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

Prognosis Impact and Prediction of Trans-Radial Access Failure in Patients With STEMI, A Nationwide Observational Study

Trans-radial access (TRA) is the primary arterial approach for percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). However, occasionally, a crossover to trans-femoral access is necessary because of unsuccessful TRA. The impact of failed TRA on the prognosis in STEMI patients and the utility of predictive models for TRA failure remains uncertain. Data from the Hungarian Myocardial Infarction Registry (January 2014 to December 2020) were analyzed. Primary endpoints were 1-year mortality and major adverse cardiovascular events. Propensity score matching was employed to create a balanced cohort for comparing successful and failed TRA. The impact of unsuccessful TRA on prognosis was evaluated using Cox regression analysis. Machine learning techniques were applied to predict TRA failure. The performance and the clinical applicability of the novel and previous prediction models were comprehensively evaluated. Of 76,625 registered patients, 34,293 (69.8 ± 13.4 years, male/female: 21,893/12,400) underwent TRA (33,573) or failed TRA (720) PCI for STEMI. After propensity score matching, in the unsuccessful TRA group, the risk of mortality (34.3% vs 22.5%, hazard ratio 1.6, 95% confidence interval 1.3 to 2.0, p <0.001) and major adverse cardiovascular events (37.4% vs 26.8%, hazard ratio 1.5, 95% confidence interval 1.3 to 1.8, p <0.001) were significantly higher. Door-to-balloon time did not differ significantly (p = 0.835). In predictive analysis, Regularized Discriminant Analysis emerged as the most promising model, surpassing previous prediction models (area under the curve: 0.66, sensitivity: 0.32, specificity: 0.86). Nevertheless, Global Registry of Acute Coronary Events (GRACE) 2.0 score demonstrated a remarkable performance (area under the curve: 0.65, sensitivity: 0.51, specificity: 0.73). This study underscores the pivotal role of successful TRA in enhancing outcomes in STEMI cases, advocating for its prioritization. The inability to conclude interventions through this approach is linked to a poorer prognosis, even in risk-adjusted analyses. Our findings indicate that prediction models utilizing clinical parameters do not outperform the established GRACE 2.0 algorithm, questioning their utility. In conclusion, the results emphasize the significance of TRA success and the continued relevance of the GRACE score in clinical decision-making to optimize patient outcomes.

The prevalence and outcomes in STEMI patients aged ≥75 undergoing primary percutaneous coronary intervention in China

Objective

To investigate the prevalence and outcomes of primary percutaneous coronary intervention (PCI) in Chinese patients with ST-segment elevation myocardial infarction (STEMI) aged ≥75 years.

Methods

We identified STEMI patients aged ≥75 years between 2013 and 2014 from a multicenter registry. The primary outcome was all-cause mortality. The secondary outcome was major adverse cardiac and cerebrovascular event (MACCE) including a composite of all-cause mortality, cardiac death, recurrent MI, stroke, revascularization, and major bleeding. Hazard ratios (HR) and associated 95% confidence interval (CI) were calculated.

Results

Approximately 32.9% (n = 999) patients received primary PCI. Primary PCI was associated with lower risks of two-year all-cause mortality (18.0% vs. 36.4%; adjusted HR: 0.54, 95% CI: 0.45 to 0.65, P < 0.0001), MACCE (28.7% vs. 43.5%; adjusted HR: 0.68, 95% CI: 0.59 to 0.80, P < 0.0001), and cardiac death (10.0% vs. 23.6%; adjusted HR: 0.49, 95% CI: 0.38 to 0.62, P < 0.0001) relative to no reperfusion (n = 2041) in patients aged ≥75 years. The better outcomes in two-year all-cause mortality, MACCE, and cardiac death were consistently observed in STEMI patients aged ≥85 years. No differences were observed in recurrent MI, stroke, revascularization, and major bleeding between the two groups. Additionally, in patients with relatively high-risk profiles such as cardiogenic shock or delaying hospital admission, primary PCI was also superior to no reperfusion.

Conclusion

Primary PCI may decrease two-year all-cause mortality, MACCE, and cardiac death in STEMI patients aged ≥75 years, even in these with age ≥85 years, cardiogenic shock, or delaying hospital admission. However, primary PCI was underutilized in Chinese clinical practice.

The impact of delirium on clinical and functional outcomes in hospitalized patients with acute coronary syndrome

BACKGROUND

Delirium, which is prevalent in critical care settings, remains underexplored in acute coronary syndrome (ACS) patients in the cardiac intensive care unit (CICU).

AIMS

To investigate the prevalence and clinical significance of delirium in patients with ACS admitted to the CICU.

STUDY DESIGN

A prospective study (n = 106, mean age 74.2 ± 5.7 years) assessed delirium using the confusion assessment method-intensive care unit (CAM-ICU) tool in 21.7% of ACS patients during their CICU stay. Baseline characteristics, geriatric conditions and clinical procedures were compared between delirious and nondelirious patients. The outcomes included in-hospital mortality, 30-day and 6-month mortality, acute adverse events and length of CICU stay and hospital stay (LOS).

RESULTS

Delirious patients who were older and had a higher incidence of coronary artery disease underwent more complex procedures (e.g., pacemaker placement). Multivariate analysis identified central venous catheter insertion, urinary catheterization and benzodiazepine use as independent predictors of delirium. Delirium was correlated with prolonged LOS (p < .001) and increased in-hospital, 30-day and 6-month mortality (p < .001).

CONCLUSIONS

Delirium in ACS patients in the CICU extends hospitalization and increases in-hospital, 30-day and 6-month mortality. Early recognition and targeted interventions are crucial for mitigating adverse outcomes in this high-risk population.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the critical impact of delirium on outcomes in hospitalized patients with ACS in the CICU. Delirium, often overlooked in ACS management, significantly extends hospitalization and increases mortality rates. Nurses and physicians must be vigilant in identifying delirium early, particularly in older ACS patients or those with comorbidities. Recognizing independent predictors such as catheterization and benzodiazepine use allows for targeted interventions to reduce delirium incidence. Integrating routine delirium assessments and preventive strategies into ACS management protocols can improve outcomes, optimize resource utilization and enhance overall patient care in the CICU setting.

Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years

BACKGROUND

The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous.

OBJECTIVES

To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA).

METHODS

Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant.

RESULTS

Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%).

CONCLUSIONS

Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.

Oral anticoagulation and outcomes in patients with acute myocardial infarction: Insights from the Hungarian Myocardial Infarction Registry

INTRODUCTION

Anticoagulation reduces the risk of stroke and embolization and is recommended in most patients with atrial fibrillation. Patients after coronary intervention and acute coronary syndromes require antiplatelet treatment. Although oral anticoagulation (OAC) therapy may interfere with the outcome of patients after coronary intervention, its exact impact remains unclear. Importantly, risk-benefit relations may be considerably different after myocardial infarction.

MATERIAL AND METHODS

Data of patients registered from the Hungarian Myocardial Infarction Registry, a mandatory nationwide program for hospitals treating patients with myocardial infarction, were processed. Patients registered between 01.2014. and 12.2017 were included. All-cause mortality, the composite of cardiac events (MACE), and transfusion were compared between patients receiving OAC treatment and a propensity score (PS) matched control group. Subgroup analyses of different anticoagulation and antiplatelet strategies were performed with propensity weighted Cox proportional hazards' models to estimate risk during the first year after the index event.

RESULTS

From 30 681 patients 1875 cases received OAC treatment and had apparently worse prognosis. After PS-matching, however, we found no difference regarding mortality (hazard ratio [HR]: 0.91 95% CI 0.77-1.09, P = .303), MACE (HR: 0.92 95% CI 0.78-1.09, P = .335) or transfusion (HR: 1.21, 95% CI 0.97-1.49, P = .086). In PS-adjusted analyses for the OAC group, patients who received aspirin were associated with lower mortality (HR: 0.77, 95% CI: 0.60-0.997, P = .048) and MACE (HR:0.73, 95% CI 0.58-0.92, P = .008) compared to those without aspirin.

CONCLUSIONS

In patients with acute myocardial infarction, the prognosis of OAC-treated patients was comparable to the PS matched control; however, the omission of aspirin therapy was associated with unfavorable outcomes.

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.

Would treatment decisions about secondary prevention of CVD based on estimated lifetime benefit rather than 10-year risk reduction be cost-effective?

OBJECTIVE

To test the hypothesis that treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.

METHODS

A microsimulation model was constructed for 10,000 patients with stable cardiovascular disease (CVD). Costs and quality-adjusted life years (QALYs) due to recurrent cardiovascular events and (non)vascular death were estimated for lifetime benefit-based compared to 10-year risk-based treatment, with PCSK9 inhibition as an illustration example. Lifetime benefit in months gained and 10-year absolute risk reduction were estimated using the SMART-REACH model, including an individualized treatment effect of PCSK9 inhibitors based on baseline low-density lipoprotein cholesterol. For the different numbers of patients treated (i.e. the 5%, 10%, and 20% of patients with the highest estimated benefit of both strategies), cost-effectiveness was assessed using the incremental cost-effectiveness ratio (ICER), indicating additional costs per QALY gain.

RESULTS

Lifetime benefit-based treatment of 5%, 10%, and 20% of patients with the highest estimated benefit resulted in an ICER of €36,440/QALY, €39,650/QALY, or €41,426/QALY. Ten-year risk-based treatment decisions of 5%, 10%, and 20% of patients with the highest estimated risk reduction resulted in an ICER of €48,187/QALY, €53,368/QALY, or €52,390/QALY.

CONCLUSION

Treatment decisions (treatment with a PCSK9-mAb versus no treatment) are both more effective and more cost-effective when based on estimated lifetime benefit than when based on estimated risk reduction over 10 years.

Impact of delirium on patients hospitalized for myocardial infarction: A propensity score analysis of the National Inpatient Sample

BACKGROUND

Delirium is associated with worse outcomes in critically ill patients. In the subset of patients with myocardial infarction (MI), the impact on clinical outcomes of delirium is not as well elucidated.

HYPOTHESIS

Delirium is associated with increased mortality in patients hospitalized for MI.

METHODS

The study used data from the National Inpatient Sample 2012 to 2014, Healthcare Cost and Utilization Project. We included discharges associated with the primary diagnosis of MI using the relevant International Classification of Diseases, Ninth Revision, Clinical Modification codes. The outcome was inpatient mortality between the delirium group and propensity score-matched controls without delirium.

RESULTS

The study included 1 330 020 weighted discharges with MI as the principal diagnosis. Within this cohort, 18 685 discharges (1.4%) had delirium. Delirium was associated with older age, lower rates of percutaneous coronary intervention, and increased comorbid conditions. The delirium group had higher mortality (10.5% vs 2.6%, P < 0.001). Propensity score-matching analysis showed increased mortality in the delirium group (10.5% vs 7.6%, relative risk: 1.39 [95% confidence interval: 1.2-1.6, P < 0.001) using nearest neighbor 1:1 matching.

CONCLUSIONS

In individuals with MI, delirium was associated with increased inpatient mortality.

Comparison of Platelet Function Guided Versus Unguided Treatment With P2Y12 Inhibitors in Patients With Acute Myocardial Infarction (from the Hungarian Myocardial Infarction Registry)

Evidence is conflicting regarding the clinical benefits of selecting P2Y₁₂ inhibitors based on platelet function testing (PFT). Between March 1, 2013 and March 1, 2014, we collected clinical characteristics and platelet function data in a nationwide acute myocardial infarction (AMI) registry from 15 interventional cardiology centers in Hungary. The risk of all-cause mortality at 1 year were compared after propensity score (PS) matching between patients receiving PFT-guided and unguided P2Y₁₂-inhibitor therapies. High platelet reactivity on clopidogrel (HPRoC) was uniformly defined with the Multiplate assay. A total of 5,583 patients with AMI and coronary intervention were registered. After exclusion of cases with contraindication to prasugrel, propensity matching resulted in a sample of 2,104 patients with well-adjusted characteristics. Clopidogrel was the dominant P2Y₁₂ inhibitor in both groups (unguided: 96% vs PFT guided: 85%, p <0.001). In the PFT-guided group, 19% of patients had HPRoC and 77% of them were switched to prasugrel. According to the adjusted analysis, all-cause mortality at 1 year was significantly lower in the PFT-guided compared with the unguided group (hazard ratio 0.57 [95% confidence interval 0.43 to 0.77], p <0.001). Although prasugrel treatment was not associated with lower all-cause mortality in the overall cohort, patients with HPRoC who switched to prasugrel had significantly lower mortality when compared with those continuing clopidogrel (hazard ratio 0.33 [95% confidence interval 0.12 to 0.92], p <0.05). In conclusion, in patients with AMI, PFT-guided treatment with a high rate of switchover to prasugrel was associated with a lower risk of mortality. Prasugrel was a predictor of lower mortality in patients with HPRoC but not in the overall cohort of AMI.