years, and 23.2% were women. Patients in the last age quartile (>76 years) were more frequently women, presented more risk factors (except smoking), received thrombolysis less frequently, had less complete revascularization, and presented more complications and higher mortality. Hemoglobin level at admission was associated with age and ranged from 14.8 ± 1.5 g/dl in the first quartile to 13.2 ± 1.8 g/dl in the last, p <0.001. Multivariate analysis identified age as a predictor of in-hospital and long-term mortality (odds ratio 1.04, 95% confidence interval [CI] 1.00 to 1.07, hazard ratio 1.06, 95% CI 1.04 to 1.08). Hemoglobin levels were associated with better survival (odds ratio 0.8, 95% CI 0.6 to 0.9, hazard ratio 0.85, 95% CI 0.78 to 0.92). The other predictors of inhospital mortality were Killip class, chronic kidney disease, left ventricular ejection fraction, significant pericardial effusion, and ventricular arrhythmias. The association of hemoglobin with hospital mortality was seen in men and in women ≥65 years. In men ≥65 years, this association was also present in those with hemoglobin levels in the normal range. In conclusion, in patients with STEMI, hemoglobin is an independent predictor of inhospital and long-term mortality, especially in those aged ≥65 years. This association is also present in men ≥65 years with normal hemoglobin levels.

Challenges in secondary prevention after acute myocardial infarction: A call for action

Worldwide, each year more than 7 million people experience myocardial infarction, in which one-year mortality rates are now in the range of 10%, but vary with patient characteristics. The consequences are even more dramatic: among patients who survive, 20% suffer a second cardiovascular event in the first year and approximately 50% of major coronary events occur in those with a previous hospital discharge diagnosis of ischaemic heart disease. The people behind these numbers spur this call for action. Prevention after myocardial infarction is crucial to reduce risk and suffering. Evidence-based interventions include optimal medical treatment with anti-platelets and statins, achievement of blood pressure, lipid and blood glucose targets, and appropriate lifestyle changes. The European Society of Cardiology and its constituent bodies are determined to embrace this challenge by developing a consensus document in which the existing gaps for secondary prevention strategies are reviewed. Effective interventions in relation to the patients, healthcare providers and healthcare systems are proposed and discussed. Finally, innovative strategies in hospital as well as in outpatient and long-term settings are endorsed.

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

INTRODUCTION AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term major adverse cardiovascular events and quality of life after coronary angiography in elderly patients with acute coronary syndrome

BACKGROUND

Although the elderly comprise the majority of acute coronary syndrome (ACS) patients, limited data exist on major adverse cardiovascular events (MACEs) and quality of life (QoL).

OBJECTIVES

To study MACEs and QoL prospectively in ACS patients >70years referred for coronary angiography.

METHODS

A prospective observational study that included ACS patients >70years undergoing coronary angiography. The outcomes were MACEs and QoL 3years after inclusion. MACEs were defined as death, recurrent ACS, new-onset of heart failure and repeated revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). A QoL questionnaire was completed by the patients along with a physical examination and a personal interview at the 3-year follow-up. Multivariate analysis was performed to identify the predictors for MACEs.

RESULTS

In total, 138 patients (mean age 78.8±3.8years) with ACS were included in the study. Mean follow-up was 1196±296days. In all, 42% of the patients had MACEs and 25% had post-ACS heart failure. The mortality rate was 11%. After adjusting for significant cardiovascular risk factors, the following factors were significantly associated with MACEs: Age, high-sensitive troponin T (hsTNT), use of diuretics and reduced left ventricular ejection fraction (LVEF). Furthermore, the QoL evaluated with SF-36 in survivors from ACS at the end of study was similar to the QoL in an age-matched healthy Swedish population.

CONCLUSIONS

In this prospective study on elderly ACS patients MACEs still occurred in 42% of the cases (despite low mortality and good QoL), with post-ACS heart failure as the most important event.

Outcome of 1051 Octogenarian Patients With ST-Segment Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: Observational Cohort From the London Heart Attack Group

BACKGROUND

ST-segment elevation myocardial infarction is increasingly common in octogenarians, and optimal management in this cohort is uncertain. This study aimed to describe the outcomes of octogenarians with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention.

METHODS AND RESULTS

We analyzed 10 249 consecutive patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention between 2005 and 2011 at 8 tertiary cardiac centers across London, United Kingdom. The primary end point was all-cause mortality at a median follow-up of 3 years. In total, 1051 patients (10.3%) were octogenarians, with an average age of 84.2 years, and the proportion increased over the study period (P=0.04). In-hospital mortality (7.7% vs 2.4%, P<0.0001) and long-term mortality (51.6% vs 12.8%, P<0.0001) were increased in octogenarians compared with patients aged <80 years, and age was an independent predictor of mortality in a fully adjusted model (hazard ratio 1.07, 95% CI 1.07-1.09, P<0.0001). Time-stratified analysis revealed an increasingly elderly and more complex cohort over time. Nonetheless, long-term mortality rates among octogenarians remained static over time, and this may be attributable to improved percutaneous coronary intervention techniques, including significantly higher rates of radial access and lower bleeding complications. Variables associated with bleeding complications were similar between octogenarian and younger cohorts.

CONCLUSIONS

In this large registry, octogenarians undergoing primary percutaneous coronary intervention had a higher rate of complications and mortality compared with a younger population. Over time, octogenarians undergoing primary percutaneous coronary intervention increased in number, age, and complexity. Nevertheless, in-hospital outcomes were reasonable, and long-term mortality rates were static.

Underuse of coronary intervention and its impact on mortality in the elderly with myocardial infarction. A propensity-matched analysis from the Hungarian Myocardial Infarction Registry

BACKGROUND

Data are limited on the real-life use of coronary intervention (PCI) and on its long-term efficacy and safety in elderly patients with acute myocardial infarction (AMI).

METHODS

Data from a nation-wide registry of patients treated due to an AMI event in centers of invasive cardiology were analyzed for the potential interaction of age on the utilization of invasive therapy and outcome. Follow-up data of consecutive patients between March 1, 2013, and March 1, 2014 were analyzed. Differences in the risk of all-cause death at 1year between patients undergoing PCI versus others receiving conservative treatment were determined from vital records and were compared with propensity score matching.

RESULTS

A total of 8485 consecutive patients were enrolled at 19 centers. Sixty-three percent of the patients were male; the mean age was 65.1±12.4years. The proportion of STEMI cases was 51%. STEMI cases were treated with primary PCI in 91.0% while patients with NSTEACS underwent PCI in 71.0%. The age of patients was a significant determinant of deferring coronary angiography (Hazard ratio (HR): 0.524 95% confidence interval (CI) 0.47-0.59, p<0.001) and PCI (HR: 0.76 95% CI 0.73-0.80, p<0.001). One-year survival after PCI was significantly better both in the overall and in the propensity matched cohort (HR: 0.44 [95% CI: 0.39-0.49] and HR: 0.59 [95% CI: 0.50-0.69], p<0.001, both). This benefit remained consistent in age-dependent subgroup analyses.

CONCLUSION

Coronary intervention is underused among the elderly despite the mortality benefit of interventional therapy in myocardial infarction that is consistent in all age groups.

Impact of transradial coronary intervention on bleeding complications in octogenarians

Percutaneous coronary intervention (PCI) in the elderly is a major hospital burden since this group of patients exhibits high mortality rates and many comorbidities. The aim of this study was to analyze the impact of a transradial intervention (TRI) approach for PCI on bleeding complications in octogenarians. We retrospectively analyzed a consecutive cohort of 2530 patients who underwent PCI at a tertiary care center in Japan. Octogenarians constituted 12 % (291 cases) of the total PCI cases during the study period. Bleeding complications and all-cause mortality were observed at 30 days after PCI. Average age was 83 ± 3 years and female gender was 32 %. Stable coronary artery disease was 59 %. TRI was performed in 218 patients (75 %) and transfemoral intervention (TFI) in 73 (25 %). Bleeding Academic Research Consortium (BARC) major bleeding unrelated to bypass surgery were observed in 7.6 %, which were significantly lower in TRI than TFI (5.1 vs. 15.1 %, P = 0.005). The 30-day mortality rate was significantly low in patients without bleeding (4.9 vs. 31 %, p < 0.0001). In octogenarians, major bleeding complication was significant at 30 days after PCI. TRI had lower bleeding complication rate than TFI in this population. Octogenarians may be a subgroup of patients who derive benefits from TRI.

Risk profile and in-hospital prognosis in elderly patients presenting for acute ST-elevation myocardial infarction in the Tunisian context

OBJECTIVES

Little is known about the risk profile and in-hospital prognosis of elderly patients presenting for ST-elevation myocardial infarction (STEMI) in Tunisia. We sought to determine in-hospital prognosis of elderly patients with STEMI in a Tunisian center.

METHODS

The study was carried out on a retrospective registry enrolling 1403 patients presenting with STEMI in a Tunisian center between January 1998 and January 2013. Patients ≥75 years old were considered elderly. Risk factors and in-hospital prognosis were compared between elderly and younger patients, and then predictive factors of in-hospital death were determined in elderly patients.

RESULTS

Out of the overall population, 211 (15%) were part of the elderly group. Compared to younger patients, elderly patients were more likely to have arterial hypertension but less likely to be smokers and obese. Thrombolysis was significantly less utilized in the elderly group (22.3% vs. 36.6% in the younger group, p<0.001), whereas the use primary percutaneous coronary intervention was comparable between the two sub-groups (24.2% vs. 28.8%, p=0.17). The incidence of in-hospital complications was higher in the elderly group, and so was the in-hospital mortality rate (14.2% vs. 8.1%, p=0.005). Heart failure on-admission, renal failure on-admission, and inotropic agents use were independently associated to in-hospital death in the elderly group.

CONCLUSIONS

In the Tunisian context, elderly patients presenting with STEMI have higher prevalence of risk factors and a worse in-hospital course in comparison to younger patients. Clinical presentation on-admission has a strong impact on in-hospital prognosis.

Factors Associated With Delays in Seeking Medical Attention in Patients With ST-segment Elevation Acute Coronary Syndrome

INTRODUCTION AND OBJECTIVES

Prompt coronary reperfusion is crucial in patients with ST-segment elevation acute coronary syndrome. The aim of this study was to determine factors associated with a delay in seeking medical attention after the onset of symptoms in patients with this condition.

METHODS

Prospective cohort study in consecutive patients with ST segment elevation infarction. Multiple logistic regression analysis was used to identify factors independently associated with a longer delay in requesting medical help.

RESULTS

In total, 444 consecutive patients were included (mean age, 63 years; 76% men, 20% with diabetes). Median total ischemia time was 225 (160-317) minutes; median delay in seeking medical attention was 110 (51-190) minutes. Older patients (age > 75 years; odds ratio = 11.6), women (odds ratio = 3.4), individuals with diabetes (odds ratio = 2.3), and those requesting medical care from home (odds ratio = 2.2) showed the longest delays in seeking medical attention. Lengthy delay was associated with higher in-hospital mortality (9.8% vs 2.7%; P<.005) and 1-year mortality (7.3% vs 2.9%; P<.05) than when attention was promptly solicited.

CONCLUSIONS

Elderly patients, women, and diabetic individuals with ST-segment elevation myocardial infarction show longer delays in seeking medical attention for their condition. Delays in seeking medical attention are associated with greater in-hospital and 1-year mortality.

[A case review: About a STEMI in the very elderly]

Because of the demographic growth of our societies and the increasing prevalence of coronary artery disease with age, we will be increasingly faced with the treatment of myocardial ST+ very elderly patients (>90 years?). If evidence-based medicine does not exist within this framework, there are many registries that can guide us in their care. First, age should not in itself be an indication against reperfusion conventional techniques. In fact recommendations put no upper age limit. The primary angioplasty technical success, which is identical to the younger populations, is the treatment of choice and should be performed preferably by radial arterial access. The thrombolytic alternative, validated for octogenarians, has not been studied for older. Bleeding, neurological, ischemic complications and hospital mortality are more common than in younger populations, especially as the initial hemodynamic alteration is important, but the survivors have the same life-threatening or even better than that of a same reference population ages. Which in itself even justifies maximum adhesion to the therapeutic recommendations taking into account the co-morbidities and possible visceral shortcomings.

Unrecognized myocardial infarctions assessed by cardiovascular magnetic resonance are associated with the severity of the stenosis in the supplying coronary artery

BACKGROUND

A previous study has shown an increased prevalence of late gadolinium enhancement cardiovascular magnetic resonance (LGE CMR) detected unrecognized myocardial infarction (UMI) with increasing extent and severity of coronary artery disease. However, the coronary artery disease was evaluated on a patient level assuming normal coronary anatomy. Therefore, the aims of the present study were to investigate the prevalence of UMI identified by LGE CMR imaging in patients with stable angina pectoris and no known previous myocardial infarction; and to investigate whether presence of UMI is associated with stenotic lesions in the coronary artery supplying the segment of the myocardium in which the UMI is located, using coronary angiography to determine the individual coronary anatomy in each patient.

METHODS

In this prospective multicenter study, we included patients with stable angina pectoris and without prior myocardial infarction, scheduled for coronary angiography. A LGE CMR examination was performed prior to the coronary angiography. The study cohort consisted of 235 patients (80 women, 155 men) with a mean age of 64.8 years.

RESULTS

UMIs were found in 25% of patients. There was a strong association between stenotic lesions (≥70% stenosis) in a coronary artery and the presence of an UMI in the myocardial segments supplied by the stenotic artery; it was significantly more likely to have an UMI downstream a stenosis ≥ 70% as compared to < 70% (OR 5.1, CI 3.1-8.3, p < 0.0001). 56% of the UMIs were located in the inferior and infero-lateral myocardial segments, despite predominance for stenotic lesions in the left anterior descending artery.

CONCLUSION

UMI is common in patients with stable angina and the results indicate that the majority of the UMIs are of ischemic origin due to severe coronary atherosclerosis. In contrast to what is seen in recognized myocardial infarctions, UMIs are predominately located in the inferior and infero-lateral myocardial segments.

TRIAL REGISTRATION

The PUMI study is registered at ClinicalTrials.gov (NCT01257282).

Temporal trends in acute myocardial infarction: What about survival of hospital survivors? Disparities between STEMI & NSTEMI remain. Soroka acute myocardial infarction II (SAMI-II) project

BACKGROUND

Contemporary data on trends of acute myocardial infarction (AMI), particularly outcomes of hospital survivors by AMI type is sparse.

METHODS

Analysis of 11,107 consecutive AMI patients in a tertiary hospital in Israel throughout 2002-2012. The annual incidence of ST-segment elevation (STEMI) and non-ST-segment elevation (NSTEMI) admissions was calculated using age-gender-ethnicity direct adjustment. A multivariate prognostic model was built to evaluate in-hospital and 1-year post-discharge all-cause-mortality, adjusted for patients' risk factors.

RESULTS

A decline in the adjusted incidence of AMI admissions (per-1000 persons) was documented (2002 vs. 2012) for STEMI: 4.70 vs. 1.38 (p<0.001) and non-significant tendency of increase for NSTEMI: 1.86 vs. 2.37 (p=0.109). The prevalence of most cardiovascular risk-factors, some non-cardiovascular comorbidities and invasive interventions increased. In-hospital mortality declined significantly for STEMI: 10.8% vs. 7.7% (p<0.001) and with no change for NSTEMI: 5.0% vs. 5.5% (p=0.137). Consistently, 1-year post-discharge mortality declined for STEMI: 13% vs. 5.9% (p<0.001) and with a non-significant increase for NSTEMI: 12.6% vs. 17.0% (p=0.377). Adjusting for the risk factors, an increase of one year was associated with a decline of in-hospital mortality for STEMI: AdjOR=0.86 (p<0.001) and for NSTEMI: AdjOR=0.92 (p<0.001). However, the risk for post-discharge mortality increased for STEMI: AdjOR=1.11 (p<0.001) and for NSTEMI: AdjOR=1.12 (p<0.001).

CONCLUSIONS

Throughout 2002-2012 significant decline in the incidence and of in-hospital mortality of STEMI were found. However, adjusted post-discharge mortality rates increased significantly with time. Measures for improving incidence and outcomes of AMI patients focusing on NSTEMI and hospital-survivors are warranted.

Long-term ischaemic and bleeding outcomes after primary percutaneous coronary intervention for ST-elevation myocardial infarction in the elderly

Background

The population is ageing rapidly and the proportion of patients aged ≥ 80 years undergoing primary percutaneous coronary intervention (PCI) is rising, but clinical trials have primarily been performed in younger patients.

Methods

Patients undergoing primary PCI between 2003 and 2008 were subdivided into 3 groups: < 60, 60-79, and ≥ 80 years. Endpoints at 3-year follow-up included all-cause mortality, recurrent myocardial infarction (reMI), stent thrombosis, target lesion revascularisation (TLR), bleeding (BARC bleeding ≥ 3), stroke, and major adverse cardiovascular events (MACE, a composite of cardiac mortality, reMI, stroke and TLR).

Results

2002 patients with ST-segment elevation myocardial infarction (STEMI) were included, 885 (44.2 %) aged < 60, 921 (46.0 %) 60–79, and 196 (9.7 %) ≥ 80 years. Comorbidities such as diabetes mellitus, prior stroke, malignant disease, anaemia, and chronic kidney disease were more prevalent in patients ≥ 80 years. The incidence of both ischaemic and bleeding events strongly increased with age. Age ≥ 80 years was an independent predictor of mortality (HR 2.56, 95 % CI1.69–3.87, p < 0.001), a borderline non-significant predictor of overall bleeding (HR 1.38, 95 %CI 0.95–2.00, p = 0.088), and a significant predictor of non-access site bleeding (HR 2.26, 95 %CI 1.46–3.51, p < 0.001).

Conclusion

Patients ≥ 80 years experienced high rates of ischaemic and bleeding complications; especially in this high-risk patient group individualised therapy is needed to optimise clinical outcomes.

Electronic Supplementary Material

The online version of this article (doi:10.1007/s12471-015-0733-2 contains supplementary material, which is available to authorized users.

Prevalence and Impact of Co-morbidity Burden as Defined by the Charlson Co-morbidity Index on 30-Day and 1- and 5-Year Outcomes After Coronary Stent Implantation (from the Nobori-2 Study)

Co-morbidities have typically been considered as prevalent cardiovascular risk factors and cardiovascular diseases rather than systematic measures of general co-morbidity burden in patients who underwent percutaneous coronary intervention (PCI). Charlson co-morbidity index (CCI) is a measure of co-morbidity burden providing a means of quantifying the prognostic impact of 22 co-morbid conditions on the basis of their number and prognostic impact. The study evaluated the impact of the CCI on cardiac mortality and major adverse cardiovascular events (MACE) after PCI through analysis of the Nobori-2 study. The prognostic impact of CCI was studied in 3,067 patients who underwent PCI in 4,479 lesions across 125 centers worldwide on 30-day and 1- and 5-year cardiac mortality and MACE. Data were adjusted for potential confounders using stepwise logistic regression; 2,280 of 3,067 patients (74.4%) had ≥1 co-morbid conditions. CCI (per unit increase) was independently associated with an increase in both cardiac death (odds ratio [OR] 1.47 95% confidence interval [CI] 1.20 to 1.80, p = 0.0002) and MACE (OR 1.29 95% CI 1.14 to 1.47, p ≤0.0011) at 30 days, with similar observations recorded at 1 and 5 years. CCI score ≥2 was independently associated with increased 30-day cardiac death (OR 4.25, 95% CI 1.24 to 14.56, p = 0.02) at 1 month, and this increased risk was also observed at 1 and 5 years. In conclusion, co-morbid burden, as measured using CCI, is an independent predictor of adverse outcomes in the short, medium, and long term. Co-morbidity should be considered in the decision-making process when counseling patients regarding the periprocedural risks associated with PCI, in conjunction with traditional risk factors.