Impact of age on long-term outcome after primary angioplasty with bare-metal or drug-eluting stent (from the DESERT cooperation)

Five-Year Prognostic Value of DAPT Score in Older Patients undergoing Percutaneous Coronary Intervention: A Large-Sample Study in the Real World

AIM

The dual-antiplatelet therapy (DAPT) score is recommended for predicting the risk of ischemia and bleeding for patients undergoing percutaneous coronary intervention (PCI). This study aimed to investigate the long-term prognostic value of the DAPT score in older PCI patients.

METHODS

This study enrolled 10,724 consecutive patients who underwent PCI from January 2013 to December 2013 in Fu Wai hospital, among whom 2,981 (27.8%) were aged ≥ 65 years. The ischemic endpoint was major adverse cardiovascular and cerebrovascular events (MACCE, including myocardial infarction, all-cause death, and stroke). The bleeding endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding.

RESULTS

After a 5-year follow-up, 256 (12.0%) MACCEs and 53 (2.5%) BARC 2, 3, or 5 bleeding occurred. The patients were divided into two groups according to the DAPT score: the low-score (＜2, n=1,646) and high-score (≥ 2, n=485) group. Multivariate Cox regression revealed that the risk of MACCE was similar between the two groups [hazard ratio (HR): 1.214, 95% confidence interval (CI): 0.916-1.609, P=0.178], whereas the risk of bleeding was significantly higher in the high-score group than in the low-score group (HR: 2.447, 95% CI: 1.407-4.257, P=0.002). The DAPT score did not show prognostic value in MACCE [area under the receiver operating characteristic curve (AUROC), 0.534; 95% CI: 0.496-0.572, P=0.079]; however, it demonstrated a certain prognostic value in BARC 2, 3, or 5 bleeding (AUROC, 0.646; 95% CI: 0.573-0.719, P＜0.001).

CONCLUSION

This study suggested that in older PCI patients, the DAPT score did not show predictive value for MACCE; however, it had a certain predictive value for 5-year BARC 2, 3, or 5 bleeding.

Impact of Age at the Time of the First ST-Elevation Myocardial Infarction on 10-Year Outcomes (from the EXAMINATION-EXTEND Trial)

The aim of this substudy of the EXAMINATION-EXTEND was to analyze 10-year outcomes according to the patient's age at the time of the first ST-elevation myocardial infarction (STEMI). Of 1,498 patients with STEMI included in the EXAMINATION-EXTEND study, those with a previous history of coronary ischemic even or ischemic stroke were excluded from this analysis. The remaining 1,375 patients were divided into 4 age groups: <55, 55 to 65, 65 to 75, and >75 years. The primary end point was 10-year patient-oriented composite end point (POCE) of all-cause death, any MI, or any revascularization. At 10-year follow-up, patients aged <55 years (adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.18 to 0.31, p = 0.001), 55 to 65 years (adjusted HR 0.26, 95% CI 0.20 to 0.34, p = 0.001), and 65 to 75 years (adjusted HR 0.38, 95% CI 0.30 to 0.50, p = 0.001) showed lower risk of POCE than those aged >75 years, led by a lower incidence of all-cause death (<55 : 6% vs 55 to 65: 11.9% vs 65 to 75: 25.7% vs >75 years: 61.6%, p = 0.001). Cardiac death was more prevalent in the older group (<55: 3.7% vs 55 to 65: 5.8% vs 65 to 75: 10.9% vs >75 years: 35.5%, p = 0.001). In the landmark analyses, between 5- and 10-year follow-up, young patients exhibited a higher incidence of any revascularization (<55: 7.4% vs 55 to 65: 4.9% vs 65 to 75: 1.8% vs >65 years: 1.6%, p = 0.001). In conclusion, in patients with a first STEMI, advanced age was associated with high rates of POCE at 10-year follow-up due to all-cause and cardiac death. Conversely, younger patients exhibited a high risk of revascularization at long-term follow-up.

The FAST-STEMI Network in Biella From 2013 to 2019: Impact of the Delocalization of the Hospital Facilities on Ischemia Time and In-hospital Outcomes

BACKGROUND

The optimization of the strategies for myocardial revascularization has improved the outcomes of patients with ST-segment elevation myocardial infarction. In Piedmont, the FAST-STEMI regional network was created for improving the management and transportation of ST-segment elevation (STEMI) patients to primary percutaneous coronary intervention facilities, reducing the time to reperfusion. Within this network, the Hospital of Biella was delocalized in December 2014 to a new suburban structure designed for an easier access, which might have shortened the duration of patients' transportation and ischemia, with potential positive prognostic effects. The aim of the present study was to define the impact of the decentralization of the hospital structure on the time to reperfusion and in-hospital outcomes among STEMI patients admitted to the Hospital of Biella.

METHODS

We included STEMI patients admitted to our urban hospital between 2013 and 2019 and included in the FAST-STEMI database. The primary endpoint was the duration of ischemia, defined as pain to balloon (PTB). The primary outcome endpoint (PE) was in-hospital mortality.

RESULTS

We included 276 consecutive patients with STEMI undergoing primary percutaneous coronary intervention between 2016 and 2019 in the new hospital facility, which were compared with 170 patients treated between 2013 and June 2014 in the prior structure. Patients' characteristics included a mean age of 67.5 ± 12.5 years, 72.1% males and 18.7% patients with diabetes. In the new facility, the median PTB was 188 minutes [interquartile range: 125-340 min], reduced as compared with the period 2013-2014 [215 (128.5-352 min), P = 0.002]. The median in-hospital stay was also shorter (P = 0.004), whereas a nonsignificant improvement was noted for ejection fraction (EF) at discharge (P = 0.14). A linear relationship was demonstrated between PTB and the EF (r = -0.183, P = 0.003) in patients treated between 2016 and 2019 while not affecting the length of hospitalization or in-hospital outcomes. In fact, in-hospital death occurred in 36 patients, 8% in the new structure versus 7.7% in 2013-2014 [hazard ratio (HR) (95% confidence interval [CI]) = 1.20 (0.59-2.42), P = 0.62]. The independent predictors of mortality were patients' age and EF at discharge (age ≥ 75 y: adjusted HR [95% CI] = 6.75 [1.51-30.1], P = 0.01; EF: adjusted HR [95% CI] = 0.91 [0.88-0.95], P < 0.001).

CONCLUSIONS

The present study shows that, among the STEMI patients treated in our center, the delocalization of the hospital facilities and the optimization of the FAST-STEMI network reduced the duration of ischemia, with positive effects on left ventricular function at discharge. However, this did not translate into a significant benefit in survival, which was instead conditioned by the aging of the population.

Impact of age on the comparison between short-term vs 12-month dual antiplatelet therapy in patients with acute coronary syndrome treated with the COMBO dual therapy stent: 2-Year follow-up results of the REDUCE trial

BACKGROUND AND AIMS

The impact of advanced age on the optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary revascularization (PCI) is still greatly debated. Therefore, the aim of the present sub-analysis of the REDUCE trial was to assess the impact of age on the comparison between a short 3 months vs standard 12 months DAPT in ACS patients treated with the COMBO Dual Stent Therapy.

METHODS

The REDUCE trial is a prospective, multicenter, investigator-initiated study that randomized ACS patients undergoing PCI with the COMBO drug eluting stent to either 3 or 12 months of DAPT. The study population was divided according to age (<or ≥ 75 years). Primary study endpoint was a composite of all-cause mortality, myocardial infarction, definite/probable stent thrombosis (ST), stroke, target-vessel revascularization (TVR) and bleeding (BARC II, III, V) at 12 months. Secondary endpoints were cardiovascular mortality and the individual components of the primary endpoint within 24 months.

RESULTS

From June 2014 to May 2016, 1496 patients were included in the study, of whom 205 (13.7%) ≥75 years of age. Among them, 50.7% of the elderly and 50.2% of younger patients were assigned to the 3-month DAPT treatment. Baseline characteristics were well matched between the two arms, except for a higher rate of males (p=0.02) and a reduced number of lesions on the right coronary artery (p=0.02) in elderly patients treated for the short DAPT duration. Median follow-up was 682.5 days [IQR:667-731]. At 12 months, no difference in the primary endpoint was observed according to DAPT duration in both patients aged ≥75 years (22.1% vs 18.8%, HR [95%CI] = 1.6 [0.73-3.5], p=0.24) and younger ones (9.7% vs 10.9%, HR [95%CI] = 0.85 [0.59-1.27], p=0.44; p INT = 0.15). Results were confirmed after correction for baseline differences among the elderly (adjusted HR [95%CI] = 1.7 [0.75-3.9], p=0.21). Comparable rates of survival, thrombotic (MI, stent thrombosis, TVR, stroke) and bleeding events were observed with the two DAPT strategies, with no impact of age.

CONCLUSIONS

The present study shows that among ACS patients randomized in the REDUCE trial, a 3-month DAPT strategy was comparable to a standard 12-month DAPT at a 2-year follow-up for both ischemic and bleeding endpoints, in elderly and younger patients. Thus, despite presenting the limitations of a subgroup analysis, our study strengthens the feasibility of a shorter DAPT duration even among high-risk subsets of ACS patients.

Impact of the rs73598374 polymorphism of the adenosine deaminase gene on platelet reactivity and long-term outcomes among patients with acute coronary syndrome treated with ticagrelor

BACKGROUND

The positive interaction of ticagrelor with the metabolism of adenosine has been claimed for the large antithrombotic and antiischemic benefits of this antiplatelet agent in acute coronary syndromes (ACS). Adenosine catabolism is regulated by the activity of the adenosine deaminase enzyme (ADA), for which several polymorphisms have been identified. Therefore, the aim of our study was to explore the impact of the rs73598374 polymorphism of ADA gene on platelet reactivity in ACS patients treated with ticagrelor.

METHODS

We included consecutive patients receiving ASA and ticagrelor after an ACS and coronary intervention. Platelet reactivity was evaluated by impedance aggregometry at 30-90 days post-discharge. The genetic analysis was carried out by PCR and RFLP. Clinical endpoints were mortality, cardiovascular death, recurrent myocardial infarction or coronary revascularization at the maximum available follow-up.

RESULTS

Our population is represented by 464 patients, of whom 33.4% were A-heterozygotes and 6 homozygotes. A-allele carriers showed a greater prevalence of renal failure (p = 0.02) and a lower rate of previous coronary artery bypass graft (p = 0.03) and statin treatment (p = 0.02). No differences in the mean values of platelet reactivity or HRPR on ticagrelor were found according to the ADA genotype (11.3%vs13.9%, p = 0.45; adjusted OR[95% CI] = 1.17[0.64-2.14], p = 0.61). At follow up, patients carrying the A-allele showed a non-significantly lower incidence of ACS and repeated unplanned revascularization, although with no effect on mortality.

CONCLUSIONS

In the present study the rs73598374 polymorphism of the ADA gene did not affect platelet reactivity or the long-term prognosis in patients with ACS receiving dual antiplatelet therapy with ASA and ticagrelor.

Low vitamin D levels affect left ventricular wall thickness in severe aortic stenosis

BACKGROUND

Vitamin D [25(OH)D] deficiency and degenerative aortic stenosis represent emerging conditions, linked to a progressive ageing of the population and increased frailty. Previous studies have associated lower levels of 25 (OH)D to the pathogenesis of atherosclerosis and vascular calcifications. However, few studies have evaluated, so far, the impact of vitamin D deficiency in patients with aortic stenosis, which was therefore the aim of present study.

METHODS

Consecutive patients with severe degenerative aortic stenosis undergoing nonurgent coronary angiography were included. Aortic stenosis was defined as aortic valve area (AVA) less than 1 cm and/or mean gradient more than 40 mmHg. Indexed area and stroke volume or dobutamine stress evaluation were performed when indicated. Fasting samples were collected at admission for 25 (OH)D levels assessment.

RESULTS

We included 137 patients with severe degenerative aortic stenosis (48.9% men, mean age 78.4 ± 6.4 years) who were divided according to vitamin D median values (≥12.4 ng/ml). Patients with lower vitamin D had a more frequent history of coronary artery bypass graft (P = 0.02) and received more often angiotensin-converting enzyme-inhibitors (P = 0.03). Among them, 38.7% had vitamin D levels less than 10 ng/ml and only five patients were in therapy with vitamin D supplementation. We observed no significant relationship between vitamin D levels and echocardiographic parameters for the severity of aortic stenosis (AVA, peak and mean gradients, volumes, ejection fraction) except for a greater wall thickness in patients with lower vitamin D levels (r = -0.34, P = 0.03). Results did not change when excluding patients with renal failure or treated with vitamin D supplementation.

CONCLUSION

Among patients with severe degenerative aortic stenosis, vitamin D deficiency is common. We found a significant association between left ventricular wall thickness and vitamin D levels, suggesting a potential role of this hormone in modulating hypertrophic remodelling in these patients. However, future larger studies are certainly needed to confirm our findings and to define their prognostic implications.

Impact of diabetes on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: insights from the ELDERLY ACS 2 trial

BACKGROUND

Despite recent improvements in percutaneous coronary revascularization and antithrombotic therapies for the treatment of acute coronary syndromes, the outcome is still unsatisfactory in high-risk patients, such as the elderly and patients with diabetes. The aim of the current study was to investigate the prognostic impact of diabetes on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study carried out at 32 centers in Italy.

METHODS

Our population is represented by 1443 patients included in the Elderly-ACS 2 trial. Diabetes was defined as known history of diabetes at admission. The primary endpoint of this analysis was cardiovascular mortality, while secondary endpoints were all-cause death, recurrent myocardial infarction, Bleeding Academic Research Consortium type 2 or 3 bleeding, and rehospitalization for cardiovascular event or stent thrombosis within 12 months after index admission.

RESULTS

Diabetes was present in 419 (29%) out of 1443 patients. Diabetic status was significantly associated with major cardiovascular risk factors and history of previous coronary disease, presentation with non-ST segment elevation myocardial infarction (P = 0.01) more extensive coronary disease (P = 0.02), more advanced Killip class at presentation (P = 0.003), use at admission of statins (P = 0.004) and diuretics at discharge (P < 0.001). Median follow-up was 367 days (interquartile range: 337-378 days). Diabetic status was associated with an absolute increase in the rate of cardiovascular mortality as compared with patients without diabetes [5.5 vs. 3.3%, hazard ratio (HR) 1.7 (0.99-2.8), P = 0.054], particularly among those treated with clopidogrel [HR (95% confidence interval (CI)) = 1.89 (0.93-3.87), P = 0.08]. However, this difference disappeared after correction for baseline differences [Adjusted HR (95% CI) 1.1(0.4-2.9), P = 0.86]. Similar findings were observed for other secondary endpoints, except for bleeding complications, significantly more frequent in diabetic patients [HR (95% CI) 2.02 (1.14-3.6), P = 0.02; adjusted HR (95% CI) = 2.1 (1.01-4.3), P = 0.05]. No significant interaction was observed between type of dual antiplatelet therapy, diabetic status and outcome.

CONCLUSION

Among elderly patients with acute coronary syndromes, diabetic status was associated with higher rates of comorbidities, more severe cardiovascular risk profile and major bleeding complications fully accounting for the absolute increase in mortality. In fact, diabetes mellitus did not emerge as an independent predictor of survival in advanced age.

Impact of aging on platelet reactivity in diabetic patients receiving dual antiplatelet therapy

Advanced age and diabetes represent summative conditions in the determination of cardiovascular risk, and especially for the management of dual antiplatelet therapy (DAPT), often requiring balancing between bleeding and thrombotic complications. However, few studies have so far evaluated the impact of age on platelet reactivity and suboptimal platelet inhibition (high-on treatment platelet reactivity-HRPR) on DAPT among diabetic patients, that was, therefore the aim of the present study. In diabetic patients treated with DAPT (ASA + clopidogrel or ticagrelor) platelet reactivity was assessed at 30-90 days post-discharge for an acute coronary syndrome or elective PCI. Aggregation was assessed by multiple-electrode aggregometry. HRPR was defined for values above the lower limit of normality (in non-treated patients). Elderly patients were considered ≥ 75 years of age. We included 462 patients, among them 149 (32.2%) were ≥ 75 years. Elderly patients were more often females (p = 0.006), with lower body size (p = 0.04), acute coronary syndrome at presentation and renal failure (p < 0.001), non-smokers (p = 0.002), in therapy with insulin (p = 0.02) and diuretics (p < 0.001) and lower rate of betablockers (p = 0.02). Age directly related with C reactive protein (p = 0.01), creatinine levels and inversely with hemoglobin (p < 0.001) and triglycerides (p = 0.003). No association was found at linear regression analysis for platelet reactivity and age with different activating stimuli, but for ASPI test (r = 0.12; p = 0.03). No significant difference in HAPR was found in elderly patients (2.4 vs. 3.2%, p = 0.76, OR[95% CI] = 0.45[0.1-2.11], p = 0.31). HRPR for ADP antagonists was similarly not affected by age (30.1% vs. 35.7%, p = 0.28, adjusted OR[95% CI] = 0.78[0.47-1.29], p = 0.33). Comparable results were obtained when considering separately the DAPT strategies with clopidogrel or ticagrelor, or when adjusting our results according to propensity score values. Among diabetic patients receiving dual antiplatelet therapy for an acute coronary syndrome or elective percutaneous coronary intervention, age does not affect platelet reactivity or the rate of high-on treatment platelet reactivity. Similar results were obtained for ASA and clopidogrel or ticagrelor.

Impact of aging on immature platelet count and its relationship with coronary artery disease

Despite the fact that elderly patients represent a prevalent and challenging population in the current practice, few data exist on the impact of platelet parameters on cardiovascular risk in these patients. Therefore, the aim of the present study was to evaluate the impact of age on the immature platelet count (IPC) and their relationship with CAD. We included a total of 2236 consecutive patients undergoing coronary angiography in a single center. Elderly patients (age ≥ 75 years) were 756 (33.7%). IPC was measured at admission. Elderly patients were more often females (p < .001), with lower BMI and prevalence of smokers (p < .001), and a more complex cardiovascular risk profile and coronary disease (p = .02). Platelet count decreased with aging (p = .05), whereas no difference in the mean IPC was found between patients < or ≥75 years. In fact, advanced age did not emerge as an independent predictor of IPC above III tertile (≥8.6*10^6/ml), (adjusted OR[95%CI] = 0.97[0.78-1.21], p = .79). When considering elderly patients according to tertiles values of IPC (<5.1,5.1-8.59; ≥8.6*10^6/ml), we found no impact of IPC on the prevalence of CAD (81.1% vs 84.5% vs 81.5%, p = .92; adjusted OR[95%CI] = 1.08[0.67-1.72], p = .75) and its extent (37.7% vs 34.5% vs 40.2%, p = .57; adjusted OR[95%CI] = 1.22[0.85-1.73], p = .28). However, we observed a higher rate of calcified and type C lesions in elderly patients with higher IPC (p = .03 and p < .001, respectively). Therefore, advanced age is not associated with higher immature platelet count and the prevalence and severity of CAD. Moreover, IPC does not contribute to explain the higher prevalence and extent of coronary artery disease observed in elderly patients.

A meta-analysis of sex-related differences in outcomes after primary percutaneous intervention for ST-segment elevation myocardial infarction

INTRODUCTION

The increasing use of primary percutaneous coronary intervention (pPCI) has improved clinical outcome in ST-segment elevation myocardial infarction (STEMI) patients, but the impact of sex on early and mid-term outcomes remains to be defined.

METHODS

Medline, Cochrane Library, Biomed Central, and Google Scholar were searched for articles describing differences in baseline, periprocedural, and midterm outcomes after pPCI, by sex. The primary end point was all-cause mortality at early and mid-term follow-up. Secondary endpoints included in-hospital bleeding and stroke.

RESULTS

Sixteen studies were included. Women were older, had more frequent hypertension, diabetes mellitus, and hypercholesterolemia, as well as longer ischemia time and more shock at presentation. Men were more likely to have had a previous myocardial infarction. Female sex emerged as independently associated to early mortality (OR 1.1; 95%CI, 1.02-1.18) but not to mid-term mortality (OR, 1.01; 95%CI, 0.99-1.03). The pooled analysis showed a significantly higher risk of in hospital stroke (OR, 1.69; 95%CI, 1.11-2.56) and major bleeding (OR, 2.04; 95%CI, 1.51-2.77) in women.

CONCLUSIONS

As compared to men, women undergoing pPCI have more bleedings and strokes, and a worse early, but not mid-term mortality. These findings may allow a better risk stratification of pPCI patients.

Advanced age and high-residual platelet reactivity in patients receiving dual antiplatelet therapy with clopidogrel or ticagrelor

ESSENTIALS: Dual antiplatelet therapy (DAPT) in elderly patients requires balancing bleedings and thrombosis. Impact of age on high residual on-treatment platelet reactivity (HRPR) on DAPT was studied. A reduced effectiveness of adenosine diphosphate antagonists was observed over 70 years of age. The occurrence of HRPR was increased among elderly patients with both clopidogrel and ticagrelor.

BACKGROUND

The aim of the present study was to evaluate the impact of age on platelet function and the occurrence of high residual on-treatment platelet reactivity (HRPR) in patients treated with dual antiplatelet therapy (DAPT) using acetylsalicilic acid (ASA) and clopidogrel or ticagrelor.

METHODS

Patients treated with DAPT (ASA and clopidogrel or ticagrelor) were scheduled for platelet function assessment at 30-90 days post-discharge. By whole blood impedance aggregometry, HRPR was considered for ASPI test values > 862 AU*min (for ASA) and adenosine diphosphate (ADP) test values > 417 AU*min (for ADP antagonists). Elderly patients were defined as those aged ≥ 70 years.

RESULTS

Among 494 patients on DAPT, 224 (45.3%) were ≥ 70 years old. ADP-mediated platelet aggregation increased with decades of age (279.3 ± 148.6 vs. 319.6 ± 171.1 vs. 347.3 ± 190.1 vs. 345.7 ± 169.2), whereas no difference was observed for ASA response. A reduced effectiveness of ADP antagonists was observed among elderly patients; in fact, among the 117 patients displaying HRPR (23.7%), a higher prevalence was observed among patients over 70 years old (30.4% vs. 18.1%; adjusted odds ratio (OR) [95% confidence interval (CI)] = 2.19 [1.29-3.71]). Similar results were obtained among the 266 clopidogrel-treated patients (38.5% vs. 27.9%; adjusted OR [95% CI] = 2.91 [1.46-5.8]) and in the 228 patients receiving ticagrelor (19.1% vs. 8.1%; adjusted OR [95% CI] = 2.55 [1.02-8.59]).

CONCLUSION

In patients receiving dual antiplatelet therapy, advanced age is independently associated with a reduced effectiveness of ADP antagonists and a higher rate of HRPR with both clopidogrel and ticagrelor.

Short and long-term survival after primary percutaneous coronary intervention in young patients with ST-elevation myocardial infarction

The long-term prognosis of patients with ST-elevation myocardial infarction (STEMI) aged 45 years or younger and differences according to gender have not been well characterized.

METHODS

We included 16,685 consecutive STEMI patients from 2003 to 2012 (67,992 patient-years follow-up) from the Eastern Danish Heart Registry and the Swedish Coronary Angiography and Angioplasty Registry who were treated with primary percutaneous coronary intervention (PCI).

RESULTS

We identified 1026 (6.2%) patients up to 45 years of age (mean age: 40.7 vs. 66.3 years, P<0.001). Patients in the young group were predominantly men (79.7% vs. 71.9%) and smokers (71.2% vs. 44.2%, P<0.001) but with a lower prevalence of hypertension (17.3% vs. 39.3%), hyperlipidemia (18.0% vs. 23.8%), diabetes (9.0% vs. 12.4%) and previous myocardial infarction (6.9% vs. 12.2%, all P<0.001) compared with older patients. Young patients had a 0.8% annual mortality. During the follow-up period 6.3% of young patients died vs. 28.5% of older patients (P<0.001). Both 30-day-mortality (adjusted hazard ratio [HR]=0.26, 95% confidence interval [CI]: 0.12-0.54, P<0.001) and mortality after 30 days and onwards (HR=0.25, CI: 0.17-0.37, P<0.001) were significantly lower in the young group. There was no difference in short-term (HR=0.78, CI: 0.32-1.90, P=0.59) or long-term (HR=0.62, CI: 0.33-1.91, P=0.59) mortality between women and men in the young group (HR=0.79, CI: 0.21-1.80, P=0.39).

CONCLUSIONS

STEMI patients, aged 45 years or younger, have an excellent prognosis after treatment with primary PCI. Long-term annual survival is more than 99% in these patients. Young women with STEMI do not have a worse long-term prognosis than young men with STEMI.

Everolimus-eluting stent versus bare-metal stent in elderly (≥75 years) versus non-elderly (<75 years) patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: insights from the examination trial

BACKGROUND

The elderly (≥75years) constitute a high-risk subset of patients who continue to have a poorer prognosis than non-elderly (<75years). Whether the effects of everolimus-eluting stent (EES) in ST-segment elevation myocardial infarction (STEMI) are independent of age has not been reported. We investigated the outcomes following primary PCI (PPCI) with bare-metal stent (BMS) or EES in elderly vs. non-elderly STEMI patients.

METHODS

The EXAMINATION trial randomized 1498 STEMI patients to BMS or EES. The primary patient-oriented endpoint (POCE) was the combined of all-cause death, any-recurrent myocardial infarction (MI) and any-revascularization at 1-year. The secondary endpoint included the device-oriented combined (DOCE) of cardiac death, target-vessel MI and target-lesion revascularization. These endpoints and their components were compared between elderly and non-elderly.

RESULTS

Among patients enrolled in the trial, 245 (16.3%) were elderly, allocated to BMS (n=132) or EES (n=113), while the remaining 1253 (83.7%) were non-elderly, allocated to BMS (n=615) or EES (n=638). At 1-year, both the POCE and DOCE were observed more frequently in elderly vs. non-elderly group (24.5% vs. 10.5%, p<0.001 and 15.9% vs. 5.1%, p<0.001). Whereas in non-elderly, both POCE and DOCE were lower in EES vs. BMS (12.4% vs. 8.8%, p=0.03 and 6.7% vs. 3.6%, p=0.01), no differences were found in elderly, with a tendency for interaction between age and stent type for POCE (p=0.05). On multivariate analysis age ≥75 years was an independent predictor of POCE (HR 2.19 [95%CI 1.59-3.01], p<0.0001) and DOCE (HR 2.42 [95%CI 1.60-3.7], p<0.001) at 1-year.

CONCLUSIONS

In STEMI patients undergoing PPCI, advanced age (≥75 years) is associated with worse outcomes. The beneficial effects of EES over BMS tended to be age-dependent.

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.