Comparison of 30-Day and Long-Term Outcomes and Hospital Complications Among Patients Aged <75 Versus ≥75 Years With ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

The Impact of Contrast-Associated Acute Kidney Injury on All-Cause Mortality in Older Patients After Coronary Angiography:A 7.5-year Follow-Up

Older patients (≥75 years) after coronary angiography constitute an increasing proportion, but only limited data are available regarding the prognosis of geriatric contrast-associated acute kidney injury (CA-AKI). Patients (≥75 years) undergoing coronary angiography between December 2010 and September 2013 were consecutively enrolled. CA-AKI was defined as an increase in serum creatinine of 25% or .5 mg/dL from the baseline within 48-72 h of contrast exposure. All-cause mortality was assessed during median 7.5 years (interquartile range [IQR] 6.7-8.7 years) follow-up period. In total, 571 patients aged >75 years undergoing coronary angiography were enrolled in a single center study; 82 (14.4%) patients had CA-AKI. The all-cause mortality during the median 7.5 years follow-up period was 22.0% in patients with CA-AKI and 13.1% in patients without CA-AKI (P = .015). After adjusting for potential confounding factors, the multivariable analysis indicated that CA-AKI was related to an increased risk of all-cause mortality during the median 7.5-year follow-up (hazard ratio [HR]: 2.46; 95% CI: 1.29-4.7; P = .006). CA-AKI is a significant and independent predictor of long-term mortality for patients aged over 75 years who underwent coronary angiography.

MRI Investigation of the Differential Impact of Left Ventricular Ejection Fraction After Myocardial Infarction in Elderly vs. Nonelderly Patients to Predict Readmission for Heart Failure

BACKGROUND

Patients with ST-segment elevation myocardial infarction (STEMI), especially elderly individuals, have an increased risk of readmission for acute heart failure (AHF).

PURPOSE

To study the impact of left ventricular ejection fraction (LVEF) by MRI to predict AHF in elderly (>70 years) and nonelderly patients after STEMI.

STUDY TYPE

Prospective.

POPULATION

Multicenter registry of 759 reperfused STEMI patients (23.3% elderly).

FIELD STRENGTH/SEQUENCE

1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences.

ASSESSMENT

One-week MRI-derived LVEF (%) was quantified. Sequential MRI data were recorded in 579 patients. Patients were categorized according to their MRI-derived LVEF as preserved (p-LVEF, ≥50%), mildly reduced (mr-LVEF, 41%-49%), or reduced (r-LVEF, ≤40%). Median follow-up was 5 [2.33-7.54] years.

STATISTICAL TESTS

Univariable (Student's t, Mann-Whitney U, chi-square, and Fisher's exact tests) and multivariable (Cox proportional hazard regression) comparisons and continuous-time multistate Markov model to analyze transitions between LVEF categories and to AHF. Hazard ratios (HR) with 95% confidence intervals (CIs) were computed. P < 0.05 was considered statistically significant.

RESULTS

Over the follow-up period, 79 (10.4%) patients presented AHF. MRI-LVEF was the most robust predictor in nonelderly (HR 0.94 [0.91-0.98]) and elderly patients (HR 0.94 [0.91-0.97]). Elderly patients had an increased AHF risk across the LVEF spectrum. An excess of risk (compared to p-LVEF) was noted in patients with r-LVEF both in nonelderly (HR 11.25 [5.67-22.32]) and elderly patients (HR 7.55 [3.29-17.34]). However, the mr-LVEF category was associated with increased AHF risk only in elderly patients (HR 3.66 [1.54-8.68]). Less transitions to higher LVEF states (n = 19, 30.2% vs. n = 98, 53%) and more transitions to AHF state (n = 34, 53.9% vs. n = 45, 24.3%) were observed in elderly than nonelderly patients.

DATA CONCLUSION

MRI-derived p-LVEF confers a favorable prognosis and r-LVEF identifies individuals at the highest risk of AHF in both elderly and nonelderly patients. Nevertheless, an excess of risk was also found in the mr-LVEF category in the elderly group.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 2.

Clinical Predictors and Prognosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) without ST-Segment Elevation in Older Adults

A non-neglectable percentage of patients with non-ST elevation myocardial infarction (NSTEMI) show non-obstructive coronary arteries (MINOCA). Specific data in older patients are scarce. We aimed to identify the clinical predictors of MINOCA in older patients admitted for NSTEMI and to explore the long-term prognosis of MINOCA. This was a single-center, observational, consecutive cohort study of older (≥70 years) patients admitted for NSTEMI between 2010 and 2014 who underwent coronary angiography. Univariate and multivariate Cox regression were performed to analyze the association of variables with MINOCA and all-cause mortality and with major adverse cardiac events (MACE), defined as a combined endpoint of all-cause mortality and nonfatal myocardial infarction and a combined endpoint of cardiovascular mortality, nonfatal myocardial infarction, and unplanned revascularization. The registry included 324 patients (mean age 78.8 ± 5.4 years), of which 71 (21.9%) were diagnosed with MINOCA. Predictors of MINOCA were female sex, left bundle branch block, pacemaker rhythm, chest pain at rest, peak troponin level, previous MI, Killip ≥2, and ST segment depression. Regarding prognosis, patients with obstructive coronary arteries (stenosis ≥50%) and the subgroup of MINOCA patients with plaques <50% had a similar prognosis; while MINOCA patients with angiographically smooth coronary arteries had a reduced risk of MACE. We conclude that the following: (1) in elderly patients admitted for NSTEMI, certain universally available clinical, electrocardiographic, and analytical variables are associated with the diagnosis of MINOCA; (2) elderly patients with MINOCA have a better prognosis than those with obstructive coronary arteries; however, only those with angiographically smooth coronary arteries have a reduced risk of all-cause mortality and MACE.

Prevalence and associated factors of mortality after percutaneous coronary intervention for adult patients with ST-elevation myocardial infarction: A systematic review and meta-analysis

Background

There is a paucity of systematic reviews on the associated factors of mortality among ST-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention (PCI). This meta-analysis was designed to synthesize available evidence on the prevalence and associated factors of mortality after PCI for adult patients with STEMI.

Materials and Methods

Databases including the Cochrane Library, PubMed, Web of Science, Embase, Ovid, Scopus, ProQuest, MEDLINE, and CINAHL Complete were searched systematically to identify relevant articles published from January 2008 to March 2020 on factors affecting mortality after PCI in STEMI patients. Meta-analysis was conducted using Stata 12.0 software package.

Results

Our search yielded 91 cohort studies involving a total of 199, 339 participants. The pooled mortality rate for STEMI patients after PCI was 10%. After controlling for grouping criteria or follow-up time, the following 17 risk factors were significantly associated with mortality for STEMI patients after PCI: advanced age (odds ratio [OR] = 3.89), female (OR = 2.01), out-of-hospital cardiac arrest (OR = 5.55), cardiogenic shock (OR = 4.83), renal dysfunction (OR = 3.50), admission anemia (OR = 3.28), hyperuricemia (OR = 2.71), elevated blood glucose level (OR = 2.00), diabetes mellitus (OR = 1.8), chronic total occlusion (OR = 2.56), Q wave (OR = 2.18), without prodromal angina (OR = 2.12), delay in door-to-balloon time (OR = 1.72), delay in symptom onset-to-balloon time (OR = 1.43), anterior infarction (OR = 1.66), ST-segment resolution (OR = 1.40), and delay in symptom onset-to-door time (OR = 1.29).

Conclusion

The pooled prevalence of mortality after PCI for STEMI patients was 10%, and 17 risk factors were significantly associated with mortality for STEMI patients after PCI.

Prognostic value of cardiac magnetic resonance early after ST-segment elevation myocardial infarction in older patients

BACKGROUND

older patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce.

METHODS

the registry comprised 247 STEMI patients over 70 years of age treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

RESULTS

during a 4.8-year mean follow-up, the number of first major adverse cardiac events (MACE) was 66 (26.7%): 27 all-cause deaths and 39 re-admissions for acute heart failure. Predictors of MACE were GRACE score (HR 1.03 [1.02-1.04], P < 0.001), CMR-LVEF (HR 0.97 [0.95-0.99] per percent increase, P = 0.006) and MVO (HR 1.24 [1.09-1.4] per segment, P = 0.001). Adding CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694-0.824] vs. 0.685 [0.613-0.756], NRI = 0.6, IDI = 0.08, P < 0.001). The best cut-offs for independent variables were GRACE score > 155, LVEF < 40% and MVO ≥ 2 segments. A simple score (0, 1, 2, 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (P < 0.001).

CONCLUSIONS

CMR data contribute valuable prognostic information in older patients submitted to undergo CMR soon after STEMI. The Older-STEMI-CMR score should be externally validated.

Acute Coronary Syndrome in the Older Patient

Coronary artery disease is one of the leading causes of morbidity and mortality, and its prevalence increases with age. The growing number of older patients and their differential characteristics make its management a challenge in clinical practice. The aim of this review is to summarize the state-of-the-art in diagnosis and treatment of acute coronary syndromes in this subgroup of patients. This comprises peculiarities of ST-segment elevation myocardial infarction (STEMI) management, updated evidence of non-STEMI therapeutic strategies, individualization of antiplatelet treatment (weighting ischemic and hemorrhagic risks), as well as assessment of geriatric conditions and ethical issues in decision making.

Off-hours admission does not impact outcomes in patients undergoing primary percutaneous coronary intervention and with a first medical contact-to-device time within 90 min

Background:

It remains unclear whether the outcomes of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) during off-hours are as favorable as those treated during on-hours, especially those with a first medical contact-to-device (FMC-to-device) time within 90 min. We aimed to determine whether off-hours admission impacted late outcomes in patients undergoing PPCI and with an FMC-to-device time ≤90 min.

Methods:

This multicenter retrospective study included 670 STEMI patients who underwent successful PPCI and had an FMC-to-device time ≤90 min from 19 chest pain centers in Beijing from January 2018 to December 2018. Patients were divided into on-hours group and off-hours group based on their arrival time. Baseline characteristics, clinical data, and key time intervals during treatment were collected from the Quality Control & Improvement Center of Cardiovascular Intervention of Beijing by the “Heart and Brain Green Channel” app.

Results:

Overall, the median age of the patients was 58.8 years and 19.9% (133/670) were female. Of these, 296 (44.2%) patients underwent PPCI during on-hours and 374 (55.8%) patients underwent PPCI during off-hours. Compared with the on-hours group, the off-hours group had a longer FMC-to-device time and fewer patients with FMC-to-device time ≤60 min (P < 0.05). During the mean follow-up period of 24 months, a total of 64 (9.6%) participants experienced a major adverse cardiovascular event (MACE), with 28 (9.1%) in the on-hours group and 36 (9.6%) in the off-hours group (P > 0.05). According to the Cox regression analyses, off-hours admission was not a predictor of 2-year MACEs (P = 0.788). Similarly, the Kaplan-Meier curves showed that the risks of a MACE, all-cause death, reinfarction, and target vessel revascularization were not significantly different between the two groups (P > 0.05).

Conclusions:

This real-world, multicenter retrospective study demonstrated that for STEMI patients who underwent PPCI within 90 min, off-hours admission was safe, with no difference in the risk of 2-year MACEs compared with those with on-hours admission.

Outcomes following the percutaneous coronary intervention in contemporary Vietnamese practice: Insight from a single centre prospective cohort

BACKGROUND

Evidence regarding the outcomes of percutaneous coronary intervention (PCI) in low-and-middle incomes countries remains limited.

OBJECTIVES

To report the outcomes post PCI at discharge, 30 days and 12 months in Vietnam and identify the key factors associated with adverse outcomes at 12 months.

METHODS

We used data from a single centre prospective cohort in Vietnam. Data regarding demographics, clinical presentation, procedural information, and outcomes of patients were collected and analysed. Primary outcomes were mortality and major adverse cardiac and cerebrovascular events.

RESULTS

In total, 926 patients were included. Poor outcomes were relatively low in those undergoing PCI. Predictors of mortality and major adverse cardiac and cerebrovascular events at 12 months post-PCI included being older than 75, being male, having acute myocardial infarction, left ventricular ejection fraction ≤ 40%, prior cerebral vascular disease and having an unsuccessful PCI.

CONCLUSIONS

Adverse outcomes of patients undergoing PCI in Vietnam are relatively low in comparison with those reported in other countries across the Asia Pacific region. Identification of factors associated with poor outcomes is beneficial for improving the quality of cardiac care and developing the prediction model of outcomes post-PCI in Vietnam.

Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population

Background

Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population.

Methods

Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality.

Results

Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6).

Conclusions

The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes.

Acute renal impairment in older adults treated with percutaneous coronary intervention for ST-segment elevation myocardial infarction

BACKGROUND

Elderly individuals ( ≥ 75 years) constitute an increasing proportion of patients presenting with myocardial infarction treated with primary percutaneous coronary intervention (PCI), but only limited data are available regarding the incidence and prognostic implications of acute kidney injury (AKI) in this group of patients.

OBJECTIVE

To evaluate the incidence and prognostic implications of AKI in older adults ( ≥ 75 years) with ST-segment elevation myocardial infarction (STEMI) treated with primary PCI.

PATIENTS AND METHODS

A retrospective cohort, observational, single-center study of consecutive 416 older patients with STEMI (≥ 75 years) treated with primary PCI between January 2008 and August 2017 was conducted. AKI was defined as an increase of at least 0.3 mg/dl in serum creatinine within 48 h following admission.

RESULTS

A total of 96/416 (23%) patients developed AKI. The occurrence of AKI was associated with adverse in-hospital outcomes, higher 30 days (25 vs. 6%; P < 0.001), and long-term mortality (46 vs. 17%; hazard ratio: 3.2; 95% confidence interval: 2.1-4.7; P < 0.001). Among patients with AKI, 46/96 (48%) demonstrated recovery of renal function at hospital discharge. Lack of renal function recovery at discharge (50/96 patients; 52%) was associated with the occurrence of new or progression of baseline chronic kidney disease.

CONCLUSION

Among older patients with STEMI undergoing primary PCI, AKI is a frequent complication associated with adverse renal short-term and long-term outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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