Management of Acute Coronary Syndromes in Geriatric Patients

Evolution of REperfusion Strategies and impact on mortality in Old and Very OLD STEMI patients. The RESOVOLD-e-MUST study

BACKGROUND

The use of myocardial reperfusion-mainly via angioplasty-has increased in our region to over 95%. We wondered whether old and very old patients have benefited from this development.

METHODS

Setting: Greater Paris Area (Ile-de-France).

DATA

Regional registry, prospective, including since 2003, data from 39 mobile intensive care units performing prehospital treatment of patients with ST segment elevation myocardial infarction (STEMI) (<24 h).

PARAMETERS

Demographic, decision to perform reperfusion and outcome (in-hospital mortality).

PRIMARY ENDPOINT

Reperfusion decision rate by decade over age 70.

SECONDARY ENDPOINT

Outcome.

RESULTS

We analysed the prehospital management of 27,294 patients. There were 21,311 (78%) men and 5,919 (22%) women with a median age of 61 (52-73 years). Among these patients, 8,138 (30%) were > 70 years, 3,784 (14%) > 80 years and 672 (2%) > 90 years.The reperfusion decision rate was 94%. It decreased significantly with age: 93, 90 and 76% in patients in their seventh, eighth and ninth decade, respectively. The reperfusion decision rate increased significantly over time. It increased in all age groups, especially the higher ones. Mortality was 6%. It increased significantly with age: 8, 16 and 25% in patients in their seventh, eighth and ninth decade, respectively. It significantly decreased over time in all age groups. The odds ratio of the impact of reperfusion decision on mortality reached 0.42 (0.26-0.68) in patients over 90 years.

CONCLUSION

the increase in the reperfusion decision rate was the greatest in the oldest patients. It reduced mortality even in patients over 90 years of age.

Impact of Geriatric Events on Clinical Outcomes and Resource Utilization of Acute Coronary Syndrome Hospitalizations

Background The effect of geriatric events (GEs) on outcomes of acute coronary syndrome (ACS) admissions is poorly understood. We evaluated the prevalence and impact of GEs on clinical outcomes and resource utilization of older patients admitted with ACS. Methods Using the 2018 National (Nationwide) Inpatient Sample, we analyzed all elective hospitalizations for ACS in older adults (age ≥ 65 years) and a younger reference group (age 55-64). Nationally-weighted descriptive statistics were generated for GEs based on ACS subtypes. Multivariate logistic regression models controlling for comorbidities, frailty, patient procedure, and hospital-level variables were used to estimate the association of age with GEs and GEs with outcomes. Results Out of 403,760 admissions analyzed, 71.9% occurred in older adults (≥65 years). The overall rate of any GE in older adults with ACS was 3.4%. With advancing age, the number of GEs was found to significantly increase (p<0.001). After adjustments, having any GE was found to have a significant impact on mortality (adjusted OR (AOR): 1.32; 95%CI: 1.15-1.54; p < 0.001), post-myocardial infarction (MI) complications (AOR: 1.53; 95%CI: 1.36-1.71; p < 0.001), prolonged hospital stays (AOR: 2.97; 95%CI: 2.56-3.30; p < 0.001), and non-home (acute care and skilled nursing home) discharge (AOR: 1.68; 95%CI: 1.53-1.85; p < 0.001). The occurrence of GEs was also associated with a substantial increase in total hospitalization costs with a mean increase of $48,325.22 ± $5,539 (p < 0.001). A dose-response relationship was established between GEs and all outcomes. Limitations of the study included the use of retrospective data and an administrative database. Conclusion Geriatric events were found to significantly worsen outcomes for older adults with ACS. There is, therefore, a need for increased awareness and effective management of GEs in older adults to improve their health outcomes and reduce the burden on the healthcare system.

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

Cardiovascular risk factors, clinical manifestations and management of myocardial infarction in elderly and long­living patients depending on geriatric status

Aim. To study cardiovascular risk factors, clinical manifestations and management of myocardial infarction (MI) in elderly and long­living patients depending on geriatric status.

Material and methods. Out of 92 patients with MI (mean age, 81,6±4,2), 3 following groups were formed: "frailty" — 35 (38,0%), "prefrailty" — 16 (17,4%), and "no frailty" — 41 (44,6%). The following questionnaires were used: Age Is Not a Hindrance, Mini Nutritional Assessment (MNA), Barthel Index for Activities of Daily Living, Lawton Instrumental Activities of Daily Living Scale, balance test, Gait Speed Test, Timed Up and Go test, grip test, Mini Mental State Examination (MMSE), Clock Drawing Test, Geriatric Depression Scale.

Results. Frailty probability in patients is higher in the presence of obesity, type 2 diabetes, a decrease in glomerular filtration rate (GFR) <60 ml/min/1,73 m2, a stroke, and heart failure. In the event of clinical manifestations of acute coronary syndrome (ACS), patients without frailty sought medical assistance earlier (in the first 2 hours — 26,8% of patients (χ2=7,8, p=0,005). Most patients with prefrailty and frailty called an ambulance later, but in the first 12 hours — 68,8 and 74,3%, respectively (χ2=15,6, p=0,012). The prevalence of thrombolysis is 23,2%, percutaneous coronary intervention — 30,4% and did not depend on geriatric status. The probability of multivessel disease is higher in patients with or at risk of malnutrition. The main hemodynamic parameters, echocardiography, laboratory parameters in patients with MI did not depend on geriatric status. According to the STOPP/START criteria, frail patients with more often received nonrecommended inhospital medicines.

Conclusion. Frailty in patients with MI was associated with multiple cardiovascular risk factors, later medical assistance, and more frequent non-recommended treatment.

Invasive versus Conservative Treatment Approach among Older Adult Patients Admitted with Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the preferred treatment strategy for patients with ST-elevation myocardial infarction (STEMI); however, its efficacy remains unclear in very older adult patients with STEMI.

METHODS

This retrospective single-center observational study included 530 patients aged &gt;75 years admitted to Tel Aviv Sourasky Medical Center with a diagnosis of acute STEMI. Primary PCI was performed for patients with symptoms ≤12 hours in duration, while the other patients were conservatively treated. We evaluated 30-day mortality and complications occurring during hospitalization based on data from patient records.

RESULTS

Among the study patients, only 28/530 (5%) were conservatively treated. In-hospital complications, including the use of inotropes or intra-aortic balloon counterpulsation and the need for mechanical ventilation, did not differ significantly between the groups. The only parameter that showed a trend toward significance was the incidence of heart failure during hospitalization (p=0.042). The risk for 30-day mortality was substantially higher in the conservative treatment group than in the invasive treatment group (27% vs. 10%; p = 0.02).

CONCLUSION

Our data suggested that despite concerns regarding the safety of the primary PCI strategy in the older adult STEMI population, this treatment strategy was associated with a survival benefit.

Recurrence risk prediction of acute coronary syndrome per patient as a personalized ACS recurrence risk: a retrospective study

Acute coronary syndrome (ACS) has been one of the most important issues in global public health. The high recurrence risk of patients with coronary heart disease (CHD) has led to the importance of post-discharge care and secondary prevention of CHD. Previous studies provided binary results of ACS recurrence risk; however, studies providing the recurrence risk of an individual patient are rare. In this study, we conducted a model which provides the recurrence risk probability for each patient, along with the binary result, with two datasets from the Korea Health Insurance Review and Assessment Service and Chungbuk National University Hospital. The total data of 6,535 patients who had been diagnosed with ACS were used to build a machine learning model by using logistic regression. Data including age, gender, procedure codes, procedure reason, prescription drug codes, and condition codes were used as the model predictors. The model performance showed 0.893, 0.894, 0.851, 0.869, and 0.921 for accuracy, precision, recall, F1-score, and AUC, respectively. Our model provides the ACS recurrence probability of each patient as a personalized ACS recurrence risk, which may help motivate the patient to reduce their own ACS recurrence risk. The model also shows that acute transmural myocardial infarction of an unspecified site, and other sites and acute transmural myocardial infarction of an unspecified site contributed most significantly to ACS recurrence with an odds ratio of 97.908 as a procedure reason code and with an odds ratio of 58.215 as a condition code, respectively.

Revascularization vs. Conservative Medical Treatment in Patients With Chronic Kidney Disease and Coronary Artery Disease: A Meta-Analysis

Background

As a strong risk factor for coronary artery disease (CAD), chronic kidney disease (CKD) indicates higher mortality in patients with CAD. However, the optimal treatment for the patients with two coexisting diseases is still not well defined.

Methods

To conduct a meta-analysis, PubMed, Embase, and the Cochrane database were searched for studies comparing medical treatment (MT) and revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)] in adults with CAD and CKD. Long-term all-cause mortality was evaluated, and subgroup analyses were performed.

Results

A total of 13 trials met our selection criteria. Long-term (with at least a 1-year follow-up) mortality was significantly lower in the revascularization arm [relative risk (RR) = 0.66; 95% CI = 0.60–0.72] by either PCI (RR = 0.61; 95% CI = 0.55–0.68) or CABG (RR = 0.62; 95% CI = 0.46–0.84). The results were consistent in dialysis patients (RR = 0.68; 95% CI = 0.59–0.79), patients with stable CAD (RR = 0.75; 95% CI = 0.61–0.92), patients with acute coronary syndrome (RR = 0.62; 95% CI = 0.58–0.66), and geriatric patients (RR = 0.57; 95% CI = 0.54–0.61).

Conclusion

In patients with CKD and CAD, revascularization is more effective in reducing mortality than MT alone. This observed benefit is consistent in patients with stable CAD and elderly patients. However, future randomized controlled trials (RCTs) are required to confirm these findings.

Global, regional, and national quality of care of ischaemic heart disease from 1990 to 2017: a systematic analysis for the Global Burden of Disease Study 2017

AIMS

By 2030, we seek to reduce premature deaths from non-communicable diseases, including ischaemic heart disease (IHD), by one-third to reach the sustainable development goal (SDG) target 3.4. We aimed to investigate the quality of care of IHD across countries, genders, age groups, and time using the Global Burden of Diseases Study (GBD) 2017 estimates.

METHODS AND RESULTS

We did a principal component analysis on IHD mortality to incidence ratio, disability-adjusted life-years (DALYs) to prevalence ratio, and years of life lost to years lived with disability ratio using the results of the GBD 2017. The first principal component was scaled from 0 to 100 and designated as the quality of care index (QCI). We evaluated gender inequity by the gender disparity ratio (GDR), defined as female to male QCI. From 1990 to 2017, the QCI and GDR increased from 71.2 to 76.4 and from 1.04 to 1.08, respectively, worldwide. In the study period, countries of Western Europe, Scandinavia, and Australasia had the highest QCIs and a GDR of 1 to 1.2; however, African and South Asian countries had the lowest QCIs and a GDR of 0.8 to 1. Moreover, the young population experienced more significant improvements in the QCI compared to the elderly in 2017.

CONCLUSION

From 1990 to 2017, the QCI of IHD has improved; nonetheless, there are remarkable disparities between countries, genders, and age groups that should be addressed. These findings may guide policymakers in monitoring and modifying our path to achieve SDGs.

Invasive versus Conservative Management in Patients ≥85 years presenting with Non-ST Elevation Myocardial Infarction

BACKGROUND

Guidelines recommend early coronary angiography (CA) in patients with non-ST-elevation myocardial infarction (NSTEMI), irrespective of age. However, elderly patients are less likely to be treated according to these guidelines due to their perceived high risk and medical comorbidities. Whether an invasive strategy is associated with improved survival in patients aged ≥85 years remains uncertain due to their exclusion from randomised trials.

METHODS

Consecutive patients aged ≥85 years presenting to a tertiary centre with NSTEMI between 2008-18 were included in this retrospective cohort study. Patients were stratified based on whether they underwent invasive management with CA with a view to revascularisation versus conservative management. The primary outcome was long-term mortality.

RESULTS

Of 7,591 patients with NSTEMI, 1052 patients ≥85years were included. 99(9.4%) patients underwent CA. Those undergoing CA were more likely to be younger, male, live independently, without mobility or cognitive issues (all p<0.01). Overall, 495(47%) patients died during a mean follow-up of 1.3±1 year. On Cox regression, after adjusting for age, pre-morbid functional status, cognition and cardiovascular risk factors, invasive management was the strongest predictor for survival (HR 0.47; 95%CI 0.26-0.85; p=0.01). Invasive management was associated with a trend to increased risk of in-hospital bleeding (6.1% vs 2.6%, p=0.054) with no significant difference in stroke (2.0% vs 3.8%, p=0.37).

CONCLUSION

In patients aged ≥85 years who presented with NSTEMI, invasive management was associated with improved survival without significant differences in bleeding or stroke. A randomised controlled study assessing the efficacy and safety of invasive management in very elderly patients with NSTEMI is warranted. This article is protected by copyright. All rights reserved.

The effects of percutaneous coronary intervention on mortality in elderly patients with non-ST-segment elevation myocardial infarction undergoing coronary angiography

INTRODUCTION

Although it is recommended that elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) should undergo an assessment for invasive revascularization, these patients undergo fewer coronary interventions despite the current guidelines. The aim of the study is to evaluate the effectiveness of percutaneous coronary intervention on all-cause mortalities monthly and annually in the population.

METHODS

Three hundred and twenty-four patients with NSTEMI aged 65 years or older who underwent coronary angiography and treated with conservative strategy or percutaneous coronary intervention were included in the study. All demographic and clinical characteristics of the patients were recorded and one-month and one-year follow-up results were analysed.

RESULTS

Two hundred eight cases (64.19%) were treated with percutaneous coronary intervention and 116 cases (35.81%) of the participant were treated with conservative methods. The mean age of the participants was 75.41 ± 6.65 years. The treatment strategy was an independent predictor for the mortality of one-year (HR: 1.965). Furthermore, Killip class ≥2 (HR:2.392), Left Ventricular Ejection Fraction (HR:2.637) and renal failure (HR: 3.471) were independent predictors for one-year mortality.

CONCLUSION

The present study has revealed that percutaneous coronary intervention was effective on one-year mortality in NSTEMI patients over the age of 65. It is considered that percutaneous coronary intervention would decrease mortality in these patients but it should be addressed in larger population studies.

Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation (AF) is a very common arrhythmia in clinical practice. Its incidence and prevalence are age-related and are growing in the last years. Age is a risk factor also for coronary artery disease (CAD), and with the evolution of preventive care, the first event (acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)) takes place at a later age. If elderly patients with AF and CAD undergo ACS or PCI, they have indication to assume triple therapy. Triple therapy (oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT)) exposes patients to high bleeding risk. In the last 10 years, several clinical trials have tested dual therapy (OAC plus single antiplatelet therapy) in AF patients who undergo ACS or elective PCI. WOEST trial has tested warfarin + clopidogrel against triple therapy. PIONEER AF-PCI trial has tested low-dose rivaroxaban + P2Y12 inhibitor or very low-dose rivaroxaban + DAPT against standard triple therapy with warfarin. RE-DUAL PCI trial has tested two doses of dabigatran + P2Y12 inhibitor against standard triple therapy with Warfarin. AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin. ENTRUST-AF PCI, last published study, has tested edoxaban + P2Y12 inhibitor against triple therapy. All these trials show dual therapy reduces significantly bleeding risk than triple therapy. In this paper, we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Incidence and Outcomes of Acute Coronary Syndrome After Transcatheter Aortic Valve Replacement

OBJECTIVES

This study sought to address a knowledge gap by examining the incidence, timing, and predictors of acute coronary syndrome (ACS) after transcatheter aortic valve replacement (TAVR) in Medicare beneficiaries.

BACKGROUND

Evidence about incidence and outcomes of ACS after TAVR is scarce.

METHODS

We identified Medicare patients who underwent TAVR from 2012 to 2017 and were admitted with ACS during follow-up. We compared outcomes based on the type of ACS: ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. In patients with non-ST-segment elevation ACS, we compared outcomes based on the treatment strategy (invasive vs. conservative) using inverse probability weighting analysis.

RESULTS

Out of 142,845 patients with TAVR, 6,741 patients (4.7%) were admitted with ACS after a median time of 297 days (interquartile range: 85 to 662 days), with 48% of admissions occurring within 6 months. The most common presentation was NSTEMI. Predictors of ACS were history of coronary artery disease, prior revascularization, diabetes, valve-in-TAVR, and acute kidney injury. STEMI was associated with higher 30-day and 1-year mortality compared with NSTEMI (31.4% vs. 15.5% and 51.2% vs. 41.3%, respectively; p < 0.01). Overall, 30.3% of patients with non-ST-segment elevation ACS were treated with invasive approach. On inverse probability weighting analysis, invasive approach was associated with lower adjusted long-term mortality (adjusted hazard ratio: 0.69; 95% confidence interval: 0.66 to 0.73; p < 0.01) and higher risk of repeat revascularization (adjusted hazard ratio: 1.29; 95% confidence interval: 1.16 to 1.43; p < 0.001).

CONCLUSIONS

After TAVR, ACS is infrequent (<5%), and the most common presentation is NSTEMI. Occurrence of STEMI after TAVR is associated with a high mortality with nearly one-third of patients dying within 30 days. Optimization of care is needed for post-TAVR ACS patients and if feasible, invasive approach should be considered in these high-risk patients.

Octogenarian preferences and expectations for acute coronary syndrome treatment

Background:

The number of elderly persons with cardiovascular disease is increasing. In Sweden, the incidence of acute myocardial infarction is the highest among individuals aged 85 years and over. However, there is still little evidence about whether this population benefits from established treatments. Furthermore, the values and preferences of octogenarians (age ⩾80 years), as well as how they could be involved in treatment decisions, have been largely overlooked in research. Overall, increased knowledge about the preferences and expectations of octogenarians is needed to incorporate their treatment expectations into the decision-making process.

Aims:

This study aimed to describe the treatment choice preferences and post-treatment life expectations of octogenarians with acute coronary syndrome.

Methods:

A total of 19 patients (eight women, 11 men) aged 80 years and older and diagnosed with non-ST-elevation myocardial infarction or unstable angina were enrolled in this qualitative study. Data were collected between May 2011 and June 2013 through semistructured interviews. The data were analysed using qualitative content analysis.

Results:

We identified two main categories: Wanting the best and Hope for increased wellbeing. Participant preferences were influenced by their own and others’ previous experiences and their confidence in healthcare professionals. With respect to treatment outcomes, the participants hoped to get well, stay active, experience fewer symptoms and regain vitality.

Conclusion:

The studied octogenarians desired the best treatment option and trusted that their healthcare providers will make appropriate recommendations. These patients expected their treatment to result in increased wellbeing and fewer symptoms.

Incidence, Clinical Characteristics, and Impact of Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

OBJECTIVES

The authors sought to assess the incidence, predictors, management, and prognosis of acute coronary syndrome (ACS) following TAVR.

BACKGROUND

About one-half of the patients undergoing transcatheter aortic valve replacement (TAVR) have concurrent coronary artery disease (CAD). However, the occurrence and clinical impact of coronary events following TAVR remain largely unknown.

METHODS

Consecutive patients undergoing TAVR in our institution between May 2007 and November 2017 were included. Patients were followed at 1, 6, and 12 months, and yearly thereafter. ACS was diagnosed and classified according to the Third Universal Definition of Myocardial Infarction.

RESULTS

A total of 779 patients (mean age 79 ± 9 years, 52% male, mean STS: 6.8 ± 5.1%) were included, 68% of which had a history of CAD. At a median follow-up of 25 (interquartile range: 10 to 44) months, 78 patients (10%) presented at least 1 episode of ACS, with one-half of the events occurring within the year following TAVR. Clinical presentation was type 2 non-ST-segment elevation myocardial infarction (35.9%), unstable angina (34.6%), type 1 non-ST-segment elevation myocardial infarction (28.2%), and ST-segment elevation myocardial infarction (1.3%). Male sex (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.36 to 3.54; p = 0.001), prior CAD (HR: 2.78; 95% CI: 1.50 to 5.18; p = 0.001), and nontransfemoral approach (HR: 1.71; 95% CI: 1.04 to 2.75; p = 0.035) were independently associated with ACS. Coronary angiography was performed in 53 (67.9%) patients with ACS, and 30 of them (56.6%) underwent percutaneous coronary intervention. In-hospital death rate at the time of the ACS episode was 3.8%. At a median follow-up of 21 (interquartile range: 8 to 34) months post-ACS, all-cause and cardiovascular death rates were 37.3% and 25.3%, respectively.

CONCLUSIONS

Approximately one-tenth of patients undergoing TAVR were readmitted for an ACS after a median follow-up of 25 months. Male sex, prior CAD, and nontransfemoral approach were independent predictors of ACS. ACS was associated with high midterm mortality.

Prognostic value of frailty in elderly patients with acute coronary syndrome: a systematic review and meta-analysis

Background

Frailty is common and associated with poorer outcomes in the elderly, but its prognostic value in acute coronary syndromes (ACS) requires clarification. We thus undertook a systematic review and meta-analysis to evaluate the relationship between frailty and poor prognosis in patients with ACS.

Methods

We systematically searched PubMed, Embase to find literatures which studied the prognostic value of frailty in elderly patients with ACS. Our main endpoints were the all-cause mortality, cardiovascular disease (CVD), major bleeding and readmissions. We pooled studies using random-effect generic inverse variance method, and conducted three pre-specified subgroup analyses.

Results

Of 1216 identified studies, 15 studies were included in our analysis. Compared with the normal group, frailty (HR = 2.65; 95%CI: 1.81–3.89, I² = 60.2%) and pre-frailty (HR = 1.41; 95%CI: 1.19–1.66, I² = 0%) were characterized by a higher risk of mortality after adjustment. Frailty also was associated with increased risk of any-type CVD, major bleeding and hospital readmissions in elderly patients with ACS. The pooled effect sizes in frail patients were 1.54 (95%CI: 1.32–1.79), 1.51 (95%CI: 1.14–1.99) and 1.51 (95%CI: 1.09–2.10).

Conclusions

Frailty provides quantifiable and significant prognostic value for mortality and adverse events in elderly ACS patients, helping doctors to appraise the comprehensive prognosis risk and to applicate appropriate management strategies.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1242-8) contains supplementary material, which is available to authorized users.

Revascularisation in older adult patients with non-ST-segment elevation acute coronary syndrome: effect and impact on 6-month mortality

Although revascularisation in non-ST-segment elevation acute coronary syndrome (NSTEACS) is associated with better outcomes, its impact in older adult patients is unclear. This is a retrospective analyses of three national NSTEACS registries conducted during the past decade in Spain. Patients aged 75 years and older were included: DESCARTES (DES; year 2002; n=534), MASCARA (MAS; 2005; n=1736) and DIOCLES (DIO; 2012; n=593). The adjusted association between revascularisation and total (inhospital and 6-month) mortality was estimated by two-stage meta-analysis (pooled effect across the three registries with inverse-variability weights) and one-stage meta-analysis (multilevel model with random effects across studies). The impact of revascularisation was assessed comparing the observed and the expected mortality based on a logistic regression model in the pooled database. Although revascularisation was associated with a lower risk of mortality in meta-analyses (two-stage: odds ratio 0.44, 95% confidence interval 0.29-0.67; one-stage: odds ratio 0.54, 95% confidence interval 0.36-0.81) and the revascularisation rate increased steadily from 2002 (DES 14.2%) to 2012 (DIO 43.7%), its impact was not patent across registries, probably because this increase was concentrated in low and medium-risk GRACE strata (tertile 1, 2 and 3: MAS 59%, 20% and 6%; DIO 64%, 39% and 19%, respectively). In conclusion, a consistent increase of revascularisation in NSTEACS in older adults was not followed by a decrease in mortality at 6 months, probably because the impact of this strategy is limited to the higher risk population, the stratum with the lowest revascularisation rate in real life.

The prognostic value of mean platelet volume to platelet count ratio in older patients with non-ST elevation acute coronary syndrome receiving primary percutaneous coronary intervention: a retrospective study

BACKGROUND

The aim of this study was to investigate the value of the mean platelet volume to platelet count (MPV/P) ratio for predicting in-hospital and long-term cardiac mortality in older non-ST elevation-acute coronary syndrome (NSTE-ACS) patients after primary percutaneous coronary intervention (PCI).

METHODS

We retrospectively reviewed 452 older NSTE-ACS patients who received primary PCI. The patients were divided into two groups based on MPV/P ratios: high MPV/P group (N.=150) defined as a value in the third tertile (>0.056628) and low MPV/P group (N.=302) in the lower two tertiles (≤0.056628). Clinical outcomes included non-fatal reinfarction, heart failure, and cardiac mortality.

RESULTS

Multivariate analyses showed that high MPV/P and MPV values were independent predictors of cardiac mortality. The in-hospital cardiac mortality of the high MPV/P group was higher than the low MPV/P group (1.3% vs. 14.7%, P<0.001). The rates of heart failure and cardiac mortality in one year were significantly higher in the high MPV/P group compared to the low MPV/P group (P<0.05). The cut-off value of MPV/P for predicting cardiac death was 0.067107, with a sensitivity of 0.707 and a specificity of 0.868. MPV/P was superior to MPV (z=9.235, P<0.001) for predicting cardiac mortality.

CONCLUSIONS

High MPV/P and MPV values are independent predictors of cardiac mortality in older patients with NSTE-ACS receive primary PCI. Moreover, MPV/P is better than MPV for predicting cardiac mortality.

Invasive Versus Conservative Strategy in Frail Patients With NSTEMI: The MOSCA-FRAIL Clinical Trial Study Design

INTRODUCTION AND OBJECTIVES

Although clinical guidelines recommend invasive management in non-ST-segment elevation myocardial infarction (NSTEMI), this strategy is underused in frail elderly patients in the real world. Furthermore, these patients are underrepresented in clinical trials and therefore the evidence is scarce. Our hypothesis is that an invasive strategy will improve prognosis in elderly frail patients with NSTEMI.

METHODS

This will be a prospective, multicenter, randomized trial, in which the conservative and invasive strategies will be compared in patients meeting all of the following inclusion criteria: NSTEMI diagnosis, age ≥ 70 years, and frailty defined by a category ≥ 4 in the Clinical Frailty Scale. Participants will be randomized to an invasive (coronary angiogram and revascularization if anatomically amenable) or conservative (medical treatment and coronary angiogram only if persistent clinical instability) strategy. The primary endpoint will be the number of days alive out of hospital during the first year. The coprimary endpoint will be the time until the first cardiac event (cardiac death, reinfarction or postdischarge revascularization). We estimate a sample size of 178 patients (89 per arm), considering an increase of 20% in the proportion of days alive out of hospital with the invasive management.

RESULTS

The results of this study will add important knowledge to inform the management of frail elderly patients hospitalized with NSTEMI.

CONCLUSIONS

We hypothesize that the invasive strategy will improve outcomes in frail elderly patients with NSTEMI. If this is confirmed, frailty status should not dissuade physicians from implementing an invasive management strategy.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov.Identifier: NCT03208153.