Comparison of clinical outcomes between octogenarians and non-octogenarians with acute myocardial infarction in the drug-eluting stent era: analysis of the Korean Acute Myocardial Infarction Registry

Elderly Suffering from ST-Segment Elevation Myocardial Infarction-Results from a Database Analysis from Two Mediterranean Medical Centers

Background: Little is known regarding primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) in the elderly. Methods: Data on 319 octogenarians, 641 septuagenarians, and 2451 younger patients was collected from an ongoing prospective registry of patients treated with pPCI for STEMI at two Mediterranean-area medical centers in 2009–2017. Results: More octogenarian patients were female (40.8 vs. 31.9 septuagenarians and 26.5% under 70 y, p < 0.01), had hypertension (79.5 vs. 69.5 and 45.9%, p < 0.01), renal failure (32.5 vs. 20.1 and 5.2%, p < 0.01), and a lower left-ventricular ejection fraction (42.0 vs. 44.9 and 47.6%, p = 0.012). At 1 month and 3 years after intervention, mortality was higher in the octogenarian patients (12.2 vs. 7.9%, p = 0.01; and 36.7 vs. 23.1%, p < 0.01, respectively), with no significant differences in the rates of recurrent myocardial infarction, target vessel revascularization, coronary artery bypass surgery, and cardiovascular death. Following adjustment for confounders, 3-year mortality was significantly higher in the octogenarians (HR 3.89 vs. 3.19 for septuagenarians, p < 0.01), but rates of major adverse cardiac events or cardiovascular death were not. Conclusions: Despite suffering from higher all-cause mortality, octogenarian patients treated with pPCI for STEMI do not suffer an increased risk of ischemic cardiac events relative to younger patients.

Clinical characteristics and in-hospital outcomes in patients aged 80 years or over with cardiac troponin-positive acute myocardial infarction -J-MINUET study

BACKGROUND

The prevalence of acute myocardial infarction (AMI) in elderly people is increasing worldwide. However, their characteristics and prognosis have been rarely investigated. This study aimed to investigate the characteristics and prognosis in elderly patients with cardiac troponin-positive AMI.

METHODS

Consecutive patients with AMI from the J-MINUET study were divided into the following 3 groups: patients aged less than 65 years, those aged between 65 and 79 years, and those aged 80 years or over. Their characteristics and in-hospital outcomes were compared.

RESULTS

Patients with AMI aged 80 years or over had the highest incidence of female gender, and the highest incidence of hypertension, chronic kidney disease, and cardiovascular disease, such as peripheral artery disease, atrial fibrillation, and stroke, whereas they had the lowest body mass index, and the lowest incidence of current smoker, diabetes mellitus, and dyslipidemia. Patients with AMI aged 80 years or over had significantly longer onset to door time and longer door to device time, and lower peak creatine kinase (CK). The incidence of ST-segment elevation myocardial infarction (STEMI) was the lowest in the AMI patients aged 80 years or over, but the patients had a higher incidence of in-hospital death and cardiac failure than the other two groups. In addition, the presentation with STEMI and non-ST-segment elevation myocardial infarction with CK elevation among patients aged 80 years or over showed the highest incidence of in-hospital death and cardiac failure.

CONCLUSIONS

J-MINUET showed different clinical characteristics between the aged and younger populations. The incidence of in-hospital death and cardiac failure in patients aged 80 years or over with AMI was poorer than their younger counterparts.

Association between discharge destination and mid-term mortality in octogenarian patients with ST-elevation myocardial infarction

BACKGROUND

Owing to an increasing aging population, the number of elderly patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is escalating. The onset of STEMI in elderly patients may lead to increased frailty, resulting in failure of discharge to home despite survival. However, the association of discharge destination with prognosis has not been fully evaluated in this population.

METHODS

Between January 2014 and December 2016, a total of 245 octogenarian STEMI survivors who underwent PCI (mean age, 84.4 years; male, 46.5%) were evaluated from a multicenter registry. The 2-year mortalities of the home discharge and non-home discharge groups were compared and analyzed using a Cox regression model.

RESULTS

Non-home discharge, which was defined as transfer to another hospital or nursing home after STEMI, was seen in 36 patients. During the 2 years, 37 patients died (home discharge, 27 patients; non-home discharge, 10 patients). The most frequent cause of death was due to infection (21.6%), followed by sudden death (18.9%) and heart failure (16.2%). The cumulative all-cause mortality was significantly higher in the non-home discharge group than in the home discharge group [36.4% vs. 14.8%; hazard ratio (HR), 2.95; 95% confidence interval (CI), 1.43-6.10; p = 0.003]. After multivariate analysis, non-home discharge (adjusted HR, 2.62; 95% CI, 1.20-5.75; p = 0.016) together with left ventricular ejection fraction <40% (adjusted HR, 3.15; 95% CI, 1.57-6.31; p = 0.001), prior heart failure (adjusted HR, 4.88; 95% CI, 1.82-13.13; p = 0.002), target lesion in the left anterior descending artery (adjusted HR, 2.20; 95% CI, 1.12-4.32; p = 0.022), and serum albumin level <3.5 g/dL (adjusted HR, 2.13; 95% CI, 1.06-4.27; p = 0.034) remained significant predictors of all-cause mortality.

CONCLUSION

Non-home discharge was associated with an increased risk of mid-term mortality in octogenarian STEMI survivors.

Influence of Preadmission Frailty on Short- and Mid-Term Prognoses in Octogenarians With ST-Elevation Myocardial Infarction

BACKGROUND

Octogenarians, who are frequently frail, represent a large proportion of patients admitted for ST-segment elevation myocardial infarction (STEMI). We investigated the relationship between frailty, assessed by the Canadian Study of Health and Aging Clinical Frailty Scale (CFS), and short- and mid-term prognoses in octogenarian STEMI patients.

METHODS AND RESULTS

We used a multicenter registry data of 1,301 patients with STEMI undergoing percutaneous coronary intervention (PCI) between January 2014 and December 2016. Of them, 273 were retrospectively analyzed after categorization into 3 groups based on the preadmission CFS (CFS 1-3, 140 patients; CFS 4-5, 99 patients; and CFS 6-8, 34 patients). We evaluated the influence of CFS on overall mortality at 2 years and on non-home discharge, defined as the composite of in-hospital death and new transfer to a hospital or nursing home. During the study period (median, 565 days), the overall mortality and ratio of non-home discharge increased as CFS increased. After adjustment for multivariable analysis, the severely frail continued to be significantly associated with an increased risk of overall mortality (adjusted hazard ratio 2.37; 95% confidence interval [CI] 1.11-5.05; P=0.026) and non-home discharge (adjusted odds ratio 9.50; 95% CI 3.48-25.99; P<0.001).

CONCLUSIONS

Frailty, as assessed by CFS, had an influence on short- and mid-term prognoses in octogenarian patients with STEMI.

Comparison of Outcomes After Percutaneous Coronary Interventions in Patients of Eighty Years and Above Compared With Those Less Than 80 Years

Life expectancy in the United States has increased due to advances in health care. Despite increased utilization of percutaneous coronary intervention (PCI), octogenarian patients are less likely to be referred to the catheterization laboratory for coronary interventions. This is in part due to multiple patient co-morbidities and lack of established guidelines. We examined in-hospital clinical outcomes of octogenarian and nonoctogenarian patients who underwent PCI in the United States. Using the National Inpatient Sampling database, we identified all adult patients who are older than 18 years and underwent PCI. Patient were stratified by age into 2 groups, ≥80 years old and <80 years old and in-hospital adverse outcome rates were determined. A total of 11,056,559 patients underwent PCI between the years of 2002 and 2014 and 1,544,563 patients were ≥80 years old (14%). After multivariable adjustment, patients who are ≥80 years old had higher in-hospital mortality (3.3% vs 1.3%, adjusted Odds Ratio, 1.624; 95% confidence interval, 1.602 to 1.647, p <0.0001) and longer length of stay (median length of stay days 3, range 2 to 8 days vs median 2 days, range 1 to 4 days) (p <0.0001). Patients ≥80 years old had a higher rate of cardiopulmonary complications, postprocedural stroke, acute kidney injury, postprocedural thromboembolic complications, and hemorrhage requiring transfusion. There was no difference in vascular complications between the 2 groups. In conclusion, octogenarians who underwent PCI were at increased risk for in-hospital mortality and morbidity compared with nonoctogenarians. The decision to proceed with PCI in this patient population should be individualized, taking into consideration known risk factors and patient's wishes.

Clinical characteristics and outcomes of octogenarians presenting with ST elevation myocardial infarction in the Australian population

AIM

To investigate the characteristics and outcomes of octogenarians who presented with ST-elevation myocardial infarction (STEMI) compared to non-octogenarians and to investigate the outcomes of octogenarians that received primary percutaneous coronary intervention (PCI) compared to those managed conservatively.

METHODS

We performed a single center retrospective case controlled study. All octogenarians who presented with STEMI to a tertiary referring hospital between 2007 and 2012 were included. The subsequent non-octogenarian patient who presented with a STEMI following the octogenarian patient was assigned to the control group in a 1:1 manner. The outcomes measured were peri-procedural cardiac arrest, death on table, cerebrovascular accidents (CVA), in-hospital and 30-d mortality.

RESULTS

A total of 146 patients were analyzed. The octogenarian group had a higher percentage of females, higher overall comorbidities, higher Charlson Comorbidity Index score, worse renal function and were more likely to require residential care and home help. The octogenarian group were also less likely to have PCI attempted and had a longer symptom onset to PCI time. Mortality rate was high amongst octogenarians who presented with STEMI. However, those managed conservatively had a higher in-hospital and 30-d mortality rate

CONCLUSION

Octogenarians who presented with STEMI that were managed conservatively had a higher mortality rate compared to those who had primary PCI. Therefore, we propose that revascularization may be beneficial to patients in this age group.

COHgb levels predict the long-term development of acute myocardial infarction in CO poisoning

BACKGROUND

There are several studies evaluating the cardiac effects of carbon monoxide (CO) poisoning during the acute period; however, the number of studies evaluating the long-term cardiac effects is limited.

OBJECTIVE

The present study aimed to evaluate the effects of blood carboxyhemoglobin (COHb) levels, elevated due to CO poisoning on the long-term development of acute myocardial infarction (AMI).

METHODS

This cross-sectional cohort study included a total of 1013 consecutive patients who presented to the emergency department (ED) due to CO poisoning, between January 2005 and December 2007. The diagnosis of CO poisoning was made according to the medical history and a COHb level of greater than 5%. In terms of AMI development, the patients were followed up for an average of 56 months.

RESULTS

At the end of follow-up, 100 (10%) of 1013 patients experienced AMI. Carboxyhemoglobin levels at the time of poisoning were higher among those who were diagnosed with AMI compared to those who were not (55%±6% vs 30%±7%; P<.001). Using a multivariate Cox proportional hazards model with forward stepwise method, age, COHb level, CO exposure time, and smoking remained associated with an increased risk of AMI after adjustment for the variables found to be statistically significant in a univariate analysis. According to a receiver operating characteristic curve analysis, the optimal cutoff value of COHb used to predict the development of AMI was found to be greater than 45%, with 98% sensitivity and 94.1% specificity.

CONCLUSION

In patients presenting to the ED with CO poisoning, COHb levels can be helpful for risk stratification in the long-term development of AMI.

Favorable outcomes in octogenarians treated with bioresorbable polymer drug-eluting stent

AIM

As a result of a higher prevalence of comorbidities, elderly adults are often underrepresented in clinical trials, and more often experience complications during percutaneous coronary intervention. Our aim was to evaluate clinical outcomes of patients older than 80 years, compared with their younger counterparts, when bioresorbable polymer biolimus A9 drug-eluting stent is used for their treatment.

METHODS

The prospective, observational e-Nobori registry was created to validate the safety and efficacy of bioresorbable polymer drug-eluting stent in unselected patients. The primary end-point of the study was freedom from target lesion failure defined as a composite of cardiac death, target vessel-related myocardial infarction and clinically-driven target lesion revascularization at 1 year.

RESULTS

There were 781 (7.8%) octogenarians, they were less frequently male (62% vs 77%; P < 0.0001) and more often presented as acute coronary syndrome (44% vs 39%; P = 0.0182). The index percutaneous coronary intervention success was lower in the elderly patients (98% vs 99%; P = 0.0398). One-year follow up was completed for 97% of the elderly patients and 99% of the younger patients. The difference in target lesion failure (3.33% vs 2.83%; log-rank P = 0.0114) was mainly driven by increased mortality in octogenarians (3.73% vs 1.47%; P < 0.0001). Elderly patients had more bleeding and vascular complications (2.67% vs 1.05%; P = 0.0001).

CONCLUSIONS

Despite advanced age, multiple comorbidities and complexity of treated lesions, clinical outcomes are favorable in octogenarians treated by bioresorbable polymer biolimus A9 drug-eluting stent. Geriatr Gerontol Int 2016; 16: 1246-1253.

Impact of hypoalbuminemia, frailty, and body mass index on early prognosis in older patients (≥85 years) with ST-elevation myocardial infarction

BACKGROUND

The optimal treatment strategies for acute ST-elevation myocardial infarction (STEMI) in older patients are unclear because of the high risk of mortality in this population. Hypoalbuminemia, frailty, and body mass index (BMI) have been reported to worsen the prognosis of some older patients with cardiovascular disease, but the specific impact of these factors on the prognosis after STEMI is poorly understood. The aim of this study was to investigate the impact of these factors on early outcomes in patients aged ≥85 years with acute STEMI.

METHODS

Sixty-two consecutive eligible patients aged ≥85 years (mean age, 88.1±2.5 years; age range, 85-94 years; female, 41.9%; primary percutaneous coronary intervention, 67.7%) who were admitted to our hospital with STEMI were retrospectively reviewed. Baseline patient characteristics, echocardiographic, electrocardiographic, and laboratory findings, and the Canadian Study of Health and Aging Clinical Frailty Scale (CSHA-CFS) score were assessed. The primary endpoint was in-hospital mortality and the secondary endpoint was failure of discharge to home. Independent baseline variables with a p-value of <0.15 in the univariate analyses were included in the multivariate analyses.

RESULTS

Multivariate analysis identified a higher baseline serum troponin I level [p=0.046; odds ratio (OR): 1.02], lower baseline albumin level (p=0.035, OR: 0.16), and CSHA-CFS score ≥6 (p=0.028, OR: 6.38) as independent predictors of in-hospital mortality. Lower BMI (p<0.001, OR: 0.49) and CSHA-CFS frailty score ≥6 (p=0.002, OR: 16.69) were identified as independent predictors of failure of discharge to home.

CONCLUSIONS

These findings indicate that the serum albumin level, CSHA-CFS score, and BMI, in addition to serum troponin I level, have an impact on the early prognosis of older patients with STEMI.

The scientific achievements of the decades in Korean Acute Myocardial Infarction Registry

The Korea Acute Myocardial Infarction Registry (KAMIR) was the first nationwide registry data collection designed to track outcomes of patients with acute myocardial infarction (AMI). These studies reflect the current therapeutic approaches and management for AMI in Korea. The results of KAMIR could help clinicians to predict the prognosis of their patients and identify better diagnostic and treatment tools to improve the quality of care. The KAMIR score was proposed to be a predictor of the prognosis of AMI patients. Triple antiplatelet therapy, consisting of aspirin, clopidogrel and cilostazol, was effective at preventing major adverse clinical outcomes. Drug-eluting stents were effective and safe in AMI patients with no increased risk of stent thrombosis. Statin therapy was effective in Korean AMI patients, including those with very low levels of low density cholesterol. The present review summarizes the 10-year scientific achievements of KAMIR from admission to outpatient care during long-term clinical follow-up.

Percutaneous coronary intervention in the elderly with ST-segment elevation myocardial infarction

As a result of increased life expectancy, octogenarians constitute an increasing proportion of patients admitted to hospital for ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention is currently the treatment of choice for octogenarians presenting with STEMI. The recent literature on this topic has yielded controversial results, even though advances in drug-eluting stents and new types of antithrombotic agents are improving the management of STEMI and postoperative care. In this paper, we review the current status of percutaneous coronary intervention in the elderly with STEMI, including the reasons for their high mortality and morbidity, predictors of mortality, and strategies to improve outcomes.

Direct implantation versus platelet-rich fibrin-embedded adipose-derived mesenchymal stem cells in treating rat acute myocardial infarction

BACKGROUND

This study tested whether adipose-derived mesenchymal stem cells (ADMSC) embedded in platelet-rich fibrin (PRF) scaffold is superior to direct ADMSC implantation in improving left ventricular (LV) performance and reducing LV remodeling in a rat acute myocardial infarction (AMI) model of left anterior descending coronary artery (LAD) ligation.

METHODS

Twenty-eight male adult Sprague Dawley rats equally divided into group 1 [sham control], group 2 (AMI only), group 3 (AMI+direct ADMSC implantation), and group 4 (AMI+PRF-embedded autologous ADMSC) were sacrificed on day 42 after AMI.

RESULTS

LV systolic and diastolic dimensions and volumes, and infarct/fibrotic areas were highest in group 2, lowest in group 1 and significantly higher in group 3 than in group 4, whereas LV performance and LV fractional shortening exhibited a reversed pattern (p<0.005). Protein expressions of inflammation (oxidative stress, IL-1β, MMP-9), apoptosis (mitochondrial Bax, cleaved PARP), fibrosis (Smad3, TGF-β), and pressure-overload biomarkers (BNP, MHC-β) displayed a pattern similar to that of LV dimensions, whereas anti-inflammatory (IL-10), anti-apoptotic (Bcl-2), and anti-fibrotic (Smad1/5, BMP-2) indices showed a pattern similar to that of LV performance among the four groups (all p<0.05). Angiogenesis biomarkers at protein (CXCR4, SDF-1α, VEGF), cellular (CD31+, CXCR4+, SDF-1α+), and immunohistochemical (small vessels) levels, and cardiac stem cell markers (C-kit+, Sca-1+) in infarct myocardium were highest in group 4, lowest in group 1, and significantly higher in group 3 than in group 2 (all p<0.005).

CONCLUSION

PRF-embedded ADMSC is superior to direct ADMSC implantation in preserving LV function and attenuating LV remodeling.