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Sanchis J, Bueno H, García-Blas S, Gómez-Hospital JA, Martí D, Martínez-Sellés M, Domínguez-Pérez L, Díez-Villanueva P, Barrabés JA, Marín F, Villa A, Sanmartín M, Llibre C, Sionis A, Carol A, Valero E, Calvo E, Morales MJ, Elízaga J, Gómez I, Alfonso F, García Del Blanco B, Formiga F, Núñez E, Núñez J, Ariza-Solé A. Geriatric conditions and invasive management in frail patients with NSTEMI. A subgroup analysis of a randomized clinical trial. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024:S1885-5857(24)00270-6. [PMID: 39270775 DOI: 10.1016/j.rec.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024]
Abstract
INTRODUCTION AND OBJECTIVES Invasive management in frail patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions. METHODS The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n=84) or conservative (n=83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years. RESULTS A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS=4; 157 days, 95%CI, 18-295; P=.027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS=4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS >4 did not (-16 days, 95%CI, -217 to 186; interaction P=.16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction. CONCLUSIONS Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS >4 could serve as a valuable threshold for decision-making.
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Affiliation(s)
- Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Héctor Bueno
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense, Madrid, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Joan A Gómez-Hospital
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - David Martí
- Servicio de Cardiología, Hospital Central de La Defensa Gómez Ulla, Universidad de Alcalá, Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Laura Domínguez-Pérez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense, Madrid, Spain
| | - Pablo Díez-Villanueva
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Instituto de Investigación la Princesa, Madrid, Spain
| | - José A Barrabés
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Francisco Marín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB)-Arrixaca, El Palmar, Murcia, Spain
| | - Adolfo Villa
- Servicio de Cardiología, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | - Marcelo Sanmartín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Cinta Llibre
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alessandro Sionis
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Sant Pau, Barcelona, Spain
| | - Antoni Carol
- Servicio de Cardiología, Hospital de Sant Joan Despí Moisés Broggi, Sant Joan Despí, Barcelona, Spain
| | - Ernesto Valero
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Elena Calvo
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - María José Morales
- Servicio de Cardiología, Hospital Central de La Defensa Gómez Ulla, Universidad de Alcalá, Madrid, Madrid, Spain
| | - Jaime Elízaga
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Iván Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense, Madrid, Spain
| | - Fernando Alfonso
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Instituto de Investigación la Princesa, Madrid, Spain
| | - Bruno García Del Blanco
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Francesc Formiga
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Universidad de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Kunadian V, Mossop H, Shields C, Bardgett M, Watts P, Teare MD, Pritchard J, Adams-Hall J, Runnett C, Ripley DP, Carter J, Quigley J, Cooke J, Austin D, Murphy J, Kelly D, McGowan J, Veerasamy M, Felmeden D, Contractor H, Mutgi S, Irving J, Lindsay S, Galasko G, Lee K, Sultan A, Dastidar AG, Hussain S, Haq IU, de Belder M, Denvir M, Flather M, Storey RF, Newby DE, Pocock SJ, Fox KAA. Invasive Treatment Strategy for Older Patients with Myocardial Infarction. N Engl J Med 2024. [PMID: 39225274 DOI: 10.1056/nejmoa2407791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Whether a conservative strategy of medical therapy alone or a strategy of medical therapy plus invasive treatment is more beneficial in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear. METHODS We conducted a prospective, multicenter, randomized trial involving patients 75 years of age or older with NSTEMI at 48 sites in the United Kingdom. The patients were assigned in a 1:1 ratio to a conservative strategy of the best available medical therapy or an invasive strategy of coronary angiography and revascularization plus the best available medical therapy. Patients who were frail or had a high burden of coexisting conditions were eligible. The primary outcome was a composite of death from cardiovascular causes (cardiovascular death) or nonfatal myocardial infarction assessed in a time-to-event analysis. RESULTS A total of 1518 patients underwent randomization; 753 patients were assigned to the invasive-strategy group and 765 to the conservative-strategy group. The mean age of the patients was 82 years, 45% were women, and 32% were frail. A primary-outcome event occurred in 193 patients (25.6%) in the invasive-strategy group and 201 patients (26.3%) in the conservative-strategy group (hazard ratio, 0.94; 95% confidence interval [CI], 0.77 to 1.14; P = 0.53) over a median follow-up of 4.1 years. Cardiovascular death occurred in 15.8% of the patients in the invasive-strategy group and 14.2% of the patients in the conservative-strategy group (hazard ratio, 1.11; 95% CI, 0.86 to 1.44). Nonfatal myocardial infarction occurred in 11.7% in the invasive-strategy group and 15.0% in the conservative-strategy group (hazard ratio, 0.75; 95% CI, 0.57 to 0.99). Procedural complications occurred in less than 1% of the patients. CONCLUSIONS In older adults with NSTEMI, an invasive strategy did not result in a significantly lower risk of cardiovascular death or nonfatal myocardial infarction (the composite primary outcome) than a conservative strategy over a median follow-up of 4.1 years. (Funded by the British Heart Foundation; BHF SENIOR-RITA ISRCTN Registry number, ISRCTN11343602.).
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Affiliation(s)
- Vijay Kunadian
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Helen Mossop
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Carol Shields
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Michelle Bardgett
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Philippa Watts
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - M Dawn Teare
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Jonathan Pritchard
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Jennifer Adams-Hall
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Craig Runnett
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - David P Ripley
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Justin Carter
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Julie Quigley
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Justin Cooke
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - David Austin
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Jerry Murphy
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Damian Kelly
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - James McGowan
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Murugapathy Veerasamy
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Dirk Felmeden
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Hussain Contractor
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Sanjay Mutgi
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - John Irving
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Steven Lindsay
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Gavin Galasko
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Kelvin Lee
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Ayyaz Sultan
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Amardeep G Dastidar
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Shazia Hussain
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Iftikhar Ul Haq
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Mark de Belder
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Martin Denvir
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Marcus Flather
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Robert F Storey
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - David E Newby
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Stuart J Pocock
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
| | - Keith A A Fox
- From the Translational and Clinical Research Institute, Faculty of Medical Sciences (V.K.), the Population Health Sciences Institute (H.M., M.D.T.), and the Newcastle Clinical Trials Unit (C.S., M. Bardgett, P.W., M.D.T., J.P.), Newcastle University, and the Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust (V.K., J.A.H., I.U.H.), Newcastle upon Tyne; Northumbria Healthcare NHS Foundation Trust, Cramlington (C.R., D.P.R.); the Faculty of Health Sciences and Wellbeing, School of Medicine, University of Sunderland Medical School, Sunderland (D.P.R.); North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees (J. Carter, J.Q.); Chesterfield Royal Hospital, Chesterfield (J. Cooke); South Tees NHS Foundation Trust, Middlesbrough (D.A.); County Darlington and Durham NHS Foundation Trust, Darlington (J. Murphy); Royal Derby Hospital, Derby (D.K.); University Hospital Ayr, Ayr (J. McGowan); Leeds Teaching Hospital NHS Trust, Leeds (M.V.); Torbay and South Devon NHS Foundation Trust, Torquay (D.F.); Manchester University NHS Foundation Trust, Manchester (H.C.); Epsom and St. Helier University Hospitals, Epsom (S.M.); Ninewells Hospital, Dundee (J.I.); Bradford Royal Infirmary, Bradford (S.L.); Blackpool Victoria Hospital, Blackpool (G.G.); United Lincolnshire Hospitals NHS Trust, Lincoln (K.L.); Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan (A.S.); North Bristol NHS Trust, Bristol (A.G.D.); University Hospital of Leicester NHS Trust, Leicester (S.H.); Barts Health NHS Trust (M. Belder) and London School of Hygiene and Tropical Medicine (S.J.P.), London; the Centre for Cardiovascular Science, University of Edinburgh, Edinburgh (M.D., D.E.N., K.A.A.F.); Norwich Medical School, University of East Anglia, Norwich (M.F.); and Sheffield Teaching Hospital, Sheffield (R.F.S.) - all in the United Kingdom
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Pavasini R, Biscaglia S, Kunadian V, Hakeem A, Campo G. Coronary artery disease management in older adults: revascularization and exercise training. Eur Heart J 2024; 45:2811-2823. [PMID: 38985545 DOI: 10.1093/eurheartj/ehae435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/10/2024] [Accepted: 06/23/2024] [Indexed: 07/12/2024] Open
Abstract
The mean age of patients with coronary artery disease (CAD) is steadily increasing. In older patients, there is a tendency to underutilize invasive approach, coronary revascularization, up-to-date pharmacological therapies, and secondary prevention strategies, including cardiac rehabilitation. Older adults with CAD commonly exhibit atypical symptoms, multi-vessel disease involvement, complex coronary anatomy, and a higher presence of risk factors and comorbidities. Although both invasive procedures and medical treatments are characterized by a higher risk of complications, avoidance may result in a suboptimal outcome. Often, overlooked factors, such as coronary microvascular disease, malnutrition, and poor physical performance, play a key role in determining prognosis, yet they are not routinely assessed or addressed in older patients. Historically, clinicians have relied on sub-analyses or observational findings to make clinical decisions, as older adults were frequently excluded or under-represented in clinical studies. Recently, dedicated evidence through randomized clinical trials has become available for older CAD patients. Nevertheless, the management of older CAD patients still raises several important questions. This review aims to comprehensively summarize and critically evaluate this emerging evidence, focusing on invasive management and coronary revascularization. Furthermore, it seeks to contextualize these interventions within the framework of improved risk stratification tools for older CAD patients, through user-friendly scales along with emphasizing the importance of promoting physical activity and exercise training to enhance the outcomes of invasive and medical treatments. This comprehensive approach may represent the key to improving prognosis in the complex and growing patient population of older CAD patients.
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Affiliation(s)
- Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Abdul Hakeem
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
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Nadarajah R, Ludman P, Laroche C, Appelman Y, Brugaletta S, Budaj A, Bueno H, Huber K, Kunadian V, Leonardi S, Lettino M, Milasinovic D, Clegg A, Gale CP. Presentation, care, coronary intervention and outcomes of patients with NSTEMI according to age: insights from the international prospective ACVC-EAPCI EORP NSTEMI registry. Age Ageing 2024; 53:afae179. [PMID: 39158485 DOI: 10.1093/ageing/afae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 06/26/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND Older people less frequently receive invasive coronary angiography (ICA) for NSTEMI than younger patients. We describe care, ICA data, and in-hospital and 30-day outcomes of NSTEMI by age in a contemporary and geographically diverse cohort. METHODS Prospective cohort study including 2947 patients with NSTEMI from 287 centres in 59 countries, stratified by age (≥75 years, n = 761). Quality of care was evaluated based on 12 guideline-recommended care interventions, and data collected on ICA. Outcomes included in hospital acute heart failure, cardiogenic shock, repeat myocardial infarction, stroke/transient ischaemic attack, BARC Type ≥3 bleeding and death, as well as 30-day mortality. RESULTS Patients aged ≥75 years, compared with younger patients, at presentation had a higher prevalence of comorbidities and oral anticoagulation prescription (22.4% vs 7.6%, p < 0.001). Older patients less frequently received ICA than younger patients (78.6% vs 90.6%, p < 0.001) with the recorded reason more often being advanced age, comorbidities or frailty. Of those who underwent ICA, older patients more frequently demonstrated 3-vessel, 4-vessel and/or left main stem coronary artery disease compared to younger patients (49.7% vs 34.1%, p < 0.001) but less frequently received revascularisation (63.6% vs 76.9%, p < 0.001). Older patients experienced higher rates of in-hospital acute heart failure (15.0% vs 8.4%, p < 0.001) and bleeding (2.8% vs 1.3%, p = 0.006), as well as in-hospital and 30-day mortality (3.4% vs 1.3%, p < 0.001; 4.8% vs 1.7%, p < 0.001; respectively), than younger patients. CONCLUSIONS Patients aged ≥75 years with NSTEMI, compared with younger patients, less frequently received ICA and guideline-recommended care, and had worse short-term outcomes.
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Affiliation(s)
- Ramesh Nadarajah
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Cécile Laroche
- EURObservational Research Programme, European Society of Cardiology, European Heart House, 2035 Route des Colles, Sophia Antipolis, France
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC-Vrije Universiteit, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Salvatore Brugaletta
- Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Andrzej Budaj
- Department of Cardiology, Center of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Hector Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (nimas12), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sergio Leonardi
- University of Pavia, Pavia, Italy
- Fondazione IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardio-Thoracic and Vascular Department, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy
| | - Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia and Faculty of Medicine, University of Begrade, Belgrade, Serbia
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, University of Leeds, LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford BD9 6RJ, UK
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute of Data Analytics, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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5
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Kelham M, Vyas R, Ramaseshan R, Rathod K, de Winter RJ, de Winter RW, Bendz B, Thiele H, Hirlekar G, Morici N, Myat A, Michalis LK, Sanchis J, Kunadian V, Berry C, Mathur A, Jones DA. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J 2024; 45:2380-2391. [PMID: 38805681 PMCID: PMC11242441 DOI: 10.1093/eurheartj/ehae245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 03/20/2024] [Accepted: 04/07/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.
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Affiliation(s)
- Matthew Kelham
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohan Vyas
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohini Ramaseshan
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Krishnaraj Rathod
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Robbert J de Winter
- Department of Cardiology Heart Center, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bjorn Bendz
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Aung Myat
- Medical Director (Cardiology), Medpace UK, London, UK
| | - Lampros K Michalis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, University Campus, Ioannina 45110, Greece
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, INCLIVA University of València, CIBER CV, València, Spain
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
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6
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Komatsu J, Nishimura YK, Sugane H, Hosoda H, Imai RI, Nakaoka Y, Nishida K, Mito S, Seki SI, Kubo T, Kitaoka H, Kubokawa SI, Kawai K, Hamashige N, Doi YL. Early Invasive Strategy for Octogenarians and Nonagenarians With Acute Myocardial Infarction. Circ Rep 2024; 6:263-271. [PMID: 38989106 PMCID: PMC11233166 DOI: 10.1253/circrep.cr-24-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 07/12/2024] Open
Abstract
Background: Older adults with acute myocardial infarction (AMI) are currently a rapidly growing population. However, their clinical presentation and outcomes remain unresolved. Methods and Results: A total of 268 consecutive AMI patients were analyzed for clinical characteristics and outcomes with major adverse cardiovascular events (MACE) and all-cause mortality within 1 year. Patients aged ≥80 years (Over-80; n=100) were compared with those aged ≤79 years (Under-79; n=168). (1) Primary percutaneous coronary intervention (PCI) was frequently and similarly performed in both the Over-80 group and the Under-79 group (86% vs. 89%; P=0.52). (2) Killip class III-IV (P<0.01), in-hospital mortality (P<0.01), MACE (P=0.03) and all-cause mortality (P<0.01) were more prevalent in the Over-80 group than in the Under-79 group. (3) In the Over-80 group, frail patients showed a significantly worse clinical outcome compared with non-frail patients. (4) Multivariate analysis revealed Killip class III-IV was associated with MACE (odds ratio [OR]=3.51; P=0.02) and all-cause mortality (OR=9.49; P<0.01) in the Over-80 group. PCI was inversely associated with all-cause mortality (OR=0.13; P=0.02) in the Over-80 group. Conclusions: The rate of primary PCI did not decline with age. Although octogenarians/nonagenarians showed more severe clinical presentation and worse short-term outcomes compared with younger patients, particularly in those with frailty, the prognosis may be improved by early invasive strategy even in these very old patients.
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Affiliation(s)
- Junya Komatsu
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Hiroki Sugane
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Hayato Hosoda
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoko Nakaoka
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Koji Nishida
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shinji Mito
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shu-Ichi Seki
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Toru Kubo
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | | | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoshinori L Doi
- Department of Cardiology, Chikamori Hospital Kochi Japan
- Cardiomyopathy Institute, Chikamori Hospital Kochi Japan
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Kotanidis CP, Mills GB, Bendz B, Berg ES, Hildick-Smith D, Hirlekar G, Milasinovic D, Morici N, Myat A, Tegn N, Sanchis J, Savonitto S, De Servi S, Fox KAA, Pocock S, Kunadian V. Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis. Eur Heart J 2024; 45:2052-2062. [PMID: 38596853 PMCID: PMC11177715 DOI: 10.1093/eurheartj/ehae151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/30/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND AND AIMS Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients. METHODS MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819). RESULTS Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality. CONCLUSIONS No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.
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Affiliation(s)
- Christos P Kotanidis
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Gregory B Mills
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erlend S Berg
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - David Hildick-Smith
- Sussex Cardiac Centre, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Geir Hirlekar
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | | | - Nicolai Tegn
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Juan Sanchis
- Department of Cardiology, Hospital Clinico Universitario, INCLIVA, Universitat de Valencia, CIBER-Cardiovascular, Valencia, Spain
| | | | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
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8
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Roberts SM, Malhotra A, Cios TJ. Invasive Cardiac Therapies in Older People-Can We Raise the Bar? J Cardiothorac Vasc Anesth 2024; 38:1296-1298. [PMID: 38490901 DOI: 10.1053/j.jvca.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 03/17/2024]
Affiliation(s)
- S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
| | - Anita Malhotra
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - Theodore J Cios
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
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9
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Alfraih A, Tago A, Lacombe M, Kussmaul WG. Cardiology: What You May Have Missed in 2023. Ann Intern Med 2024; 177:S3-S14. [PMID: 38621242 DOI: 10.7326/m24-0581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Cardiology and all its subspecialties continue to push the envelope in developing new treatment strategies for a wide variety of diseases. After screening more than 1300 articles, we highlight a selection of important cardiology articles published in 2023. Starting with prevention, we note articles that look at the effect of semaglutide in patients with obesity as well as a first-in-class drug, bempedoic acid, on cardiovascular outcomes. We have also examined new evidence comparing conservative management with invasive management of frail, older patients with non-ST-segment elevation myocardial infarction (NSTEMI). In patients with cardiac arrest secondary to NSTEMI, another article examines the rationale for expedited transfer to a cardiac arrest center. The STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) trial builds on looking at half-dose thrombolysis in older populations with STEMI. Emphasis is placed on guideline-directed medical therapy before hospital discharge in those with heart failure. In addition, in patients with stable symptomatic coronary artery disease, initial noninvasive testing using coronary computed tomography angiography may be a viable option compared with invasive strategies. More details have emerged on anticoagulation strategies in those with device-detected atrial fibrillation. Finally, transcatheter approaches to treat both mitral and tricuspid regurgitation have also been included.
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Affiliation(s)
| | - Achieng Tago
- McMaster University, Hamilton, Ontario, Canada (A.A., A.T.)
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10
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Sanchis J, Bueno H, García-Blas S, Alegre O, Martí D, Martínez-Sellés M, Domínguez-Pérez L, Díez-Villanueva P, Barrabés JA, Marín F, Villa A, Sanmartín M, Llibre C, Sionís A, Carol A, Fernández-Cisnal A, Calvo E, Morales MJ, Elízaga J, Gómez I, Alfonso F, García del Blanco B, Formiga F, Núñez E, Núñez J, Ariza-Solé A. Invasive Treatment Strategy in Adults With Frailty and Non-ST-Segment Elevation Myocardial Infarction: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e240809. [PMID: 38446482 PMCID: PMC10918507 DOI: 10.1001/jamanetworkopen.2024.0809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/10/2024] [Indexed: 03/07/2024] Open
Abstract
Importance The MOSCA-FRAIL randomized clinical trial compared invasive and conservative treatment strategies in patients with frailty with non-ST-segment elevation myocardial infarction (NSTEMI). It showed no differences in the number of days alive and out of the hospital at 1 year. Objective To assess the outcomes of the MOSCA-FRAIL trial during extended follow-up. Design, Setting, and Participants The MOSCA-FRAIL randomized clinical trial was conducted at 13 hospitals in Spain between July 7, 2017, and January 9, 2021, and included 167 adults (aged ≥70 years) with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. In this preplanned secondary analysis, follow-up was extended to January 31, 2023. Data analysis was performed from April 5 to 29, 2023, using the intention-to-treat principle. Interventions Patients were randomized to a routine invasive (coronary angiography and revascularization if feasible [n = 84]) or a conservative (medical treatment with coronary angiography only if recurrent ischemia [n = 83]) strategy. Main outcomes and measures The primary end point was the difference in restricted mean survival time (RMST). Secondary end points included readmissions for any cause, considering recurrent readmissions. Results Among the 167 patients included in the analysis, the mean (SD) age was 86 (5) years; 79 (47.3%) were men and 88 (52.7%) were women. A total of 93 deaths and 367 readmissions accrued. The RMST for all-cause death over the entire follow-up was 3.13 (95% CI, 2.72-3.60) years in the invasive and 3.06 (95% CI, 2.84-3.32) years in the conservative treatment groups. The RMST analysis showed inconclusive differences in survival time (invasive minus conservative difference, 28 [95% CI, -188 to 230] days). Patients under invasive treatment tended to have shorter survival in the first year (-28 [95% CI, -63 to 7] days), which improved after the first year (192 [95% CI, 90-230] days). Kaplan-Meier mortality curves intersected, displaying higher mortality to 1 year in the invasive group that shifted to a late benefit (landmark analysis hazard ratio, 0.58 [95% CI, 0.33-0.99]; P = .045). Early harm was more evident in the subgroup with a Clinical Frailty Scale score greater than 4. No differences were found for the secondary end points. Conclusions and Relevance In this extended follow-up of a randomized clinical trial of patients with frailty and NSTEMI, an invasive treatment strategy did not improve outcomes at a median follow-up of 1113 (IQR, 443-1441) days. However, a differential distribution of deaths was observed, with early harm followed by later benefit. The phenomenon of depletion of susceptible patients may be responsible for this behavior. Trial registration ClinicalTrials.gov Identifier: NCT03208153.
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Affiliation(s)
- Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Oriol Alegre
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - David Martí
- Central Defense Hospital, Alcalá University, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Laura Domínguez-Pérez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Pablo Díez-Villanueva
- University Hospital La Princesa, Autonomous University of Madrid, Instituto de Investigación Sanitaria Princesa, CIBERCV, Madrid, Spain
| | | | - Francisco Marín
- University Hospital Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria–Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | - Adolfo Villa
- Southeast University Hospital, Arganda del Rey, Madrid, Spain
| | | | - Cinta Llibre
- University Hospital Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | | | - Antoni Carol
- Moisés Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Agustín Fernández-Cisnal
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Elena Calvo
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jaime Elízaga
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Iván Gómez
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), CIBERCV, Madrid, Spain
- Complutense University, Madrid, Spain
| | - Fernando Alfonso
- University Hospital La Princesa, Autonomous University of Madrid, Instituto de Investigación Sanitaria Princesa, CIBERCV, Madrid, Spain
| | | | - Francesc Formiga
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Eduardo Núñez
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, University of València, Instituto de Investigación Sanitaria Clínico Valencia, Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Valencia, Spain
| | - Albert Ariza-Solé
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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Berg ES, Tegn NK, Abdelnoor M, Røysland K, Ryalen PC, Aaberge L, Eek C, Øie E, Juliebø V, Gjertsen E, Ranhoff AH, Gullestad L, Nordstrand N, Bendz B. Long-Term Outcomes of Invasive vs Conservative Strategies for Older Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2023; 82:2021-2030. [PMID: 37968019 DOI: 10.1016/j.jacc.2023.09.809] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a frequent cause of hospital admission in older people, but clinical trials targeting this population are scarce. OBJECTIVES The After Eighty Study assessed the effect of an invasive vs a conservative treatment strategy in a very old population with NSTE-ACS. METHODS Between 2010 and 2014, the investigators randomized 457 patients with NSTE-ACS aged ≥80 years (mean age 85 years) to an invasive strategy involving early coronary angiography with immediate evaluation for revascularization and optimal medical therapy or to a conservative strategy (ie, optimal medical therapy). The primary endpoint was a composite of myocardial infarction, need for urgent revascularization, stroke, and death. The long-term outcomes are presented. RESULTS After a median follow up of 5.3 years, the invasive strategy was superior to the conservative strategy in the reduction of the primary endpoint (incidence rate ratio: 0.76; 95% CI: 0.63-0.93; P = 0.0057). The invasive strategy demonstrated a significant gain in event-free survival of 276 days (95% CI: 151-400 days; P = 0.0001) at 5 years and 337 days (95% CI: 123-550 days; P = 0.0001) at 10 years. These results were consistent across subgroups of patients with respect to major cardiovascular prognostic factors. CONCLUSIONS In patients aged ≥80 years with NSTE-ACS, the invasive strategy was superior to the conservative strategy in the reduction of composite events and demonstrated a significant gain in event-free survival. (The After Eighty Study: a randomized controlled trial; NCT01255540).
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Affiliation(s)
- Erlend S Berg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicolai K Tegn
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Michael Abdelnoor
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | | | | | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Christian Eek
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Vibeke Juliebø
- Department of Cardiology, Akershus University Hospital, Nordbyhagen, Norway
| | - Erik Gjertsen
- Department of Cardiology, Drammen Hospital, Drammen, Norway
| | | | | | - Njord Nordstrand
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway.
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12
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Barrabés JA, Ródenas-Alesina E, Milà L. Delineating the Benefits of an Invasive Strategy in Octogenarians With Non-ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2023; 82:2031-2033. [PMID: 37968020 DOI: 10.1016/j.jacc.2023.09.810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 11/17/2023]
Affiliation(s)
- José A Barrabés
- Department of Cardiology, Vall d'Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares, Madrid, Spain.
| | - Eduard Ródenas-Alesina
- Department of Cardiology, Vall d'Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laia Milà
- Department of Cardiology, Vall d'Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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13
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Kalra K, Moumneh MB, Nanna MG, Damluji AA. Beyond MACE: a multidimensional approach to outcomes in clinical trials for older adults with stable ischemic heart disease. Front Cardiovasc Med 2023; 10:1276370. [PMID: 38045910 PMCID: PMC10690830 DOI: 10.3389/fcvm.2023.1276370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
The global population of older adults is expanding rapidly resulting in a shift towards managing multiple chronic diseases that coexist and may be exacerbated by cardiovascular illness. Stable ischemic heart disease (SIHD) is a predominant contributor to morbidity and mortality in the older adult population. Although results from clinical trials demonstrate that chronological age is a predictor of poor health outcomes, the current management approach remains suboptimal due to insufficient representation of older adults in randomized trials and the inadequate consideration for the interaction between biological aging, concurrent geriatric syndromes, and patient preferences. A shift towards a more patient-centered approach is necessary for appropriately and effectively managing SIHD in the older adult population. In this review, we aim to demonstrate the distinctive needs of older adults who prioritize holistic health outcomes like functional capacity, cognitive abilities, mental health, and quality of life alongside the prevention of major adverse cardiovascular outcomes reported in cardiovascular clinical trials. An individualized, patient-centered approach that involves shared decision-making regarding outcome prioritization is needed when any treatment strategy is being considered. By prioritizing patients and addressing their unique needs for successful aging, we can provide more effective care to a patient population that exhibits the highest cardiovascular risks.
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Affiliation(s)
- Kriti Kalra
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
| | - Mohamad B. Moumneh
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular, Fairfax, VA, United States
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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14
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Zhao YJ, Sun Y, Wang F, Cai YY, Alolga RN, Qi LW, Xiao P. Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197451. [PMID: 37745128 PMCID: PMC10516546 DOI: 10.3389/fcvm.2023.1197451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.
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Affiliation(s)
- Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Yangyang Sun
- Department of Pharmacy, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fan Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yuan-Yuan Cai
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N. Alolga
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Lian-Wen Qi
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
- College of Traditional Chinese Medicine and Food Engineering, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Pingxi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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15
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Formiga F, Ariza-Solé A, Sanchis J. [Non-ST-segment elevation acute coronary syndrome in the elderly patient. Lessons from the MOSCA-FRAIL study]. Rev Esp Geriatr Gerontol 2023; 58:101392. [PMID: 37611503 DOI: 10.1016/j.regg.2023.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/25/2023]
Affiliation(s)
- Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, Universitat de Barcelona; Grupo de Investigación IDIBELL, Hospitalet de Llobregat, Barcelona, España.
| | - Albert Ariza-Solé
- Servicio de Cardiología, Hospital Universitario de Bellvitge, Universitat de Barcelona; Grupo de Investigación IDIBELL, Hospitalet de Llobregat, Barcelona, España
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València; Instituto de Investigación Sanitaria INCLIVA; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Valencia, España
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16
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van den Broek WWA, Gimbel ME, Chan Pin Yin DRPP, Azzahhafi J, Hermanides RS, Runnett C, Storey RF, Austin D, Oemrawsingh R, Cooke J, Galasko G, Walhout RJ, Schellings DAAM, Brinckman SL, The HK, Stoel MG, Heestermans AACM, Nicastia D, Emans ME, van ’t Hof AWJ, Alber H, Gerber R, van Bergen PFMM, Aksoy I, Nasser A, Knaapen P, Botman CJ, Liem A, Kelder JC, ten Berg JM. Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry. J Clin Med 2023; 12:5450. [PMID: 37685517 PMCID: PMC10487667 DOI: 10.3390/jcm12175450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.
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Affiliation(s)
- Wout W. A. van den Broek
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Marieke E. Gimbel
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Dean R. P. P. Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Renicus S. Hermanides
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Craig Runnett
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, 8 Silver Fox Way, Newcastle upon Tyne NE27 0QJ, UK;
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK;
| | - David Austin
- Academic Cardiovascular Unit, The James Cook University Hospital, Marton Rd., Middlesbrough TS4 3BW, UK;
| | - Rohit Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands;
| | - Justin Cooke
- Department of Cardiology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield Rd., Calow, Chesterfield S44 5BL, UK;
| | - Gavin Galasko
- Department of Cardiology, Blackpool Teaching Hospital NHS Foundation Trust, Whinney Heys Rd., Blackpool FY3 8NR, UK;
| | - Ronald J. Walhout
- Department of Cardiology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands;
| | - Dirk A. A. M. Schellings
- Department of Cardiology, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, The Netherlands;
| | - Stijn L. Brinckman
- Department of Cardiology, Tergooi MC, Rijksstraatweg 1, 1261 AN Blaricum, The Netherlands;
| | - Hong Kie The
- Department of Cardiology, Treant Zorggroep, Boermarkeweg 60, 7824 AA Emmen, The Netherlands;
| | - Martin G. Stoel
- Department of Cardiology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands;
| | | | - Debby Nicastia
- Department of Cardiology, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands;
| | - Mireille E. Emans
- Department of Cardiology, Ikazia Hospital, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands;
| | - Arnoud W. J. van ’t Hof
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | - Hannes Alber
- Department for Internal Medicine and Cardiology, KABEG Klinikum, Feschnigstraße 11, 9020 Klagenfurt am Wörthersee, Austria;
| | - Robert Gerber
- Department of Cardiology, East Sussex Healthcare NHS Foundation Trust, Dane Rd., Seaford BN25 1DH, UK;
| | | | - Ismail Aksoy
- Department of Cardiology, Admiraal de Ruyter Hospital, ‘s-Gravenpolderseweg 114, 4462 RA Goes, The Netherlands;
| | - Abdul Nasser
- Department of Cardiology, South Tyneside and Sunderland NHS Foundation Trust, Harton Ln., South Shields NE34 0PL, UK;
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Cees-Joost Botman
- Department of Cardiology, Sint Jans Gasthuis, Vogelsbleek 5, 6001 BE Weert, The Netherlands;
| | - Anho Liem
- Department of Cardiology, Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam, The Netherlands;
| | - Johannes C. Kelder
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jurriën M. ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
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Cacciatore S, Spadafora L, Bernardi M, Galli M, Betti M, Perone F, Nicolaio G, Marzetti E, Martone AM, Landi F, Asher E, Banach M, Hanon O, Biondi-Zoccai G, Sabouret P. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J Clin Med 2023; 12:5233. [PMID: 37629275 PMCID: PMC10455820 DOI: 10.3390/jcm12165233] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.
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Affiliation(s)
- Stefano Cacciatore
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Matteo Betti
- University of Milan, 20122, Milan, Italy
- Monzino IRCCS Cardiological Center, 20137 Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, 81020 Castel Morrone, Caserta, Italy
| | - Giulia Nicolaio
- Department of Experimental and Clinical Medicine and Geriatrics, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna Maria Martone
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elad Asher
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, P.O. Box 12271, Jerusalem 9112102, Israel
| | - Maciej Banach
- Department of Preventive Cardiology, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Medical University of Lodz (MUL), 93-338 Lodz, Poland
| | - Olivier Hanon
- Assistance Publique Hôpitaux de Paris, Geriatric Department, Broca Hospital, University of Paris Cité, 54–56 Rue Pascal, 75013 Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio 2, 80122 Naples, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Sorbonne University, 47–83 Bd de l’Hôpital, 75013 Paris, France
- Department of Cardiology, National College of French Cardiologists, 13 Rue Niépce, 75014 Paris, France
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Hu M, Li X, Yang Y. Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years. Arq Bras Cardiol 2023; 120:e20220658. [PMID: 37255135 PMCID: PMC10484564 DOI: 10.36660/abc.20220658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 06/01/2023] Open
Abstract
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.
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Affiliation(s)
- Mengjin Hu
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
- Xuanwu HospitalCapital Medical UniversityBeijingChinaXuanwu Hospital, Capital Medical University, Beijing – China
| | - Xiaosong Li
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
| | - Yuejin Yang
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
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Bruno TC, Bittencourt MS, Quidim AVL, Santos IS, Lotufo PA, Benseñor IM, Goulart AC. Prognosis Related to Reperfusion Therapy Post-Acute Coronary Syndrome in Secondary Care: Long-Term Survival Analysis in the ERICO Study. Arq Bras Cardiol 2023; 120:e20220849. [PMID: 37194831 PMCID: PMC10263393 DOI: 10.36660/abc.20220849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/15/2023] [Accepted: 02/15/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Relationship between reperfusion therapy post-acute coronary syndrome (ACS) and mortality in secondary care is not well-known. OBJECTIVES To evaluate the impact of three therapeutic strategies: (1) exclusive medical therapy, (2) percutaneous coronary intervention (PCI) and (3) coronary artery bypass grafting (CABG) on long-term survival of participants in the Strategy of Registry of Acute Coronary Syndrome (ERICO) study. METHODS Survival analyses for all-cause, cardiovascular (CVD) and coronary artery disease (CAD) mortality were performed according to three therapeutic strategies (exclusive medical therapy, PCI or CABG). Cox regression models were used to estimate the hazard ratio (HR) with respective 95% confidence interval (95%CI) from 180 days to four years of follow-up after ACS. Models are presented as crude, age-sex adjusted and further adjusted for previous CAD, ACS subtype, smoking, hypertension, dyslipidemia, left ventricular ejection fraction and according to the number of obstructed (≥ 50%) major coronary arteries. RESULTS Among 800 participants, the lowest crude survival rates were detected among individuals who underwent CABG (all-cause and CVD). CABG was correlated to CAD (HR: 2.19 [95% CI: 1.05-4.55]). However, this risk lost significance in the full model. PCI was associated to lower probability of fatal events during four-year follow-up: all-cause [multivariate HR: 0.42 (95% CI: 0.26-0.70)], CVD [HR: 0.39 (95% CI: 0.20-0.73)] and CAD [multivariate HR: 0.24 (95% CI: 0.09-0.63)] compared to those submitted to exclusive medical therapy. CONCLUSION In the ERICO study, PCI after ACS was associated to better prognosis, particularly CAD survival.
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Affiliation(s)
- Tatiana C. Bruno
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
| | - Márcio S. Bittencourt
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
| | - Alessandra V. L. Quidim
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
| | - Itamar S. Santos
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
- Universidade de São PauloFaculdade de MedicinaSão PauloSPBrasil Universidade de São Paulo , Faculdade de Medicina , São Paulo , SP – Brasil
| | - Paulo A. Lotufo
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
- Universidade de São PauloFaculdade de MedicinaSão PauloSPBrasil Universidade de São Paulo , Faculdade de Medicina , São Paulo , SP – Brasil
| | - Isabela M. Benseñor
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
- Universidade de São PauloFaculdade de MedicinaSão PauloSPBrasil Universidade de São Paulo , Faculdade de Medicina , São Paulo , SP – Brasil
| | - Alessandra C. Goulart
- Centro de Pesquisa Clínica e EpidemiológicaHospital UniversitárioUniversidade de São PauloSão PauloSPBrasil Centro de Pesquisa Clínica e Epidemiológica – Hospital Universitário – Universidade de São Paulo , São Paulo , SP – Brasil
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20
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Sanchis J, Bueno H, Miñana G, Guerrero C, Martí D, Martínez-Sellés M, Domínguez-Pérez L, Díez-Villanueva P, Barrabés JA, Marín F, Villa A, Sanmartín M, Llibre C, Sionís A, Carol A, García-Blas S, Calvo E, Morales Gallardo MJ, Elízaga J, Gómez-Blázquez I, Alfonso F, García del Blanco B, Núñez J, Formiga F, Ariza-Solé A. Effect of Routine Invasive vs Conservative Strategy in Older Adults With Frailty and Non-ST-Segment Elevation Acute Myocardial Infarction: A Randomized Clinical Trial. JAMA Intern Med 2023; 183:407-415. [PMID: 36877502 PMCID: PMC9989957 DOI: 10.1001/jamainternmed.2023.0047] [Citation(s) in RCA: 31] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/09/2023] [Indexed: 03/07/2023]
Abstract
Importance To our knowledge, no randomized clinical trial has compared the invasive and conservative strategies in frail, older patients with non-ST-segment elevation acute myocardial infarction (NSTEMI). Objective To compare outcomes of invasive and conservative strategies in frail, older patients with NSTEMI at 1 year. Design, Setting, and Participants This multicenter randomized clinical trial was conducted at 13 Spanish hospitals between July 7, 2017, and January 9, 2021, and included 167 older adult (≥70 years) patients with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. Data analysis was performed from April 2022 to June 2022. Interventions Patients were randomized to routine invasive (coronary angiography and revascularization if feasible; n = 84) or conservative (medical treatment with coronary angiography for recurrent ischemia; n = 83) strategy. Main Outcomes and Measures The primary end point was the number of days alive and out of the hospital (DAOH) from discharge to 1 year. The coprimary end point was the composite of cardiac death, reinfarction, or postdischarge revascularization. Results The study was prematurely stopped due to the COVID-19 pandemic when 95% of the calculated sample size had been enrolled. Among the 167 patients included, the mean (SD) age was 86 (5) years, and mean (SD) Clinical Frailty Scale score was 5 (1). While not statistically different, DAOH were about 1 month (28 days; 95% CI, -7 to 62) greater for patients managed conservatively (312 days; 95% CI, 289 to 335) vs patients managed invasively (284 days; 95% CI, 255 to 311; P = .12). A sensitivity analysis stratified by sex did not show differences. In addition, we found no differences in all-cause mortality (hazard ratio, 1.45; 95% CI, 0.74-2.85; P = .28). There was a 28-day shorter survival in the invasive vs conservatively managed group (95% CI, -63 to 7 days; restricted mean survival time analysis). Noncardiac reasons accounted for 56% of the readmissions. There were no differences in the number of readmissions or days spent in the hospital after discharge between groups. Neither were there differences in the coprimary end point of ischemic cardiac events (subdistribution hazard ratio, 0.92; 95% CI, 0.54-1.57; P = .78). Conclusions and Relevance In this randomized clinical trial of NSTEMI in frail older patients, there was no benefit to a routine invasive strategy in DAOH during the first year. Based on these findings, a policy of medical management and watchful observation is recommended for older patients with frailty and NSTEMI. Trial Registration ClinicalTrials.gov Identifier: NCT03208153.
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Affiliation(s)
- Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, University of València, INCLIVA, CIBERCV, València, Spain
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain, Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, CIBERCV, Madrid, Spain, Complutense University, Madrid, Spain
| | - Gema Miñana
- Cardiology Department, University Clinic Hospital of València, University of València, INCLIVA, CIBERCV, València, Spain
| | - Carme Guerrero
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - David Martí
- Central Defense Hospital, Madrid, Alcalá University, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Laura Domínguez-Pérez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain, Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, CIBERCV, Madrid, Spain, Complutense University, Madrid, Spain
| | - Pablo Díez-Villanueva
- University Hospital La Princesa, Autonomous University of Madrid, IIS-IP, CIBERCV Madrid, Spain
| | | | - Francisco Marín
- University Hospital Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, El Palmar, Murcia, Spain
| | - Adolfo Villa
- Southeast University Hospital, Arganda del Rey, Madrid, Spain
| | | | - Cinta Llibre
- University Hospital Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | | | - Antoni Carol
- Moisés Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | - Sergio García-Blas
- Cardiology Department, University Clinic Hospital of València, University of València, INCLIVA, CIBERCV, València, Spain
| | - Elena Calvo
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jaime Elízaga
- Cardiology Department, University Hospital Gregorio Marañón, CIBERCV, Complutense University, European University, Madrid, Spain
| | - Iván Gómez-Blázquez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain, Cardiology Department, Universisty Hospital 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, CIBERCV, Madrid, Spain, Complutense University, Madrid, Spain
| | - Fernando Alfonso
- University Hospital La Princesa, Autonomous University of Madrid, IIS-IP, CIBERCV Madrid, Spain
| | | | - Julio Núñez
- Cardiology Department, University Clinic Hospital of València, University of València, INCLIVA, CIBERCV, València, Spain
| | - Francesc Formiga
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Ariza-Solé
- Cardiology Department, University Hospital of Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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21
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Park DY, Hu JR, Alexander KP, Nanna MG. Readmission and adverse outcomes after percutaneous coronary intervention in patients with dementia. J Am Geriatr Soc 2023; 71:1034-1046. [PMID: 36409823 PMCID: PMC10089937 DOI: 10.1111/jgs.18120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/12/2022] [Accepted: 10/14/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND As the population ages, clinicians increasingly encounter ischemic heart disease in patients with underlying dementia. Therefore, we quantified differences in inhospital adverse events and 30-day readmission rates among patients with and without dementia undergoing percutaneous coronary intervention (PCI). METHODS Using the National Readmissions Database 2017-2018, we identified 755,406 index hospitalizations in which PCI was performed, of which 17,309 (2.3%) had a diagnosis of dementia. After propensity score matching patients with and without dementia, we assessed 30-day readmission and inhospital adverse events by Cox proportional hazards and logistic regression modeling and compared them with those of other common cardiac (pacemaker placement [PP]) and noncardiac (hip replacement surgery [HRS]) procedures. RESULTS Thirty-day readmission was significantly higher in patients with dementia than patients without dementia (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.60-1.74). Patients with dementia also experienced higher odds of delirium (odds ratio [OR] 4.37, CI 3.69-5.16), inhospital mortality (OR 1.15, CI 1.01-1.30), cardiac arrest (OR 1.19, CI 1.01-1.39), acute kidney injury (OR 1.30, CI 1.21-1.39), and fall (OR 2.51, CI 2.06-3.07). On multivariable Cox modeling, dementia independently predicted 30-day readmission (HR 1.14, CI 1.07-1.20). The higher readmission risk with PCI (11%) among those with dementia was similar to that of patients undergoing PP (10%), but lower than in those undergoing HRS (41%). CONCLUSION Patients with dementia who undergo PCI experience significantly increased rates of inhospital delirium, mortality, kidney injury, falls, and 30-day readmission. These adverse outcomes should be considered during shared decision-making with patients and their families.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Karen P Alexander
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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22
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Bianco M, Mottola FF, Cerrato E, Giordana F, Cinconze S, Baralis G, Verra A, Musumeci G, Rossini R. Acute coronary syndrome in very elderly patients-a real-world experience. Heart Vessels 2023:10.1007/s00380-023-02260-x. [PMID: 36976424 DOI: 10.1007/s00380-023-02260-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
Very elderly population constitutes an increasingly larger proportion of patients admitted for acute coronary syndromes (ACS). Notably, age represents both a proxy of frailty and an exclusion criterion in clinical randomized trials, which probably contributes to lack of data and undertreatment of real-world elderly patients. The aim of the study is to describe patterns of treatment and outcome of very elderly patients with ACS. All consecutive patients aged ≥ 80 years old (yo) admitted between January 2017 and December 2019 with ACS were included. The primary endpoint was in-hospital occurrence of major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, new onset cardiogenic shock, definite/probable stent thrombosis, and ischemic stroke. The secondary endpoints were in-hospital incidence of Thrombolysis in Myocardial Infarction (TIMI) major/minor bleedings, contrast-induced nephropathy (CIN), six-month all-cause mortality, and unplanned readmission. One hundred ninety-three patients (mean age 84.1 ± 3.5 yo, 46% females) were included, of whom 86 (44.6%), 79 (40.9%), and 28 (14.5%) presented with ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina (UA), respectively. The vast majority of patients received an invasive strategy, with 92.7% undergoing coronary angiography and 84.4% to percutaneous coronary intervention (PCI). Aspirin was administered to 180 (93.3%) patients, clopidogrel to 89 (46.1%) patients, and ticagrelor to 85 (44%) patients. In-hospital MACE occurred in 29 patients (15.0%), whereas 3 (1.6%) and 12 patients (7.2%) experienced in-hospital TIMI major and TIMI minor bleeding, respectively. Of the overall population, 177 (91.7%) were discharged alive. After discharge, 11 patients (6.2%) died of all-cause death, whereas 42 patients (23.7%) required a new hospitalization within six months. Invasive strategy of ACS in elderly patients seems safe and effective. Six-month new hospitalization appears inevitably related to age.
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Affiliation(s)
- Matteo Bianco
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Filiberto Fausto Mottola
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, Naples, Italy
| | - Enrico Cerrato
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Francesca Giordana
- Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy
| | - Sebastian Cinconze
- Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy
| | - Giorgio Baralis
- Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy
| | - Alison Verra
- Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy
| | - Giuseppe Musumeci
- Division of Cardiology, Ordine Mauriziano Di Torino Hospital, Turin, Italy
| | - Roberta Rossini
- Division of Cardiology, S. Croce and Carle Hospital, Via Michele Coppino, 26, 12100, Cuneo, Italy.
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23
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Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V. Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart 2023; 109:504-510. [PMID: 36104217 DOI: 10.1136/heartjnl-2022-321470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.
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Affiliation(s)
| | - Greg B Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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24
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De Servi S, Landi A, Savonitto S, Morici N, De Luca L, Montalto C, Crimi G, De Rosa R, De Luca G. Antiplatelet Strategies for Older Patients with Acute Coronary Syndromes: Finding Directions in a Low-Evidence Field. J Clin Med 2023; 12:2082. [PMID: 36902869 PMCID: PMC10003933 DOI: 10.3390/jcm12052082] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 02/23/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023] Open
Abstract
Patients ≥ 75 years of age account for about one third of hospitalizations for acute coronary syndromes (ACS). Since the latest European Society of Cardiology guidelines recommend that older ACS patients use the same diagnostic and interventional strategies used by the younger ones, most elderly patients are currently treated invasively. Therefore, an appropriate dual antiplatelet therapy (DAPT) is indicated as part of the secondary prevention strategy to be implemented in such patients. The choice of the composition and duration of DAPT should be tailored on an individual basis, after careful assessment of the thrombotic and bleeding risk of each patient. Advanced age is a main risk factor for bleeding. Recent data show that in patients of high bleeding risk short DAPT (1 to 3 months) is associated with decreased bleeding complications and similar thrombotic events, as compared to standard 12-month DAPT. Clopidogrel seems the preferable P2Y12 inhibitor, due to a better safety profile than ticagrelor. When the bleeding risk is associated with a high thrombotic risk (a circumstance present in about two thirds of older ACS patients) it is important to tailor the treatment by taking into account the fact that the thrombotic risk is high during the first months after the index event and then wanes gradually over time, whereas the bleeding risk remains constant. Under these circumstances, a de-escalation strategy seems reasonable, starting with DAPT that includes aspirin and low-dose prasugrel (a more potent and reliable P2Y12 inhibitor than clopidogrel) then switching after 2-3 months to DAPT with aspirin and clopidogrel for up to 12 months.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, 27100 Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), 6900 Lugano, Switzerland
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS, 20148 Milan, Italy
| | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, 00152 Roma, Italy
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
- Clinical and Interventional Cardiology, Istituto Clinico Sant’Ambrogio, Gruppo San Donato, 20122 Milan, Italy
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS, Ospedale Policlinico San Martino, 16132 Genova, Italy
| | - Roberta De Rosa
- University Hospital San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, Italy
- Goethe University Hospital Frankfurt, 60528 Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU “Policlinico G. Martino”, Department of Clinical and Experimental Medicine, University of Messina, 98039 Messina, Italy
- Division of Cardiology, Nuovo Galeazzi-Sant’Ambrogio Hospital, 20161 Milan, Italy
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25
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Beska B, Ratcovich H, Bagnall A, Burrell A, Edwards R, Egred M, Jordan R, Khan A, Mills GB, Morrison E, Raharjo DE, Singh F, Wilkinson C, Zaman A, Kunadian V. Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome. Interv Cardiol 2023; 18:e04. [PMID: 37614703 PMCID: PMC10442670 DOI: 10.15420/icr.2022.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/10/2022] [Indexed: 08/25/2023] Open
Abstract
Background Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. Methods In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Results Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Conclusion Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.
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Affiliation(s)
- Benjamin Beska
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Hanna Ratcovich
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Department of Cardiology, Rigshospitalet, Copenhagen University HospitalCopenhagen, Denmark
| | - Alan Bagnall
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Amy Burrell
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Mohaned Egred
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | | | - Amina Khan
- Leeds Teaching Hospitals NHS TrustLeeds, UK
| | - Greg B Mills
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | - Emma Morrison
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | | | - Fateh Singh
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham, UK
| | - Chris Wilkinson
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle UniversityNewcastle, UK
| | - Azfar Zaman
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
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26
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De Servi S, Landi A, Savonitto S, De Luca L, De Luca G, Morici N, Montalto C, Crimi G, Cattaneo M. Tailoring oral antiplatelet therapy in acute coronary syndromes: from guidelines to clinical practice. J Cardiovasc Med (Hagerstown) 2023; 24:77-86. [PMID: 36583976 DOI: 10.2459/jcm.0000000000001399] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The assessment of bleeding and ischemic risk is a crucial step in establishing appropriate composition and duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndrome (ACS) treated with percutaneous coronary angioplasty. Evidence from recent randomized clinical trials led to some paradigm shifts in current guidelines recommendations. Options alternative to the standard 12-month DAPT duration include shorter periods of DAPT followed by single antiplatelet treatment with either aspirin or P2Y12 monotherapy, guided or unguided de-escalation DAPT, prolonged DAPT beyond the 12-month treatment period. Although DAPT composition and duration should be selected for each ACS patient on an individual basis weighing clinical and procedural variables, data from latest trials and meta-analyses may permit suggesting the most appropriate DAPT strategy according to the ischemic and bleeding risk assessed using validated tools and scores.
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Affiliation(s)
- Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
| | - Antonio Landi
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | | | - Leonardo De Luca
- Department of Cardiovascular Sciences, A.O. San Camillo-Forlanini, Roma
| | - Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria di Sassari, University of Sassari, Sassari.,Clinical and Interventional Cardiology, Istituto Clinico Sant'Ambrogio, Gruppo San Donato
| | - Nuccia Morici
- IRCCS S. Maria Nascente - Fondazione Don Carlo Gnocchi ONLUS
| | - Claudio Montalto
- Interventional Cardiology, De Gasperis Cardio Center, Niguarda Hospital, Milan
| | - Gabriele Crimi
- Interventional Cardiology Unit, Cardio-Thoraco Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Genova
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 PMCID: PMC10312228 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Cacciatore S, Martone AM, Landi F, Tosato M. Acute Coronary Syndrome in Older Adults: an Update from the 2022 Scientific Statement by the American Heart Association. HEART, VESSELS AND TRANSPLANTATION 2023. [DOI: 10.24969/hvt.2023.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Khalil M, Maqsood MH, Basir MB, Saad M, Yassa G, Hakam L, Abraham J, Hennawy BS, Etriby SE, Ribeiro MH, Ong K, Garcia S, Brilakis ES, Alaswad K, Megaly M. Meta-Analysis on Invasive Versus Conservative Strategy in Patients Older Than Seventy Years With Non-ST Elevation Myocardial Infarction. Am J Cardiol 2023; 186:66-70. [PMID: 36347067 DOI: 10.1016/j.amjcard.2022.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/23/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
Abstract
Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (>70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I2 = 54%; 3 trials] and unplanned revascularization (OR 0.31, 95% CI 0.15 to 0.64, I2 = 1.7%; 3 trials] than was the conservative strategy. There was no difference in all-cause mortality (OR 0.88, 95% CI 0.65 to 1.18, I2 = 0%; 4 trials], myocardial infarction (OR 0.70, 95% CI 0.42 to 1.19, I2 = 54.7%; 4 trials], or bleeding (OR 0.87, 95% CI 0.39 to 1.93, I2 = 0%; 3 trials] between the strategies. In conclusion, the use of initial invasive strategy in older patients presenting with NSTEMI was associated with a significantly lower risk of major adverse cardiac and cerebrovascular event and unplanned revascularization than that of the initial conservative strategy without increased bleeding.
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Affiliation(s)
| | | | - Mir B Basir
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Marwan Saad
- Department of Cardiology, Brown University, Providence, Rhode Island
| | - George Yassa
- Department of Cardiology Ascension Macomb-Oakland, Warren, Michigan
| | - Laila Hakam
- Internal Medicine Department, Mayo Clinic, Jacksonville, Florida
| | - Joseph Abraham
- Department of Cardiology Unity Health White County Medical Center, Searcy, Arkansas
| | | | | | | | - Kenneth Ong
- Cardiovascular Medicine, Lincoln Medical Center, New York City, New York
| | - Santiago Garcia
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Michael Megaly
- Division of Cardiology, Henry Ford Hospital, Detroit, Michigan.
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Menditto A, Protic O, Di Rosa M, Bonfigli AR, Lattanzio F, Antonicelli R. Admission high-sensitivity cardiac troponin levels as a prognostic indicator for in-hospital mortality rates in the elderly and very elderly COVID-19 patients. Arch Gerontol Geriatr 2023; 104:104822. [PMID: 36156408 PMCID: PMC9484855 DOI: 10.1016/j.archger.2022.104822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/13/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elevation of cardiac troponin (cTn) is associated with the worst prognosis not only in cardiovascular disease but also in non-cardiovascular disease. The aim of this study is to verify if cTn has a prognostic role in elderly and very elderly coronavirus disease 2019 (COVID-19) patients. METHODS This study enrolled consecutive COVID-19 elderly patients hospitalized at INRCA hospital, with available admission high sensitivity cardiac troponin T (HS-cTnT) level. Patients were divided into three groups based on HS-cTnT level: group A (Hs-cTnT ≤ 40 pg/ml), group B (Hs-cTnT 41-100 pg/ml), and group C (Hs-cTnT ≥ 101 pg/ml). The correlation between HS-cTnT levels and mortality rates was analyzed. RESULTS 461 patients (mean age 86 years; 59% female) were divided into group A (261 patients), group B (129 patients), and group C (71 patients). Group C resulted significantly older, more affected by heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and dementia, and with higher levels of creatinine, C-reactive protein, pro-calcitonin, interleukin-6, ferritin, NT-proBNP, D-dimer then group A and group B. Mortality rate increased significantly across groups (group A: 18.4%; group B: 36.4%; group C: 62.0%; p<0.001). Group C had a significant increase in mortality risk compared to group A, both univariate analysis (HR 3.78) and multivariate analysis (model 2 HR 3.10; model 3 HR 3.59; model 4 HR 1.72). CONCLUSION HS-cTnT has demonstrated a prognostic role in elderly and very elderly COVID-19 patients. HS-cTnT is a simple and inexpensive laboratory exam that gives clinicians important information on mortality risk stratification.
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Affiliation(s)
| | | | - Mirko Di Rosa
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona, Italy
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31
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De Luca G, Verdoia M, Morici N, Ferri LA, Piatti L, Grosseto D, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Antonicelli R, Cesana BM, De Luca L, Ottani F, Moffa N, Savonitto S, De Servi S. Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial. Int J Cardiol 2022; 369:5-11. [PMID: 35907504 DOI: 10.1016/j.ijcard.2022.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 11/15/2022]
Abstract
Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk. METHODS All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission. RESULTS We included in our analysis 1364 patients, divided in quartiles of Hb values (<12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients. CONCLUSIONS Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.
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Affiliation(s)
- Giuseppe De Luca
- Clinical and Experimental Cardiology Unit, Azienda Ospedaliera-Universitaria "Sassari", University of Sassari, Sassari, Italy.
| | - Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, Biella, Italy
| | - Nuccia Morici
- IRCCSS. Maria Nascente Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | | | | | | | - Irene Bossi
- IRCCSS. Maria Nascente Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | | | | | | | | | | | | | | | | | | | - Elena Corrada
- Humanitas Clinical and Research Center, Rozzano, Italy
| | | | | | | | | | | | | | - Bruno M Cesana
- Statistics and Biomathematics Unit, Department of Molecular and Transactional Medicine, University of Brescia, Brescia, Italy
| | - Leonardo De Luca
- Department of Cardiosciences, AO San Camillo-Forlanini, Roma, Italy
| | | | | | | | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia Medical School, Pavia, Italy
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Management and Outcomes in the Elderly with Non-ST-Elevation Acute Coronary Syndromes Admitted to Spoke Hospitals with No Catheterization Laboratory Facility. J Clin Med 2022; 11:jcm11206179. [PMID: 36294500 PMCID: PMC9605530 DOI: 10.3390/jcm11206179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational−retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82−89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25−87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7−27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0−4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.
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Acute Coronary Syndrome in Women. Emerg Med Clin North Am 2022; 40:629-636. [DOI: 10.1016/j.emc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hanna JM, Nanna MG. An age-old dilemma: Defining the optimal revascularization approach in older adults. J Am Geriatr Soc 2022; 70:2205-2208. [PMID: 35596677 PMCID: PMC9378558 DOI: 10.1111/jgs.17831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Jonathan M. Hanna
- Department of Internal Medicine, Yale School of Medicine,
New Haven, Connecticut, USA
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Department of Internal
Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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35
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Marino M, Digiacomo S, Cacucci M, Catanoso A, Valentini P, Landolina M. Complete Percutaneous Revascularization in Patients Aged ≥85 Years With Acute Coronary Syndrome and Multivessel Coronary Artery Disease. Am J Cardiol 2022; 180:10-16. [PMID: 35906125 DOI: 10.1016/j.amjcard.2022.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022]
Abstract
Multivessel coronary disease is frequent in older patients who underwent coronary angiography for acute coronary syndrome. Whether a complete revascularization or a culprit-only approach is preferable in these patients is still debated. We included consecutive patients aged ≥85 years, presenting with acute coronary syndrome and showing multivessel coronary disease at coronary angiography. Patients were grouped according to complete (residual SYNTAX score [RSS] 0 to 8) or incomplete (RSS >8) revascularization. Primary end point was the rate of major adverse cardiovascular events (MACEs, the composite of cardiovascular death, re-myocardial infarction [re-MI], clinically driven percutaneous coronary intervention, and rehospitalization because of cardiac disease) at 2 years follow-up. A total of 166 patients met the criteria for enrollment; 108 patients had a final RSS 0 to 8 (complete revascularization) and 58 patients had a final RSS >8 (incomplete revascularization). The rate of MACE was reduced in patients who underwent complete revascularization (35.2% vs 51.7%, p = 0.039, adjusted hazard ratio 0.60, 95% confidence interval 0.37 to 0.98, p = 0.04), a difference mainly driven by a reduction in re-MI (8.3% vs 19.0%, p = 0.045), clinically driven percutaneous coronary intervention (2.8% vs 19.0%, p <0.001), and rehospitalization for cardiac disease (9.3% vs 24.1%, p = 0.009). Other independent predictors of MACE were active malignancy, previous MI, left ventricle ejection fraction <35% (increasing risk of events), and radial access (reducing risk of events). In conclusion, in patients aged ≥85 years, a complete revascularization is associated with a better prognosis, especially in terms of nonfatal events.
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Affiliation(s)
| | - Simonluca Digiacomo
- Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Policlinico San Marco, Zingonia, Italy
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Abusnina W, Radaideh Q, Al-Abdouh A, Ismayl M, Algheriani H, Lee J, Alam M, Ben-Dor I, Jimenez E, Azrin M, Paul TK, Dahal K. Routine Invasive Strategy in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Systematic Review and Meta-analysis of Randomized Trials. Curr Probl Cardiol 2022; 47:101304. [PMID: 35803333 DOI: 10.1016/j.cpcardiol.2022.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. AIM To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. METHODS AND RESULTS We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70-1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P=0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). CONCLUSION This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE.
| | - Qais Radaideh
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, KY
| | - Mahmoud Ismayl
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | | | - Juyong Lee
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington DC
| | - Enrique Jimenez
- Section of Cardiology, Overton Brooks Veterans Affairs Medical Center, Shreveport, LA
| | - Michael Azrin
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Timir K Paul
- Department of medical education, University of Tennessee at Nashville, Nashville, TN
| | - Khagendra Dahal
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
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Fishman B, Sharon A, Itelman E, Tsur AM, Fefer P, Barbash IM, Segev A, Matetzky S, Guetta V, Grossman E, Maor E. Invasive Management in Older Adults (≥80 Years) With Non-ST Elevation Myocardial Infarction. Mayo Clin Proc 2022; 97:1247-1256. [PMID: 35787854 DOI: 10.1016/j.mayocp.2022.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 02/08/2022] [Accepted: 03/15/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate the association of invasive management (coronary angiogram) with all-cause mortality among older adult (≥80 years of age) patients presenting with non-ST elevation myocardial infarction (NSTEMI) by frailty status. PATIENTS AND METHODS This study used a retrospective cohort of consecutive older adult patients who were hospitalized with NSTEMI as their primary clinical diagnosis between August 1, 2008, and December 31, 2019. Cox regression models were applied with stratification by frailty status (low, medium, and high). Extensive sensitivity analyses were conducted including propensity score matching and inverse probability treatment weighting models. RESULTS The study population included 2317 patients with median age of 86 years (IQR, 83-90 years) of whom 1243 (53.6%) were men. Patients who were managed invasively (n=581 [25%]) were less likely to be frail (7% vs 44%, P<.001). During the follow-up (median, 19 months, IQR, 4-41 months), 1599 (69%) patients died. In a multivariable Cox model, invasive approach was associated with adjusted hazard ratio (HR) of 0.61 (95% CI, 0.53 to 0.71) for the risk of death. The benefit of invasive approach was consistent among low, medium, and high frailty subgroups with adjusted HRs of 0.74 (95% CI, 0.58 to 0.93), 0.65 (95% CI, 0.50 to 0.85), and 0.52 (95% CI, 0.34 to 0.78), respectively (P for interaction = 0.48). Results were consistent with propensity score matching and inverse probability treatment weighting analyses (HR, 0.6; 95% CI, 0.50 to 0.71 and HR, 0.67; 95% CI, 0.55 to 0.82, respectively). Sensitivity analysis addressing potential immortal time bias and residual confounding yielded similar results. CONCLUSION Invasive approach is associated with improved survival among older adults with NSTEMI irrespective of frailty status.
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Affiliation(s)
- Boris Fishman
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Department of Medicine D and the Hypertension Unit, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Sharon
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward Itelman
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine T, Sheba Medical Center, Tel-Hashomer, Israel
| | - Avishai M Tsur
- Department of Medicine B, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Israel Defense Forces, Medical Corps, Tel Hashomer, Ramat Gan, Israel; Department of Military Medicine, Hebrew University of Jerusalem Faculty of Medicine, Jerusalem, Israel
| | - Paul Fefer
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Moshe Barbash
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Segev
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Matetzky
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Victor Guetta
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Grossman
- Department of Medicine D and the Hypertension Unit, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- Olga and Lev Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Oberoi M, Ainani N, Abbott JD, Mamas MA, Velagapudi P. Age Considerations in the Invasive Management of Acute Coronary Syndromes. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.
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Affiliation(s)
- Mansi Oberoi
- Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD
| | - Nitesh Ainani
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - J Dawn Abbott
- Department of Internal Medicine, Division of Cardiology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, UK
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
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De Luca L, D’Errigo P, Rosato S, Mureddu GF, Badoni G, Seccareccia F, Baglio G. Impact of myocardial revascularization on long-term outcomes in a nationwide cohort of first acute myocardial infarction survivors. Eur Heart J Suppl 2022; 24:C225-C232. [PMID: 35663587 PMCID: PMC9155238 DOI: 10.1093/eurheartj/suac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The long-term clinical benefits of myocardial revascularization in a contemporary, nationwide cohort of acute myocardial infarction (AMI) survivors are unclear. We aimed to compare the mortality rates and clinical outcomes at 8 years of patients admitted in Italy for a first AMI managed with or without myocardial revascularization during the index event. This is a national retrospective cohort study that enrolled patients admitted for a first AMI in 2012 in all Italian hospitals who survived at 30 days. The outcomes of interest were all-cause mortality, major cardio-cerebrovascular events (MACCE), and re-hospitalization for heart failure (HF) at 8 years. Time to events was analysed using a Cox and Fine and Gray multivariate regression model. A total of 127 431 patients with AMI were admitted to Italian hospitals in 2012. The study cohort consisted of 62 336 AMI events, of whom 63.8% underwent percutaneous or surgical revascularization ≤30 days of the index hospital admission. At 8 years, the cumulative incidence of all-cause death was 36.5% (24.6% in revascularized and 57.6% in not revascularized patients). After multiple corrections, the hazard ratio (HR) for all-cause mortality in revascularized vs. not revascularized patients was 0.61 (P < 0.0001). The rate of MACCE was 45.7% and 65.8% (adjusted HR 0.83; P < 0.0001), while re-hospitalizations for HF occurred in 17.6% and 29.8% (adjusted HR 0.97; P = 0.16) in AMI survivors revascularized and not revascularized, respectively. In our contemporary nationwide cohort of patients at their first AMI episode, those who underwent myocardial revascularization within 1 month from the index event compared to those not revascularized presented an adjusted 39% risk reduction in all-cause mortality and 17% in MACCE at 8-year follow-up.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, A.O. San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
- UniCamillus-Saint Camillus International, University of Health Sciences, Rome, Italy
| | - Paola D’Errigo
- National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Stefano Rosato
- National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Gabriella Badoni
- National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Fulvia Seccareccia
- National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, Rome, Italy
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Zhang D, Xing YL, Wang H, Wang S, Miao Y, Huang W, Zhang K, Li HW, Sun Y, Chen H. Invasive treatment strategy in patients aged 80 years or older with non-ST-elevation acute coronary syndromes: a retrospective cohort study. Cardiovasc Diagn Ther 2022; 12:229-240. [PMID: 35433346 PMCID: PMC9011088 DOI: 10.21037/cdt-21-650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Invasive treatment is commonly recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the efficacy of this approach in patients aged ≥80 years remains uncertain. METHODS We retrospectively assessed consecutive NSTE-ACS patients ≥80 years of age who were hospitalized at our cardiovascular center from December 2012 to July 2019. Patients were divided into two groups based on whether they received invasive treatment (coronary angiography and, if indicated, revascularization) or not. Patients who died in the first 3 days after admission without receiving invasive treatment were excluded. The effect of invasive timed treatment was also explored by dividing patients into timely invasive or delayed invasive groups according to their risk classification. Multivariate COX regression, invasive probability weighting and propensity score matching were used to adjust for confounding variables. The primary outcome was all-cause death during follow-up. RESULTS A total of 1,201 patients with a median age of 82.0 (IQR, 81.0-84.0) were divided into two groups: 656 (54.6%) patients in the invasive group and 545 (45.4%) patients in the conservative group. Follow-up survival information was available for up to 6 years (median 3.0 years). During the follow-up, 296 (24.6%) patients died. After adjusting for confounding variables, the invasive treatment strategy was significantly associated with a lower risk of long-term mortality (HR =0.70, 95% CI: 0.54-0.92, P=0.010). No difference was found between timely invasive and delayed invasive interventions with mortality (HR =0.92, 95% CI: 0.57-1.47, P=0.725). CONCLUSIONS Invasive treatment was associated with lower mortality in patients ≥80 years of age with NSTE-ACS over a median of a 3-year follow-up. The invasive intervention time did not impact the outcome.
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Affiliation(s)
- Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yun-Li Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ye Miao
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong-Wei Li
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Percutaneous coronary intervention in octogenarians: 10-year experience from a primary percutaneous coronary intervention centre with off-site cardiothoracic support. J Geriatr Cardiol 2022; 19:189-197. [PMID: 35464649 PMCID: PMC9002084 DOI: 10.11909/j.issn.1671-5411.2022.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To examine the trends in patient characteristics and clinical outcomes over a ten-year period and to analyse the predictors of mortality in octogenarians undergoing percutaneous coronary intervention (PCI) in our centre. METHODS A total of 782 consecutive octogenarians (aged 80 and above) were identified from a prospectively collected PCI database within our non-surgical, medium volume centre between 1st January 2007 and 31st December 2016. This represented 10.9% of all PCI procedures performed in our centre during this period. We evaluated the demographic and procedural characteristics of the cohort with respect to clinical outcomes (all-cause in-hospital and 1-year mortality, in-hospital complication rates, duration of hospital admission, coronary disease angiographic complexity and major co-morbidities). The cohort was further stratified into three chronological tertiles (January 2007 to July 2012, 261 cases; August 2012 to May 2015, 261 cases; June 2015 to December 2016, 260 cases) to assess for differences over time. Predictors of mortality were identified through a multivariate regression analysis. RESULTS The number of octogenarians undergoing PCI increased nearly ten-fold over the studied period. Despite this, there were no significant differences in clinical outcomes or patient characteristics, except for the increased use of trans-radial vascular access [11.9% in first tertile vs. 73.2% in third tertile (P < 0.0001)]. The all-cause in-hospital (5.8% vs. 4.6% vs. 3.8%, P = 0.578) and 1-year mortality (12.4% vs. 12.5% vs. 14.4%, P = 0.746) remained constant in all three tertiles respectively. Six independent predictors of mortality were identified - increasing age [HR = 1.12 (1.03−1.22), P = 0.008], cardiogenic shock [HR = 16.40 (4.04–66.65), P < 0.0001], severe left ventricular impairment [HR = 3.52 (1.69−7.33), P = 0.001], peripheral vascular disease [HR = 2.73 (1.22−6.13), P = 0.015], diabetes [HR = 2.59 (1.30−5.17), P = 0.007] and low creatinine clearance [HR = 0.98 (0.96−1.00), P = 0.031].
CONCLUSION This contemporary observational study provides a useful insight into the real-world practice of PCI in octogenarians.
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Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, Eurenius L, Fredrikson M, Gudnadottir G, Held C, Ängerud KH, Jahjah R, Jernberg T, Mattsson E, Melander K, Mellbin L, Ohlsson M, Ravn-Fischer A, Svennberg L, Yndigegn T, Alfredsson J. Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:89-98. [PMID: 34905049 PMCID: PMC8826894 DOI: 10.1093/ehjacc/zuab114] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/09/2021] [Accepted: 11/19/2021] [Indexed: 12/22/2022]
Abstract
Aims Data on the prognostic value of frailty to guide clinical decision-making for patients with myocardial infarction (MI) are scarce. To analyse the association between frailty classification, treatment patterns, in-hospital outcomes, and 6-month mortality in a large population of patients with MI. Methods and results An observational, multicentre study with a retrospective analysis of prospectively collected data using the SWEDEHEART registry. In total, 3381 MI patients with a level of frailty assessed using the Clinical Frailty Scale (CFS-9) were included. Of these patients, 2509 (74.2%) were classified as non-vulnerable non-frail (CFS 1–3), 446 (13.2%) were vulnerable non-frail (CFS 4), and 426 (12.6%) were frail (CFS 5–9). Frailty and non-frail vulnerability were associated with worse in-hospital outcomes compared with non-frailty, i.e. higher rates of mortality (13.4% vs. 4.0% vs. 1.8%), cardiogenic shock (4.7% vs. 2.5% vs. 1.9%), and major bleeding (4.5% vs. 2.7% vs. 1.1%) (all P < 0.001), and less frequent use of evidence-based therapies. In Cox regression analyses, frailty was strongly and independently associated with 6-month mortality compared with non-frailty, after adjustment for age, sex, the GRACE risk score components, and other potential risk factors [hazard ratio (HR) 3.32, 95% confidence interval (CI) 2.30–4.79]. A similar pattern was seen for vulnerable non-frail patients (fully adjusted HR 2.07, 95% CI 1.41–3.02). Conclusion Frailty assessed with the CFS was independently and strongly associated with all-cause 6-month mortality, also after comprehensive adjustment for baseline differences in other risk factors. Similarly, non-frail vulnerability was independently associated with higher mortality compared with those with preserved functional ability.
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Affiliation(s)
- Niklas Ekerstad
- Department of Health, Medicine and Caring Sciences, Unit of Health Care Analysis and National Centre for Priorities in Health, Linköping University, Sandbäcksgatan 7, 58183 Linköping, Sweden.,The Research and Development Unit, NU Hospital Group, Trollhättan, Sweden
| | | | | | - Olle Bergström
- Department of Medicine, Växjö County Hospital, Växjö, Sweden
| | - Lars Eurenius
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Fredrikson
- Department of Biomedical and Clinical Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Gudny Gudnadottir
- Section of Geriatrics, Department of Acute Medicine and Geriatrics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Radwan Jahjah
- Department of Cardiology, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Ewa Mattsson
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | - Linda Mellbin
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Monica Ohlsson
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Svennberg
- Department of Cardiology, County Hospital of Gävle, Region Gävleborg, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden.,Department of Health, Medicine and Caring Sciences, Unit of Cardiovascular Sciences, Linköping University, Linköping, Sweden
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Ferrero TG, Álvarez BÁ, Cordero A, Martínez JM, Antonio CC, Muiños PA, Casas CAJ, García ÓO, Arias FGR, Dominguez MP, Fortuny AT, Álvarez DI, Bermejo RA, Veloso PR, Alvarez BC, Acuña JMG, Zuazola P, Escribano D, Lage R, Sampedro FG, Juanatey JRG. Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry. Int J Cardiol 2021; 351:8-14. [PMID: 34942303 DOI: 10.1016/j.ijcard.2021.12.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/08/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. METHODS This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS. RESULTS Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. CONCUSIONS In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. BRIEF SUMMARY In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.
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Affiliation(s)
- Teba González Ferrero
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV).
| | - Belén Álvarez Álvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Alberto Cordero
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - Jesús Martinón Martínez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carla Cacho Antonio
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pablo Antúnez Muiños
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Charigan Abou Jokh Casas
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Óscar Otero García
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Federico García-Rodeja Arias
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Marta Pérez Dominguez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Abel Torrelles Fortuny
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Diego Iglesias Álvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Rosa Agra Bermejo
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pedro Rigueiro Veloso
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Belén Cid Alvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - José María García Acuña
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pilar Zuazola
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - David Escribano
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - Ricardo Lage
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Francisco Gude Sampedro
- Epidemiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Ramón González Juanatey
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
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De Rosa R, Morici N, De Servi S, De Luca G, Galasso G, Piscione F, Ferri LA, Piatti L, Grosseto D, Tortorella G, Franco N, Lenatti L, Misuraca L, Leuzzi C, Verdoia M, Sganzerla P, Cacucci M, Ferrario M, Murena E, Sibilio G, Toso A, Savonitto S. Impact of renal dysfunction and acute kidney injury on outcome in elderly patients with acute coronary syndrome undergoing percutaneous coronary intervention. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:1160–1169. [PMID: 32374175 DOI: 10.1177/2048872620920475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/30/2020] [Indexed: 02/24/2024]
Abstract
BACKGROUND Chronic kidney disease is common in patients admitted with acute coronary syndrome and its prevalence dramatically increases with age. Understanding the determinants of adverse outcomes in this extremely high-risk population may be useful for the development of specific treatment strategies and planning of secondary prevention modalities. AIM The aim of this study was to assess the impact of baseline renal function and acute kidney injury on one-year outcome of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention. METHODS Patients aged 75 years and older with acute coronary syndrome undergoing successful percutaneous coronary intervention were selected among those enrolled in three Italian multicentre studies. Based on the baseline estimated glomerular filtration rate (eGFR) calculated using the Cockcroft-Gault formula ([(140-age) × body weight × 0.85 if female]/(72 × serum creatinine)* 1.73 m2 of body surface area), patients were classified as having none or mild (eGFR ≥60 ml/min/1.73 m2), moderate (eGFR 30-59 ml/min/1.73 m2) or severe (eGFR <30 ml/min/1.73 m2) renal dysfunction. Acute kidney injury was defined according to the Acute Kidney Injury Network classification. All-cause and cardiovascular mortality, non-fatal myocardial infarction, rehospitalisation for cardiovascular causes, stroke and type 2, 3 and 5 Bleeding Academic Research Consortium bleedings were analysed up to 12 months. RESULTS A total of 1904 patients were included. Of these, 57% had moderate and 11% severe renal dysfunction. At 12 months, patients with renal dysfunction had higher rates (P < 0.001) of all-cause (4.5%, 7.5% and 17.8% in patients with none or mild, moderate and severe renal dysfunction, respectively) and cardiovascular mortality (2.8%, 5.2% and 10.2%, respectively). After multivariable adjustment, severe renal dysfunction was associated with a higher risk of all-cause (hazard ratio (HR) 2.86, 95% confidence interval (CI) 1.52-5.37, P = 0.001) and cardiovascular death (HR 3.11, 95% CI 1.41-6.83, P = 0.005), whereas non-fatal events were unaffected. Acute kidney injury incidence was significantly higher in ST-elevation myocardial infarction versus non-ST-elevation acute coronary syndrome patients (11.7% vs. 7.8%, P = 0.036) and in those with reduced baseline renal function (P < 0.001), and it was associated with increased mortality independently from baseline renal function and clinical presentation. CONCLUSIONS Baseline renal dysfunction is highly prevalent and is associated with higher mortality in elderly acute coronary syndrome patients undergoing percutaneous coronary intervention. Acute kidney injury occurs more frequently among ST-elevation myocardial infarction patients and those with pre-existing renal dysfunction and is independently associated with one-year mortality.
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Affiliation(s)
- Roberta De Rosa
- Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Italy
| | - Nuccia Morici
- Intensive Cardiac Care Unit and De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Italy
| | | | - Giuseppe De Luca
- Azienda Ospedaliera Universitaria Maggiore della Carità, Eastern Piedmont University, Italy
| | - Gennaro Galasso
- Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Italy
| | - Federico Piscione
- Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Italy
| | - Luca A Ferri
- Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Italy
| | | | | | | | | | | | | | - Chiara Leuzzi
- Division of Cardiology, IRCCS Arcispedale S. Maria Nuova, Italy
| | - Monica Verdoia
- Azienda Ospedaliera Universitaria Maggiore della Carità, Eastern Piedmont University, Italy
| | - Paolo Sganzerla
- Division of Cardiology, ASST Bergamo ovest-ospedale di Treviglio, Italy
| | | | - Maurizio Ferrario
- Division of Cardiology, IRCCS Fondazione Policlinico S Matteo, Italy
| | - Ernesto Murena
- Division of Cardiology, Ospedale S Maria delle Grazie, Italy
| | | | - Anna Toso
- Division of Cardiology, Ospedale S Stefano, Italy
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Wang H, Shi L, Tian W, Zhao S. Invasive versus conservative strategy in the very elderly with non-ST-elevation acute coronary syndrome: A meta-analysis of randomized controlled trials. Geriatr Gerontol Int 2021; 22:36-41. [PMID: 34796611 DOI: 10.1111/ggi.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022]
Abstract
AIM To investigate the optimal treatment strategy in patients older than 80 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS All published randomized, placebo-controlled trials (RCTs) reporting on comparisons between invasive and conservative strategies for patients aged 80 years or older with NSTE-ACS were identified. The literature search was performed using PubMed, EMBASE, Cochrane Library, and the ISI Web of Science, from their establishment to July 2021 with no language restriction. The pooled risk ratios (RRs) with 95% confidence intervals (CI) for dichotomous outcomes were calculated. RESULTS Three RCTs involving a total of 893 cases met the inclusion criteria. Compared with the conservative group, the invasive strategy could significantly improve the incidence rate of composite endpoint (I2 = 21.9%; RR 0.727, 95% CI 0.619 to 0.855, P < 0.001), recurrent myocardial infarction (MI) (I2 = 0.0%; RR 0.585, 95% CI 0.441 to 0.776, P < 0.001) and revascularization (I2 = 0.0%; RR 0.239, 95% CI 0.126 to 0.455, P < 0.001). However, no benefits were observed on outcomes of all-cause death (I2 = 0.0%; RR 0.888, 95% CI 0.681 to 1.160, P = 0.384), cardiac death (I2 = 0.0%; RR 0.769, 95% CI 0.412 to 1.433, P = 0.408) and stroke (I2 = 0.0%; RR 0.778, 95% CI 0.392 to 1.543, P = 0.473). The major bleeding events were comparable between the two groups (I2 = 0.0%; RR 1.582, 95% CI 0.622 to 4.025, P = 0.336). CONCLUSIONS Compared with a conservative strategy, the invasive treatment could reduce the incidence of composite endpoint, recurrent MI, and revascularization in the very elderly with NSTE-ACS. However, no benefits were observed on mortality. Geriatr Gerontol Int 2021; ••: ••-••.
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Affiliation(s)
- Haiyan Wang
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Liye Shi
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Wen Tian
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Shijie Zhao
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
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Shoaib A, Rashid M, Berry C, Curzen N, Kontopantelis E, Timmis A, Ahmad A, Kinnaird T, Mamas MA. Clinical Characteristics, Management Strategies, and Outcomes of Non-ST-Segment-Elevation Myocardial Infarction Patients With and Without Prior Coronary Artery Bypass Grafting. J Am Heart Assoc 2021; 10:e018823. [PMID: 34612049 PMCID: PMC8751868 DOI: 10.1161/jaha.120.018823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background There are limited data on the management strategies, temporal trends and clinical outcomes of patients who present with non–ST‐segment–elevation myocardial infarction and have a prior history of CABG. Methods and Results We identified 287 658 patients with non–ST‐segment–elevation myocardial infarction between 2010 and 2017 in the United Kingdom Myocardial Infarction National Audit Project database. Clinical and outcome data were analyzed by dividing into 2 groups by prior history of coronary artery bypass grafting (CABG): group 1, no prior CABG (n=262 362); and group 2, prior CABG (n=25 296). Patients in group 2 were older, had higher GRACE (Global Registry of Acute Coronary Events) risk scores and burden of comorbid illnesses. More patients underwent coronary angiography (69% versus 63%) and revascularization (53% versus 40%) in group 1 compared with group 2. Adjusted odds of receiving inpatient coronary angiogram (odds ratio [OR], 0.91; 95% CI, 0.88–0.95; P<0.001) and revascularization (OR, 0.73; 95% CI, 0.70–0.76; P<0.001) were lower in group 2 compared with group 1. Following multivariable logistic regression analyses, the OR of in‐hospital major adverse cardiovascular events (composite of inpatient death and reinfarction; OR, 0.97; 95% CI, 0.90–1.04; P=0.44), all‐cause mortality (OR, 0.96; 95% CI, 0.88–1.04; P=0.31), reinfarction (OR, 1.02; 95% CI, 0.89–1.17; P=0.78), and major bleeding (OR, 1.01; 95% CI, 0.90–1.11; P=0.98) were similar across groups. Lower adjusted risk of inpatient mortality (OR, 0.67; 95% CI, 0.46–0.98; P=0.04) but similar risk of bleeding (OR,1.07; CI, 0.79–1.44; P=0.68) and reinfarction (OR, 1.13; 95% CI, 0.81–1.57; P=0.47) were observed in group 2 patients who underwent percutaneous coronary intervention compared with those managed medically. Conclusions In this national cohort, patients with non–ST‐segment–elevation myocardial infarction with prior CABG had a higher risk profile, but similar risk‐adjusted in‐hospital adverse outcomes compared with patients without prior CABG. Patients with prior CABG who received percutaneous coronary intervention had lower in‐hospital mortality compared with those who received medical management.
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Affiliation(s)
- Ahmad Shoaib
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | - Colin Berry
- Institute of Cardiovascular & Medical Sciences University of Glasgow UK
| | - Nick Curzen
- Cardiothoracic Department University Hospital Southampton & Faculty of MedicineUniversity of Southampton UK
| | | | - Adam Timmis
- Barts & the London School of Medicine and Dentistry Queen Mary University London London UK
| | - Ayesha Ahmad
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Centre for Prognosis Research Institute for Primary Care and Health Sciences Keele University Stoke-on-Trent UK
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De Rosa R, Morici N, De Luca G, De Luca L, Ferri LA, Piatti L, Tortorella G, Grosseto D, Franco N, Misuraca L, Sganzerla P, Cacucci M, Antonicelli R, Cavallini C, Lenatti L, Leuzzi C, Murena E, Ravera A, Ferrario M, Corrada E, Colombo D, Prati F, Piscione F, Petronio AS, Galasso G, De Servi S, Savonitto S. Association of Sex with Outcome in Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. Am J Med 2021; 134:1135-1141.e1. [PMID: 33971166 DOI: 10.1016/j.amjmed.2021.03.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/07/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Worse outcomes have been reported for women, compared with men, after an acute coronary syndrome (ACS). Whether this difference persists in elderly patients undergoing similar invasive treatment has not been studied. We investigated sex-related differences in 1-year outcome of elderly acute coronary syndrome patients treated by percutaneous coronary intervention (PCI). METHODS Patients 75 years and older successfully treated with PCI were selected among those enrolled in 3 Italian multicenter studies. Cox regression analysis was used to assess the independent predictive value of sex on outcome at 12-month follow-up. RESULTS A total of 2035 patients (44% women) were included. Women were older and most likely to present with ST-elevation myocardial infarction (STEMI), diabetes, hypertension, and renal dysfunction; men were more frequently overweight, with multivessel coronary disease, prior myocardial infarction, and revascularizations. Overall, no sex disparity was found about all-cause (8.3% vs 7%, P = .305) and cardiovascular mortality (5.7% vs 4.1%, P = .113). Higher cardiovascular mortality was observed in women after STEMI (8.8%) vs 5%, P = .041), but not after non ST-elevation-ACS (3.5% vs 3.7%, P = .999). A sensitivity analysis excluding patients with prior coronary events (N = 1324, 48% women) showed a significantly higher cardiovascular death in women (5.4% vs 2.9%, P = .025). After adjustment for baseline clinical variables, female sex did not predict adverse outcome. CONCLUSIONS Elderly men and women with ACS show different clinical presentation and baseline risk profile. After successful PCI, unadjusted 1-year cardiovascular mortality was significantly higher in women with STEMI and in those with a first coronary event. However, female sex did not predict cardiovascular mortality after adjustment for the different baseline variables.
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Affiliation(s)
- Roberta De Rosa
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy; Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Nuccia Morici
- ASST Grande Ospedale Metropolitano Niguarda, Milan; Department of Clinical Sciences and Community Health, Università degli Studi di Milo, Milan, Italy
| | - Giuseppe De Luca
- Azienda Ospedaliera Universitaria Maggiore della Carità, Eastern Piedmont University, Novara, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Amelia Ravera
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | | | - Elena Corrada
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | | | | | - Federico Piscione
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | | | - Gennaro Galasso
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
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48
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Morici N, De Servi S, De Luca L, Crimi G, Montalto C, De Rosa R, De Luca G, Rubboli A, Valgimigli M, Savonitto S. Management of acute coronary syndromes in older adults. Eur Heart J 2021; 43:1542-1553. [PMID: 34347065 DOI: 10.1093/eurheartj/ehab391] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/03/2021] [Accepted: 06/03/2021] [Indexed: 12/22/2022] Open
Abstract
Older patients are underrepresented in prospective studies and randomized clinical trials of acute coronary syndromes (ACS). Over the last decade, a few specific trials have been conducted in this population, allowing more evidence-based management. Older adults are a heterogeneous, complex, and high-risk group whose management requires a multidimensional clinical approach beyond coronary anatomic variables. This review focuses on available data informing evidence-based interventional and pharmacological approaches for older adults with ACS, including guideline-directed management. Overall, an invasive approach appears to demonstrate a better benefit-risk ratio compared to a conservative one across the ACS spectrum, even considering patients' clinical complexity and multiple comorbidities. Conversely, more powerful strategies of antithrombotic therapy for secondary prevention have been associated with increased bleeding events and no benefit in terms of mortality reduction. An interdisciplinary evaluation with geriatric assessment should always be considered to achieve a holistic approach and optimize any treatment on the basis of the underlying biological vulnerability.
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Affiliation(s)
- Nuccia Morici
- Unità di Cure Intensive Cardiologiche, and De Gasperis Cardio-Center, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy
| | | | - Leonardo De Luca
- Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
| | - Gabriele Crimi
- Cardio Thoraco Vascular Department (DICATOV), Interventional Cardiology Unit, IRCCS Policlinico San Martino, Genova, Italy
| | | | - Roberta De Rosa
- Department of Cardiology, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Giuseppe De Luca
- Division of Cardiology, AOU Maggiore della Carità, Università del Piemonte Orientale, Novara, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Disease-AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy
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Chest pain and acute coronary syndrome in octogenarians admitted to the Emergency Department. Aging Clin Exp Res 2021; 33:2213-2221. [PMID: 33099674 DOI: 10.1007/s40520-020-01737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although chest pain and acute coronary syndrome (ACS) are among the most common complaints in the Emergency Departments (ED), little is known about this topic in the octogenarian population. OBJECTIVES This study aimed to describe the clinical presentation and to evaluate survival time according to the ACS type in a group of 80-year-old or over patients admitted for chest pain to an ED. METHODS Patients were classified according to the discharge diagnosis. A multivariable Cox regression analysis was done to assess the association between ACS type and mortality with the non-ACS chest pain group as the reference category. RESULTS ACS was diagnosed in 170 of the 391 patients analyzed and 51% of ACS patients were female. Within the ACS patients, 18.8% presented STEMI, 57% NSTEMI, and 24% unstable angina (UA). Most of the patients were treated conservatively. In the adjusted analysis, the incidence of death at 40 months of follow-up was higher in patients with STEMI (HR 3.24; CI 1.59-6.56) than NSTEMI (HR 2.53; CI 1.56-4.11). There was no difference between patients with UA and the non-ACS group (HR 0.64; CI 0.26-1.58), and myocardial revascularization was associated with reduced mortality risk (HR 0.45; CI 0.22-0.92). CONCLUSIONS A high prevalence of ACS was found among octogenarians admitted to the ED with chest pain, and the ACS type behaved as an independent predictor of mortality. Patients with UA diagnosis had a similar prognosis to patients with non-ACS chest pain, but this needs to be demonstrated by a prospective study.
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50
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Cepas-Guillén PL, Echarte-Morales J, Caldentey G, Gómez EM, Flores-Umanzor E, Borrego-Rodriguez J, Llagostera M, Viana Tejedor A, Vidal P, Benito-Gonzalez T, Quiroga X, Ortiz AF, Freixa X, Pérez de Prado A, Sanz FN, Fernández-Vázquez F, Sabate M. Outcomes of Nonagenarians With Acute Coronary Syndrome. J Am Med Dir Assoc 2021; 23:81-86.e4. [PMID: 34197794 DOI: 10.1016/j.jamda.2021.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/23/2021] [Accepted: 04/22/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Nonagenarians are a fast-growing age group among cardiovascular patients, but data about their management and prognosis after an acute coronary syndrome (ACS) is scarce. This study aimed to analyze characteristics of nonagenarian patients with ACS and to compare in-hospital and 1-year clinical outcomes between those treated with medical treatment (MT) alone and those receiving percutaneous coronary intervention (PCI). DESIGN Multicenter observational study. SETTING AND PARTICIPANTS We included consecutive nonagenarian patients with ACS admitted at 4 academic centers between 2005 and 2018. Only patients with type 1 myocardial infarction were included. METHODS Standardized definitions of all patient-related variables, clinical diagnoses, and hospital complications and outcomes were used. The primary endpoint was 1-year all-cause mortality. Long-term survival was compared between patients undergoing PCI and those managed with MT alone. Given differences in baseline characteristics could substantially interfere in outcomes, 3 sensitivity analyses were performed to adjust for confounders. RESULTS A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non-ST-segment elevation ACS (NSTE-ACS) and 307 (45%) with ST-segment elevation myocardial infarction (STEMI). A coronary angiogram was performed in 115 (31%) of NSTE-ACS and in 182 (60%) of STEMI patients with subsequent PCI in 81 (22%) and 156 (51%), respectively. Overall mortality rates were 17% in-hospital and 39% at 1-year follow-up. PCI was independently associated with a decreased risk of 1-year all-cause death [hazard ratio (HR) 0.57, 95% confidence interval (CI) 0.35, 0.95; P < .05], mainly observed in those patients without disability (HR 0.59, 95% CI 0.37, 0.94; P < .01) and lower Killip class (HR 0.50, 95% CI 0.28, 0.89; P < .001). CONCLUSIONS AND IMPLICATIONS The prognosis of nonagenarians after an ACS was associated with comorbidities and the therapeutic approach. Although PCI appeared to be a safe and effective strategy, it is still necessary to refine the decision-making process in this high-risk population group.
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Affiliation(s)
- Pedro Luis Cepas-Guillén
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | | | - Eduardo Flores-Umanzor
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | - Ana Viana Tejedor
- Cardiology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Pablo Vidal
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Xavier Quiroga
- Cardiology Department, Hospital del Mar, Barcelona, Spain
| | | | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | | | | | - Manel Sabate
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain.
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