Mid-term mortality of very elderly patients with acute myocardial infarction with or without coronary intervention

Beta-Blockers for the Secondary Prevention of Myocardial Infarction in People with Dementia: A Systematic Review

Background:

Cardiovascular disease remains the most common cause of death in industrialized countries. The use of beta-blockers is well established as a secondary prevention of myocardial infarction. However, little is known about the benefits of beta-blockers for people living with dementia.

Objective:

To evaluate the use of beta-blockers in people with dementia who have had a myocardial infarction, in order to identify associations between medication use, mortality, re-infarction and functional decline.

Methods:

We searched for all studies (randomized trials, observational cohorts) reporting beta-blocker use in populations with both dementia and previous myocardial infarction. Relevant keywords were used in Medline, Embase, and Web of Science up to October 2018. Titles and abstracts were independently screened by two reviewers. Quality of eligible studies was assessed using the Newcastle-Ottawa Scale. PRISMA recommendations were followed throughout.

Results:

Two observational studies were included, representing 10,992 individuals in a community setting and 129,092 individuals from a hospital record-linkage study. One showed use of beta-blockers reduced all-cause mortality (HR 0.74 (95% CI 0.64– 0.86) alongside evidence for an increased rate of functional decline in individuals aged≥65 with moderate to severe cognitive impairment (OR 1.34 (95% CI 1.11– 1.61)). The second study did not find an association between beta-blocker use and mortality in the population living with dementia.

Conclusion:

There is insufficient evidence to support use of beta-blockers to persons living with dementia. A single study provides limited evidence that beta-blockers improve survival rates but with associated detrimental effects on functional status in nursing home residents with cognitive impairment. Decisions to continue beta-blockers in persons living with dementia should be made on an individual basis.

Comparison of One-Year Survival After Acute Coronary Syndrome in Patients ≥75 Years of Age With Versus Without Living With Spouse

Patients with acute coronary syndrome (ACS) face high postevent mortality. This study aims to evaluate the impact of living without spouse on 1-year mortality of ACS patients. This retrospective study enrolled a total of 600 consecutive patients (≥75 years of age) with ACS hospitalized in our hospital between January 2013 and December 2016. Patients' clinical characteristics, laboratory values, hospital course, demographic characteristics, and angiographic data were collected. Patients were divided into 2 groups according to living with (n = 396) or without (n = 204) spouse. Patients living without spouse were older (79 [77,82] vs 77 [76,80], p <0.001), more frequently female (54.9% vs 31.8%, p <0.001), less smokers (23.5% vs 38.9%, p <0.001), lower left ventricular ejection fraction value (52.1±10.7% vs 54.4±9.8%, p = 0.021) compared with patients living with spouse. In addition, compared to patients living with spouse, patients living without spouse were less likely to get percutaneous coronary intervention (41.2% vs 54.0%, p = 0.003) during hospitalization and had higher 1-year mortality post-ACS (22.1% vs 13.4%, p = 0.006). Multivariate logistic regression analysis showed that living without spouse remained an independent risk factor for 1-year mortality after ACS in patients ≥75 years (odds ratio 2.350, 95% confidence interval 1.245 to 4.434, p = 0.008), after adjusted with age, gender, heart rate, systolic blood pressure, left ventricular ejection fraction value at baseline, hemoglobin, white blood cell, alanine aminotransferase, albumin, creatinine, brain natriuretic peptide, type of ACS, severe heart failure at admission, percutaneous coronary intervention treatment, β blocker, diuretics application during hospital. In conclusion, living without spouse is an independent risk factor for 1-year all-cause mortality in ACS patients ≥75 years.

[Update on geriatric cardiology]

This article contains a review of the main developments in the field of geriatric cardiology reported during 2010. The focus is on research into the specific characteristics of elderly patients with heart failure, ischemic heart disease, valvular heart disease and arrhythmias.

[ST-elevation myocardial infarction in octogerians]

Coronary artery disease is the leading cause of death in developed countries and its incidence and severity is greater among older patients. So, because of the ageing of the population, clinicians will be increasingly confronted in daily practice with managing acute coronary syndrome in extreme old age and high-risk patients. Despite this demographic reality, several large randomized controlled trials evaluating the benefit-risk ratio of invasive versus conservative approach have systematically excluded elderly patients. The extrapolation of evidence-based medicine, initially focused on younger patients, is often contentious in this population and because of the lack of clear and specific recommendations in the elderly, the optimal management of STEMI in octogenarians remains a topic of debate. Elderly patients present unique issues related to the ageing process and multiple comorbid diseases making difficult the extrapolation of evidence obtained on younger demographics. Data from registries seem to support, nevertheless, the benefit of primary revascularization by PCI of the culprit lesion in "selected" octogenarians with a high technical success rate, few complications, acceptable short and long-term mortality rate and quality of life. Obviously, the "ideal octogenarian" doesn't exist and all the old patients are not suitable for an invasive approach. Managing elderly patients requires not only cardiological skills but also geriatric acknowledges and the individualized geriatric assessment is the corner store of the decision process. The aim is to screen for the presence of comorbidities (cognitive disorders, functional decline, anemia, renal insufficiency…), social isolation and existence of an underlying frailty. To conclude, the optimal strategy for the management of STEMI in octogenarians is not univocal: the best approach is the one that offers the greater benefits regard considerations of general health.