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

Urotensin II receptor deficiency ameliorates ligation-induced carotid intimal hyperplasia partially through the RhoA-YAP1 pathway

Intimal hyperplasia (IH) is a common pathological feature of vascular proliferative diseases, such as atherosclerosis and restenosis after angioplasty. Urotensin II (UII) and its receptor (UTR) are widely expressed in cardiovascular tissues. However, it remains unclear whether the UII/UTR system is involved in IH. Right unilateral common carotid artery ligation was performed and maintained for 21 days to induce IH in UTR knockout (UTR-/-) and wild-type (WT) mice. Histological analysis revealed that compared with WT mice, UTR-deficient mice exhibited a decreased neointimal area, angiostenosis and intima-media ratio. Immunostaining revealed fewer smooth muscle cells (SMCs), endothelial cells and macrophages in the lesions of UTR-/- mice than in those of WT mice. Protein interaction analysis suggested that the UTR may affect cell proliferation by regulating YAP and its downstream target genes. In vitro experiments revealed that UII can promote the proliferation and migration of SMCs, and western blotting also revealed that UII increased the protein expression of RhoA, CTGF, Cyclin D1 and PCNA and downregulated p-YAP protein expression, while these effects could be partly reversed by urantide. To evaluate the translational value of UTRs in IH management, WT mice were also treated with two doses of urantide, a UTR antagonist, to confirm the benefit of UTR blockade in IH progression. A high dose of urantide (600 μg/kg/day), rather than a low dose (60 μg/kg/day), successfully improved ligation-induced IH compared with that in mice receiving vehicle. The results of the present study suggested that the UII/UTR system may regulate IH partly through the RhoA-YAP signaling pathway.

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.

Use of drug-eluting stents in elderly patients with acute myocardial infarction: An analysis of the Hungarian Myocardial Infarction Registry

BACKGROUND

Bare-metal stents (BMS) are frequently implanted in elderly patients instead of drug-eluting stents (DES). We aimed to compare the prognosis of patients treated for myocardial infarction with the two types of stents over the age of 75.

METHODS

Data of patients registered in the Hungarian Myocardial Infarction Registry, a mandatory nationwide programme for hospitals treating patients with myocardial infarction were processed. From patients included between January 2014 and December 2017 we created two groups according to DES and BMS implantation. The outcome measures included all-cause mortality, the composite of cardiac events (MACE), repeated revascularisation and transfusion. Propensity score matching was used to balance the groups and Cox proportional hazards' models to estimate the risk during the 1st year after the index event.

RESULTS

From 7383 patients (age: 81.08 ± 4.38 years) 3266 (44.2%) patients received DES. The PS-matched cohort included 5780 cases with balanced characteristics. In the DES group, the mortality (HR 0.66 [0.60-0.72]), MACE (HR 0.66 [0.60-0.72]) and the rate of transfusion (HR 0.84 [0.73-0.97]) were significantly lower. The PS-matched cohort showed a similar trend but with a lower rate of benefits with a 21% reduction of mortality and 23% of MACE. Difference in transfusion did not reach the level of significance. In multivariate models, stent type prevailed as an independent predictor of mortality and but not of transfusion.

CONCLUSIONS

Based on our analysis of a real-life, high-risk population, implantation of DES seems to be an advantageous strategy for elderly patients.

Outcomes of Nonagenarians With ST Elevation Myocardial Infarction

Although older adults are the fastest-growing age group among cardiovascular patients, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are under-represented in clinical trials. The aims of this study are to analyze the clinical presentation and outcomes of nonagenarian patients presenting with STEMI and to compare in-hospital and 1-year clinical outcomes between those treated with optimal medical treatment alone and those receiving primary percutaneous coronary intervention (pPCI). We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2006 and 2018. There were no exclusion criteria. All-cause mortality was assessed in-hospital and at 1-year follow-up. In total, 167 patients (mean age 91.9 ± 0.17 years; 60% females) were included. Emergent catheterization was performed in 60% of our patients, and pPCI was performed in 50% (n = 83). Overall mortality was 22% in-hospital and 41% at 1-year follow-up. The pPCI group had lower mortality than the medical treatment group: 12% versus 32% in-hospital (p <0.01) and 26% versus 45% at 1-year follow-up (p <0.01), respectively. Multivariable analysis identified 4 independent predictors of all-cause mortality at 1 year: mechanical complications (adjusted odds ratio [OR] 9.25, p <0.01), Killip class III/IV (adjusted OR 4.22, p <0.01), serum creatinine at admission (mg/dl; adjusted OR 1.8, p <0.01), and pPCI (adjusted OR 0.52; p <0.05). In conclusion, STEMI in nonagenarians is becoming increasingly common. pPCI may be the preferred strategy in this high-risk cohort when a high grade of disability is not present. Hemodynamic compromise, the presence of complications related to myocardial infarction, renal impairment, and early revascularization may be related to prognosis in these patients.

Efficacy and safety of drug-eluting stents in elderly patients: A meta-analysis of randomized trials

BACKGROUND

Current guidelines recommend newer generation drug-eluting stents (DES) over bare-metal stents (BMS) in patients with ischemic heart disease. However, there is no age-specific recommendation in elderly patients.

METHODS

Meta-analysis was performed of 6 randomized studies enrolling 5,042 elderly patients who underwent percutaneous coronary intervention (PCI) with stent implantation (DES, n = 2,579; BMS, n = 2,463).

RESULTS

Combined data indicated a significant reduction in major adverse cardiovascular events (MACEs) with use of DES (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.44-0.71, p < 0.001). Moreover, use of DES was associated with a significantly lower incidence of myocardial infarction (OR 0.54, 95% CI 0.36-0.81, p = 0.003) and repeat revascularization (OR 0.44, 95% CI 0.31-0.62, p < 0.001), was compared to that with the use of BMS. Stent thrombosis and bleeding complication rates were not significantly different between groups. In a subgroup meta-analysis, short duration (1 or 6 months) dual antiplatelet therapy (DAPT) was associated with a significantly lower MACE rate (OR 0.49, 95% CI 0.34-0.80; p = 0.003) in elderly patients who underwent PCI with everolimuseluting stent implantation, compared with that using long duration DAPT.

CONCLUSIONS

This meta-analysis provides clinically relevant evidence that DES rather than BMS should be selected for elderly patients.

Relative survival and excess mortality following primary percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND:

High survival rates are commonly reported following primary percutaneous coronary intervention for ST-elevation myocardial infarction, with most contemporary studies reporting overall survival.

AIMS:

The aim of this study was to describe survival following primary percutaneous coronary intervention for ST-elevation myocardial infarction corrected for non-cardiovascular deaths by reporting relative survival and investigate clinically significant factors associated with poor long-term outcomes.

METHODS AND RESULTS:

Using the prospective UK Percutaneous Coronary Intervention registry, primary percutaneous coronary intervention cases ( n=88,188; 2005-2013) were matched to mortality data for the UK populace. Crude five-year relative survival was 87.1% for the patients undergoing primary percutaneous coronary intervention and 94.7% for patients <55 years. Increasing age was associated with excess mortality up to four years following primary percutaneous coronary intervention (56-65 years: excess mortality rate ratio 1.61, 95% confidence interval 1.46-1.79; 66-75 years: 2.49, 2.26-2.75; >75 years: 4.69, 4.27-5.16). After four years, there was no excess mortality for ages 56-65 years (excess mortality rate ratio 1.27, 0.95-1.70), but persisting excess mortality for older groups (66-75 years: excess mortality rate ratio 1.72, 1.30-2.27; >75 years: 1.66, 1.15-2.41). Excess mortality was associated with cardiogenic shock (excess mortality rate ratio 6.10, 5.72-6.50), renal failure (2.52, 2.27-2.81), left main stem stenosis (1.67, 1.54-1.81), diabetes (1.58, 1.47-1.69), previous myocardial infarction (1.52, 1.40-1.65) and female sex (1.33, 1.26-1.41); whereas stent deployment (0.46, 0.42-0.50) especially drug eluting stents (0.27, 0.45-0.55), radial access (0.70, 0.63-0.71) and previous percutaneous coronary intervention (0.67, 0.60-0.75) were protective.

CONCLUSIONS:

Following primary percutaneous coronary intervention for ST-elevation myocardial infarction, long-term cardiovascular survival is excellent. Failure to account for non-cardiovascular death may result in an underestimation of the efficacy of primary percutaneous coronary intervention.

Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Despite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS).

METHODS

Electronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted.

RESULTS

We included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62-0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89-1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05-2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60-0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84-1.22; P = 0.89, respectively).

CONCLUSIONS

In older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients.

SUMMARY

This meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.

Impact of Body Mass Index on 5-Year Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction After Everolimus-Eluting or Bare-Metal Stent Implantation

Patients with high body mass index (BMI) seem to have better outcomes after percutaneous coronary intervention than normal-weight patients. However, contrasting results have been reported on the "obesity paradox" in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of our study was to investigate the impact of BMI on mortality in the population enrolled in the Evaluation of the Xience-V stent in Acute Myocardial INfArcTION (EXAMINATION) trial. The EXAMINATION trial randomized 1,498 patients with STEMI to a bare-metal stent or an everolimus-eluting stent. In this substudy patients were stratified into 3 groups according to BMI values: normal (BMI < 25 kg/m²), overweight (BMI = 25 to 29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). The coprimary end points were the all-cause and cardiac deaths among the groups at the 5-year follow-up. BMI was available in 1,421 patients, divided in 401 (28.2%) normal, 702 (49.4%) overweight, and 318 (22.4%) obese. Obese patients were younger (p = 0.012) compared with the other groups, but with a worse cardiovascular risk profile. They were more frequently female (p <0.001) and with a higher rate of obesity-related co-morbidity conditions such as diabetes mellitus (p = 0.005), arterial hypertension (p <0.001), and hyperlipidemia (p = 0.001) compared with the other groups. At the 5-year follow-up, all-cause and cardiac deaths were less frequent in obese patients than in the other groups (p = 0.003 and p = 0.030, respectively). After adjustment for confounding variables, BMI was an independent predictor of all-cause death (hazard ratio 0.765, 95% confidence interval 0.599 to 0.979, p = 0.033), but not of cardiac death, without any interaction with the stent type. In conclusion, in patients with STEMI who underwent primary PCI, the long-term all-cause death rate decreased as BMI increased, confirming the obesity paradox, irrespective of the stent type.

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.

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.

Integrity(®) bare-metal coronary stent-induced platelet and endothelial cell activation results in a higher risk of restenosis compared to Xience(®) everolimus-eluting stents in stable angina patients

Drug-eluting stenting (DES) has become a reliable tool for coronary stenting; however, its direct effects on platelet and endothelium function differ from those of bare-metal stenting (BMS). This study involved a periprocedural analysis of various biomarkers of cellular activation after elective DES (Xience(®), Abbott Vascular, Santa Clara, CA, USA) or BMS (Integrity(®), Medtronic, Minneapolis, MI, USA). Forty-nine stable angina patients were recruited: 28 underwent BMS, and 21 received everolimus-eluting stents. Samples were collected (i) prior to stenting, (ii) at 24 hours after procedure, and (iii) after 1 month of dual antiplatelet therapy. Platelet activation was analyzed by surface P-selectin positivity in parallel with plasma levels of soluble P-selectin, CD40L and platelet-derived growth factor (PDGF). Endothelial cell (EC) activation was detected by measuring markers of early (von Willebrand factor) and delayed response (VCAM-1, ICAM-1, E-selectin). Patients were followed for 6 months for the occurrence of restenosis or stent thrombosis. Increased platelet activation was sustained regardless of stent type or antiplatelet medication. Concentrations of most EC markers were more elevated after BMS than after DES. No stent thrombosis was seen, but six BMS subjects displayed restenosis with significantly higher sCD40L (779 [397-899] vs. 381 [229-498] pg/mL; p = 0.032) and sICAM-1 (222 [181-272] vs. 162 [153-223] ng/mL; p = 0.046) levels than in those without complication, while DES patients exhibited significantly decreased PDGF (572 [428-626] vs. 244 [228-311] pg/mL; p = 0.004) after 1 month. Nonresponsiveness to antiplatelet drugs did not influence these changes. In conclusion, the degree of platelet and EC activation suggests that Xience(®) DES may be regarded a safer coronary intervention than Integrity(®) BMS, with a lower risk of in-stent restenosis.

Improved outcomes of elderly patients treated with drug-eluting versus bare metal stents in large coronary arteries: results from the BAsel Stent Kosten-Effektivitäts Trial PROspective Validation Examination randomized trial

BACKGROUND

Drug-eluting stents (DES) improve outcomes in elderly patients with small coronary artery disease compared with bare-metal stents (BMS), but randomized data in elderly patients in need of large coronary stents are not available.

METHODS

Planned secondary analysis of patients ≥75 years recruited to the "BASKET-PROVE" trial, in which 2,314 patients undergoing percutaneous coronary intervention for large (≥3.0 mm) native vessel disease were randomized 2:1 to DES (everolimus- vs sirolimus-eluting stents 1:1) versus BMS. All patients received 12 months of dual antiplatelet therapy. The primary end point was a composite of cardiac death or nonfatal myocardial infarction at 2 years.

RESULTS

Comparison of DES versus BMS among 405 patients ≥75 years showed significantly lower rates of the primary end point for DES (5.0% vs 11.6%; hazard ration (HR) 0.64 [0.44-0.91]; P = .014). Rates of nonfatal myocardial infarction (1.2% vs 5.5%, hazard ration (HR) 0.44 [0.21-0.83]; P = .009), all-cause death (7.4% vs 14.4%; HR 0.7 [0.51-0.95]; P = .02), and target vessel revascularization (TVR) (2.3% vs 6.2%; HR 0.59 [0.34-0.99]; P = .046) were also lower, whereas stent thrombosis and bleeding rates were similar. In contrast, among patients <75 years (n = 1,909), the only significant benefit of DES was a reduced rate of TVR (4.0% vs 8.7%, HR 0.66 [0.55-0.80]; P < .0001).

CONCLUSIONS

In patients ≥75 years requiring large (≥3.0 mm) coronary stents, use of DES was beneficial compared with BMS and reduced the rate of ischemic events, mortality, and TVR. These data suggest that DES should be preferred over BMS in elderly patients.

Treatment choices in elderly patients with ST: elevation myocardial infarction-insights from the Vital Heart Response registry

BACKGROUND

Management of elderly patients with ST elevation myocardial infarction (STEMI) is challenging and they are under-represented in trials. Accordingly, we analysed reperfusion strategies and their effectiveness in patients with STEMI ≥75 years compared to <75 years within a comprehensive inclusive registry.

METHODS

Consecutive patients with STEMI admitted to hospital and tracked within a regional registry (2006-2011) were analysed comparing reperfusion strategy (primary percutaneous coronary intervention (PPCI), fibrinolysis and no reperfusion) between patients ≥75 vs <75 years old as well as across the reperfusion strategies in those ≥75 years.

RESULTS

There were 3588 patients with STEMI with 646 (18%) ≥75 years old. Elderly patients were more likely female (46.9% vs 18.4%) and had more prior: angina (28.2% vs 17.2%), myocardial infarction (MI; 22.8% vs 13.9%), hypertension (67.6% vs 44.2%), heart failure (2.3% vs 0.3%) and atrial fibrillation (2.2% vs 0.5%) (all p<0.001). The reperfusion strategy for patients ≥75 vs <75: PPCI 45.3% vs 41.2%, fibrinolysis 24.8% vs 45.7%, and no reperfusion 29.9% vs 13.1% (p<0.001). Time from symptoms to first medical contact (median, 93 vs 78 min p=0.008) and PPCI (median, 166 vs 136 min (p<0.001) were longer for ≥75 years. In those ≥75 years outcomes by reperfusion (PPCI, fibrinolysis and none) were: in-hospital death 13.3%, 9.4% and 19.7% (p=0.018), and composite of death, recurrent-MI, cardiogenic shock and congestive heart failure 28%, 20% and 33.2% (p=0.022).

CONCLUSIONS

Elderly patients have more comorbidities, worst in-hospital clinical outcomes and are less likely to receive reperfusion. Acknowledging physician selection of the reperfusion strategy; outcomes appear favourable in the elderly receiving fibrinolysis.