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Röder F, Banning LBD, Bokkers RPH, de Vries JPPM, Schuurmann RCL, Zeebregts CJ, Pol RA. Carotid calcium burden derived from computed tomography angiography as a predictor of all-cause mortality after carotid endarterectomy. J Vasc Surg 2023; 78:995-1002. [PMID: 37257670 DOI: 10.1016/j.jvs.2023.05.036] [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: 03/20/2023] [Revised: 05/07/2023] [Accepted: 05/21/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) aims to reduce the risk of stroke in patients with atherosclerotic carotid disease. Preoperative risk assessments that predict complications are needed to optimize the care in this patient group. The current approach, namely relying solely on symptomatology and degree of stenosis, is outdated and calls for innovation. The Agatston calcium score was applied in several vascular specialties to assess cardiovascular risk profile but has been little studied in carotid surgery. It is hypothesized that a higher calcium burden at initial presentation equates to a worse prognosis attributable to an increased cerebrovascular and cardiovascular risk profile. The aim was to investigate the association between preoperative ipsilateral calcium score and postoperative all-cause mortality in patients undergoing CEA. METHODS This single-center retrospective cohort study included 89 patients who underwent CEA at a tertiary referral center between 2010 and 2018. Preoperative calcium scores were measured on contrast-enhanced computed tomography images with patient-specific Hounsfield thresholds at the level of the carotid bifurcation. The association between these calcium scores and all-cause mortality was analyzed using multivariable adjusted Cox proportional hazard analysis. RESULTS Cox proportional hazard analysis demonstrated a significant association between preoperative ipsilateral carotid calcium score and all-cause mortality (hazard ratio, 1.10; 95% confidence interval, 1.03-1.16; P = .003). After adjusting for age, preoperative estimated glomerular filtration rate, and diabetes mellitus, a significant association remained (hazard ratio, 1.07; 95% confidence interval, 1.00-1.15; P = .05). CONCLUSIONS A higher calcium burden was predictive of worse outcome, which might be explained by an overall poorer health status. These results highlight the potential of calcium measurements in combination with other traditional risk factors, for preoperative risk assessment and thus for improved patient education and care.
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Affiliation(s)
- Franziska Röder
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Louise B D Banning
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jean-Paul P M de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Richte C L Schuurmann
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
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Ariza-Solé A, Mateus-Porta G, Formiga F, Garcia-Blas S, Bonanad C, Núñez-Gil I, Vergara-Uzcategui C, Díez-Villanueva P, Bañeras J, Badia-Molins C, Aboal J, Carreras-Mora J, Gabaldón-Pérez A, Parada-Barcia JA, Martínez-Sellés M, Comín-Colet J, Raposeiras-Roubin S. Extended use of dual antiplatelet therapy among older adults with acute coronary syndromes and associated variables: a cohort study. Thromb J 2023; 21:32. [PMID: 36944967 PMCID: PMC10031931 DOI: 10.1186/s12959-023-00476-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 03/12/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Current guidelines recommend extending the use of dual antiplatelet therapy (DAPT) beyond 1 year in patients with an acute coronary syndrome (ACS) and a high risk of ischaemia and low risk of bleeding. No data exist about the implementation of this strategy in older adults from routine clinical practice. METHODS We conducted a Spanish multicentre, retrospective, observational registry-based study that included patients with ACS but no thrombotic or bleeding events during the first year of DAPT after discharge and no indication for oral anticoagulants. High bleeding risk was defined according to the Academic Research Consortium definition. We assessed the proportion of cases of extended DAPT among patients 65 ≥ years that went beyond 1 year after hospitalisation for ACS and the variables associated with the strategy. RESULTS We found that 48.1% (928/1,928) of patients were aged ≥ 65 years. DAPT was continued beyond 1 year in 32.1% (298/928) of patients ≥ 65; which was a similar proportion as with their younger counterparts. There was no significant correlation between a high bleeding risk and DAPT duration. Contrastingly, there was a strong correlation between the extent of coronary disease and DAPT duration (p < 0.001). Other variables associated with extended DAPT were a higher left ventricle ejection fraction, a history of heart failure and a prior stent thrombosis. CONCLUSION There was no correlation between age and extended use of DAPT beyond 1 year in older patients with ACS. DAPT was extended in about one-third of patients ≥ 65 years. The severity of the coronary disease, prior heart failure, left ventricle ejection fraction and prior stent thrombosis all correlated with extended DAPT.
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Affiliation(s)
- Albert Ariza-Solé
- Cardiology Department, Bioheart Grup de Malalties Cardiovasculars, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain.
| | - Gemma Mateus-Porta
- Cardiology Department, Bioheart Grup de Malalties Cardiovasculars, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
| | - Francesc Formiga
- Geriatrics Unit. Internal Medicine Department, Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sergio Garcia-Blas
- Cardiology Department, Department of Medicine, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Clara Bonanad
- Cardiology Department, Department of Medicine, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Iván Núñez-Gil
- Cardiology Department, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | - Jordi Bañeras
- Cardiology Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Clara Badia-Molins
- Cardiology Department, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Jaime Aboal
- Cardiology Department, Hospital Josep Trueta, Girona, Spain
| | | | - Ana Gabaldón-Pérez
- Cardiology Department, Department of Medicine, Hospital Clínico Universitario de Valencia, INCLIVA Biomedical Research Institute, University of Valencia, Valencia, Spain
| | | | - Manuel Martínez-Sellés
- Cardiology Department, Hospital Universitario Gregorio Marañón, CIBERCV. Universidad Europea. Universidad Complutense, Madrid, Spain
| | - Josep Comín-Colet
- Cardiology Department, Bioheart Grup de Malalties Cardiovasculars, Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Feixa Llarga s/n. 08907, Barcelona, Spain
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3
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Rodríguez-Queraltó O, Guerrero C, Formiga F, Calvo E, Lorente V, Sánchez-Salado JC, Llaó I, Mateus G, Alegre O, Ariza-Solé A. Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes. Heart Lung Circ 2021; 30:1863-1869. [PMID: 34083151 DOI: 10.1016/j.hlc.2021.05.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 03/27/2021] [Accepted: 05/04/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting. METHOD Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method. RESULTS A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index. CONCLUSIONS Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.
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Affiliation(s)
| | - Carme Guerrero
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Francesc Formiga
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Elena Calvo
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Victòria Lorente
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Isaac Llaó
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gemma Mateus
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oriol Alegre
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Albert Ariza-Solé
- Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.
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Kochly F, Haddad C, Harbaoui B, Falandry C, Lantelme P, Courand PY. Therapeutic management and outcome of nonagenarians versus octogenarians admitted to an intensive care unit for acute coronary syndromes. Arch Cardiovasc Dis 2020; 113:780-790. [DOI: 10.1016/j.acvd.2020.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/28/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
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5
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Diabetes mellitus, revascularization and outcomes in elderly patients with myocardial infarction-related cardiogenic shock. J Geriatr Cardiol 2020; 17:604-611. [PMID: 33224179 PMCID: PMC7657943 DOI: 10.11909/j.issn.1671-5411.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background The prognostic role of diabetes mellitus (DM) in elderly patients with myocardial infarction-related cardiogenic shock (MI-CS) remains controversial. Little information exists about the impact of intensive cardiac care unit (ICCU) and revascularization on outcomes of elderly patients with MI-CS. We aimed to assess the prognostic impact of DM according to age in patients with MI-CS, and to analyze the impact ICCU management and revascularization on in-hospital mortality in MI-CS patients at older ages. Methods Discharge episodes with diagnosis of CS associated with MI were selected from the Spanish National Health System's Basic Data Set. Centers were classified according to their availability of ICCU. Main outcome measured was in-hospital mortality. Results A total of 23, 590 episodes of MI-CS were identified, of whom 12, 447 (52.8%) were in patients aged ≥ 75 years. The impact of DM on in-hospital mortality was different among age subgroups. While in younger patients, DM was associated to a higher mortality risk (0.52 vs. 0.47, OR = 1.12, 95% CI: 1.06-1.18, χ2 < 0.001), this association became non-significant in older patients (0.76 vs. 0.81, χ2 = 0.09). Adjusted mortality rate of MI-CS aged ≥ 75 years was lower in patients admitted to hospitals with ICCU (adjusted mortality rate: 74.2% vs. 77.7%, P < 0.001) and in patients undergoing revascularization (74.9% vs. 77.3%, P < 0.001). Conclusions Prognostic impact of DM in patients with MI-CS was different according to age, with a significantly lower impact at older ages. The availability of ICCU and revascularization were associated with better outcomes in these complex patients.
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6
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Anemia in patients with high-risk acute coronary syndromes admitted to Intensive Cardiac Care Units. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2020; 17:35-42. [PMID: 32133035 PMCID: PMC7008098 DOI: 10.11909/j.issn.1671-5411.2020.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Little information exists about the role of anemia in patients with acute coronary syndromes (ACS) admitted to Intensive Cardiac Care Units (ICCU). The aim of this study was to assess the prevalence of anemia and its impact on management and outcomes in this clinical setting. Methods All consecutive patients admitted to eight different ICCUs with diagnosis of non-ST segment elevation ACS (NSTEACS) were prospectively included. Anemia was defined as hemoglobin < 130 g/L in men and < 120 g/L in women. The association between anemia and mortality or readmission at six months was assessed by the Cox regression method. Results A total of 629 patients were included. Mean age was 66.6 years. A total of 197 patients (31.3%) had anemia. Coronary angiography was performed in most patients (96.2%). Patients with anemia were significantly older, with a higher prevalence of comorbidities, poorer left ventricle ejection fraction and higher GRACE score values. Patients with anemia underwent less often coronary angiography, but underwent more often intraaortic counterpulsation, non-invasive mechanical ventilation and renal replacement therapies. Both ICCU and hospital stay were significantly longer in patients with anemia. Both the incidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = 0.001) and the incidence of mortality/readmission were significantly higher in patients with anemia (HR = 2.80, 95% CI: 2.03–3.86, P = 0.001). After adjusting for confounders, the association between anemia and mortality/readmission remained significant (P = 0.031). Conclusions Almost one of three NSTEACS patients admitted to ICCU had anemia. Most patients underwent coronary angiography. Anemia was independently associated to poorer outcomes at 6 months.
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7
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Keyhani S, Madden E, Cheng EM, Bravata DM, Halm E, Austin PC, Ghasemiesfe M, Abraham AS, Zhang AJ, Johanning JM. Risk Prediction Tools to Improve Patient Selection for Carotid Endarterectomy Among Patients With Asymptomatic Carotid Stenosis. JAMA Surg 2020; 154:336-344. [PMID: 30624562 DOI: 10.1001/jamasurg.2018.5119] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Randomized clinical trials have demonstrated that patients with asymptomatic carotid stenosis are eligible for carotid endarterectomy (CEA) if the 30-day surgical complication rate is less than 3% and the patient's life expectancy is at least 5 years. Objective To develop a risk prediction tool to improve patient selection for CEA among patients with asymptomatic carotid stenosis. Design, Setting, and Participants In this cohort study, veterans 65 years and older who received both carotid imaging and CEA in the Veterans Administration between January 1, 2005, and December 31, 2009 (n = 2325) were followed up for 5 years. Data were analyzed from January 2005 to December 2015. A risk prediction tool (the Carotid Mortality Index [CMI]) based on 23 candidate variables identified in the literature was developed using Veterans Administration and Medicare data. A simpler model based on the number of 4 key comorbidities that were prevalent and strongly associated with 5-year mortality was also developed (any cancer in the past 5 years, chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease [the 4C model]). Model performance was assessed using measures of discrimination (eg, area under the curve [AUC]) and calibration. Internal validation was performed by correcting for optimism using 500 bootstrapped samples. Main Outcome and Measure Five-year mortality. Results Among 2325 veterans, the mean (SD) age was 73.74 (5.92) years. The cohort was predominantly male (98.8%) and of white race/ethnicity (94.4%). Overall, 29.5% (n = 687) of patients died within 5 years of CEA. On the basis of a backward selection algorithm, 9 patient characteristics were selected (age, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, any cancer diagnosis in the past 5 years, congestive heart failure, atrial fibrillation, remote stroke or transient ischemic attack, and body mass index) for the final logistic model, which yielded an optimism-corrected AUC of 0.687 for the CMI. The 4C model had slightly worse discrimination (AUC, 0.657) compared with the CMI model; however, the calibration curve was similar to the full model in most of the range of predicted probabilities. Conclusions and Relevance According to results of this study, use of the CMI or the simpler 4C model may improve patient selection for CEA among patients with asymptomatic carotid stenosis.
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Affiliation(s)
- Salomeh Keyhani
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco.,Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Erin Madden
- Northern California Institute of Research and Education, San Francisco
| | - Eric M Cheng
- Department of Neurology, University of California, Los Angeles.,VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Dawn M Bravata
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis.,Department of Neurology, Indiana University School of Medicine, Indianapolis.,Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Department of Veterans Affairs, Indianapolis, Indiana
| | - Ethan Halm
- Division of General Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Mehrnaz Ghasemiesfe
- Visiting Scholar, Department of Medicine, University of California, San Francisco
| | - Ann S Abraham
- Northern California Institute of Research and Education, San Francisco
| | - Alysandra J Zhang
- Northern California Institute of Research and Education, San Francisco
| | - Jason M Johanning
- Department of Surgery, University of Nebraska, Omaha.,Omaha VA Medical Center, Omaha, Nebraska
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8
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Diabetes mellitus is not independently associated with mortality in elderly patients with ST-segment elevation myocardial infarction. Insights from the Codi Infart registry. Coron Artery Dis 2020; 31:1-6. [DOI: 10.1097/mca.0000000000000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Ariza-Solé A, Lorente V, Formiga F, López-Palop R, Sanchís J, Marín F, Vidán MT, Martínez-Sellés M, Sánchez-Salado JC, Garay A, Guerrero C, Bueno H, Alegre O, Abu-Assi E, Cequier À. Prognostic impact of anemia according to frailty status in elderly patients with acute coronary syndromes. J Cardiovasc Med (Hagerstown) 2020; 21:27-33. [DOI: 10.2459/jcm.0000000000000884] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Gual M, Formiga F, Ariza-Solé A, López-Palop R, Sanchís J, Marín F, Vidán MT, Martínez-Sellés M, Sionis A, Sánchez-Salado JC, Lorente V, Díez-Villanueva P, Vives-Borrás M, Cordero A, Bueno H, Alegre O, Abu-Assi E, Cequier À. Diabetes mellitus, frailty and prognosis in very elderly patients with acute coronary syndromes. Aging Clin Exp Res 2019; 31:1635-1643. [PMID: 30671867 DOI: 10.1007/s40520-018-01118-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/31/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The magnitude of the association between diabetes (DM) and outcomes in elderly patients with acute coronary syndromes (ACS) is controversial. No study assessed the prognostic impact of DM according to frailty status in these patients. METHODS The LONGEVO-SCA registry included unselected ACS patients aged ≥ 80 years. Frailty was assessed by the FRAIL scale. We evaluated the impact of previous known DM on the incidence of death or readmission at 6 months according to status frailty by the Cox regression method. RESULTS A total of 532 patients were included. Mean age was 84.3 years, and 212 patients (39.8%) had previous DM diagnosis. Patients with DM had more comorbidities and higher prevalence of frailty (33% vs 21.9%, p = 0.002). The incidence of death or readmission at 6 months was higher in patients with DM (HR 1.52, 95% CI 1.12-2.05, p 0.007), but after adjusting for potential confounders this association was not significant. The association between DM and outcomes was not significant in robust patients, but it was especially significant in patients with frailty [HR 1.72 (1.05-2.81), p = 0.030, p value for interaction = 0.049]. CONCLUSIONS About 40% of elderly patients with ACS had previous known DM diagnosis. The association between DM and outcomes was different according to frailty status.
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Affiliation(s)
- Miquel Gual
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Francesc Formiga
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Albert Ariza-Solé
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain.
| | | | - Juan Sanchís
- Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, CIBER-CV, Valencia, Spain
| | - Francisco Marín
- Hospital Virgen de la Arrixaca, IMIB-Arrixaca, CIBER-CV, Murcia, Spain
| | - María T Vidán
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
- CIBERCV, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - Alessandro Sionis
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José C Sánchez-Salado
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | - Victòria Lorente
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | | | - Miquel Vives-Borrás
- Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Héctor Bueno
- Hospital Doce de Octubre, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - Oriol Alegre
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
| | | | - Àngel Cequier
- Cardiology Department, Bellvitge University Hospital, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Spain
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11
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Frequency of Renal Dysfunction and Frailty in Patients ≥80 Years of Age With Acute Coronary Syndromes. Am J Cardiol 2019; 123:729-735. [PMID: 30593340 DOI: 10.1016/j.amjcard.2018.11.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 11/22/2022]
Abstract
Although a significant association between renal function and outcomes in patients with acute coronary syndromes (ACS) has been consistently described, little information exists about the magnitude of this association in patients at older ages. No study assessed the prognostic role of renal function according to frailty in patients with ACS. The LONGEVO-SCA registry included unselected ACS patients aged ≥80 years. Frailty was asessesed by the FRAIL scale, and baseline creatinine clearance was calculated by the Cockroff-Gault formula. We evaluated the impact of renal function on mortality or readmission at 6-months according to frailty status by the Cox regression method. A total of 473 patients were assessed, with a mean age of 84.2 years. The distribution of patients across estimated glomerular filtration rate (eGFR) subgroups was as follows: (1) <30 ml/min: n = 76 (16.1%); (2) 30 to 44 ml/min: n = 147 (31.1%); (3) 45 to 60 ml/min: n = 136 (28.8%); and (4) >60 ml/min: n = 114 (24.1%). Patients with lower eGFR values were older, had a higher proportion of comorbidities and other geriatric syndromes (p = 0.001) and underwent less often an invasive management during admission (p < 0.001). The incidence of mortality or readmission at 6 months progressively increased across renal function subgroups (p = 0.001). After adjusting for potential confounders, this association became nonsignificant (p = 0.802). The association between eGFR and outcomes was only significant in patients without frailty (p = 0.001). In conclusion, most patients aged ≥80 years with NSTEACS had renal function impairment at admission. The association between renal function and outcomes was different according to frailty status.
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12
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Calvo E, Teruel L, Rosenfeld L, Guerrero C, Romero M, Romaguera R, Izquierdo S, Asensio S, Andreu-Periz L, Gómez-Hospital JA, Ariza-Solé A. Frailty in elderly patients undergoing primary percutaneous coronary intervention. Eur J Cardiovasc Nurs 2018; 18:132-139. [PMID: 30156426 DOI: 10.1177/1474515118796836] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The prevalence of frailty, cognitive impairment and disability and its prognostic impact in patients with myocardial infarction undergoing primary percutaneous coronary intervention is unknown. AIMS The aim of this study was to assess the prevalence of frailty and other ageing-related variables and their association with inhospital mortality in consecutive elderly ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention in a tertiary care hospital. METHODS We prospectively included patients aged 75 years or older with STEMI undergoing primary percutaneous coronary intervention. The nursing team provided pre-discharge, standardised questionnaires and tests to each patient to study the presence of frailty (FRAIL scale), comorbidity (Charlson index), disability (Barthel test, Lawton-Brody index), nutritional risk (MNA-SF test) and cognitive status (Pfeiffer test). The association between ageing-related variables and mortality was assessed by binary logistic regression. RESULTS A total of 259 patients were included with a mean age of 82.6±6 years, 57.9% men. A total of 51 patients (19.7%) were frail, 26 presented with moderate or severe disability (10%), and 82 were at risk of malnutrition (31.7%). Frailty was associated with a higher prevalence of diabetes, hypertension and previous stroke, and a higher inhospital mortality (21.6% vs. 3.4%; P<0.001). After adjusting for potential confounders, this association remained significant (odds ratio 3.96; 95% confidence interval 1.16-13.56; P=0.028). CONCLUSION A not negligible proportion of elderly patients with STEMI fulfilled the frailty criteria. Frailty was independently associated with mortality. A very simple, feasible geriatric assessment by trained nurses can contribute to predict mortality.
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Affiliation(s)
- Elena Calvo
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain.,2 Fundamental and Medical-Surgical Nursing Department, Nursing School (Faculty of Medicine and Health Sciences), University of Barcelona, Spain
| | - Luis Teruel
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Laia Rosenfeld
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Carmen Guerrero
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Marta Romero
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Rafael Romaguera
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Silvia Izquierdo
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Susana Asensio
- 1 Department of Heart Disease, Bellvitge University Hospital, Spain
| | - Lola Andreu-Periz
- 2 Fundamental and Medical-Surgical Nursing Department, Nursing School (Faculty of Medicine and Health Sciences), University of Barcelona, Spain
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An Easy Assessment of Frailty at Baseline Independently Predicts Prognosis in Very Elderly Patients With Acute Coronary Syndromes. J Am Med Dir Assoc 2017; 19:296-303. [PMID: 29153753 DOI: 10.1016/j.jamda.2017.10.007] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/05/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Information about the impact of frailty in patients with acute coronary syndromes (ACS) is scarce. No study has assessed the prognostic impact of frailty as measured by the FRAIL scale in very elderly patients with ACS. METHODS The prospective multicenter LONGEVO-SCA registry included unselected patients with ACS aged 80 years or older. A comprehensive geriatric assessment was performed during hospitalization, including frailty assessment by the FRAIL scale. The primary endpoint was mortality at 6 months. RESULTS A total of 532 patients were included. Mean age was 84.3 years, 61.7% male. Most patients had positive troponin levels (84%) and high GRACE risk score values (mean 165). A total of 205 patients were classified as prefrail (38.5%) and 145 as frail (27.3%). Frail and prefrail patients had a higher prevalence of comorbidities, lower left ventricle ejection fraction, and higher mean GRACE score value. A total of 63 patients (11.8%) were dead at 6 months. Both prefrailty and frailty were associated with higher 6-month mortality rates (P < .001). After adjusting for potential confounders, this association remained significant (hazard ratio [HR] 2.71; 95% confidence interval [CI] 1.09-6.73 for prefrailty and HR 2.99; 95% CI 1.20-7.44 for frailty, P = .024). The other independent predictors of mortality were age, Charlson Index, and GRACE risk score. CONCLUSIONS The FRAIL scale is a simple tool that independently predicts mortality in unselected very elderly patients with ACS. The presence of prefrailty criteria also should be taken into account when performing risk stratification of these patients.
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Ariza-Solé A, Alegre O, Elola FJ, Fernández C, Formiga F, Martínez-Sellés M, Bernal JL, Segura JV, Iñíguez A, Bertomeu V, Salazar-Mendiguchía J, Sánchez Salado JC, Lorente V, Cequier A. Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:242-251. [DOI: 10.1177/2048872617719651] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years. Methods: We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization. Results: We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001). Conclusions: Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.
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Affiliation(s)
- Albert Ariza-Solé
- Hospital Universitario de Bellvitge, Universidad de Barcelona, Spain
| | - Oriol Alegre
- Hospital Universitario de Bellvitge, Universidad de Barcelona, Spain
| | - Francisco J Elola
- Sociedad Española de Cardiología, Guadalupe, Madrid, Spain
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
| | - Cristina Fernández
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
- Hospital Clínico Universitario San Carlos. Universidad Complutense de Madrid, Spain
| | - Francesc Formiga
- Hospital Universitario de Bellvitge, Universidad de Barcelona, Spain
| | - Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón, Universidad Complutense, Universidad Europea, Madrid, Spain
| | - José L Bernal
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
- Control Management Service, 12 de Octubre Hospital, Madrid, Spain
| | - José V Segura
- Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
- IUI Operative Research Centre, Miguel Hernández University, Alicante, Spain
| | - Andrés Iñíguez
- Sociedad Española de Cardiología, Guadalupe, Madrid, Spain
- Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Vicente Bertomeu
- Sociedad Española de Cardiología, Guadalupe, Madrid, Spain
- Hospital Universitario de San Juan, Alicante, Spain
| | | | | | - Victòria Lorente
- Hospital Universitario de Bellvitge, Universidad de Barcelona, Spain
| | - Angel Cequier
- Hospital Universitario de Bellvitge, Universidad de Barcelona, Spain
- Sociedad Española de Cardiología, Guadalupe, Madrid, Spain
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Alegre O, Ariza-Solé A, Vidán MT, Formiga F, Martínez-Sellés M, Bueno H, Sanchís J, López-Palop R, Abu-Assi E, Cequier À. Impact of Frailty and Other Geriatric Syndromes on Clinical Management and Outcomes in Elderly Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: Rationale and Design of the LONGEVO-SCA Registry. Clin Cardiol 2016; 39:373-7. [PMID: 27362592 DOI: 10.1002/clc.22550] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/29/2016] [Indexed: 11/05/2022] Open
Abstract
The incidence of acute coronary syndromes (ACS) is high in the elderly. Despite a high prevalence of frailty and other aging-related variables, little information exists about the optimal clinical management in patients with coexisting geriatric syndromes. The aim of the LONGEVO-SCA registry (Impacto de la Fragilidad y Otros Síndromes Geriátricos en el Manejo y Pronóstico Vital del Anciano con Síndrome Coronario Agudo sin Elevación de Segmento ST) is to assess the impact of aging-related variables on clinical management, prognosis, and functional status in elderly patients with ACS. A series of 500 consecutive octogenarian patients with non-ST-segment elevation ACS from 57 centers in Spain will be included. A comprehensive geriatric assessment will be performed during the admission, assessing functional status (Barthel Index, Lawton-Brody Index), frailty (FRAIL scale, Short Physical Performance Battery), comorbidity (Charlson Index), nutritional status (Mini Nutritional Assessment-Short Form), and quality of life (Seattle Angina Questionnaire). Patients will be managed according to current recommendations. The primary outcome will be the description of mortality and its causes at 6 months. Secondary outcomes will be changes in functional status and quality of life. Results from this study might significantly improve the knowledge about the impact of aging-related variables on management and outcomes of elderly patients with ACS. Clinical management of these patients has become a major health care problem due to the growing incidence of ACS in the elderly and its particularities.
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Affiliation(s)
- Oriol Alegre
- Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Albert Ariza-Solé
- Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - María T Vidán
- Hospital General Universitario Gregorio Marañón, Universidad Europea y Universidad Complutense de Madrid, Madrid, Spain
| | - Francesc Formiga
- Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Hospital General Universitario Gregorio Marañón, Universidad Europea y Universidad Complutense de Madrid, Madrid, Spain
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Instituto de Investigación y Departamento de Cardiología, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - Juan Sanchís
- Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, Spain
| | | | - Emad Abu-Assi
- Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Àngel Cequier
- Bellvitge University Hospital, University of Barcelona, Barcelona, Spain
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Kennedy-Martin T, Curtis S, Faries D, Robinson S, Johnston J. A literature review on the representativeness of randomized controlled trial samples and implications for the external validity of trial results. Trials 2015; 16:495. [PMID: 26530985 PMCID: PMC4632358 DOI: 10.1186/s13063-015-1023-4] [Citation(s) in RCA: 523] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 10/21/2015] [Indexed: 01/13/2023] Open
Abstract
Randomized controlled trials (RCTs) are conducted under idealized and rigorously controlled conditions that may compromise their external validity. A literature review was conducted of published English language articles that reported the findings of studies assessing external validity by a comparison of the patient sample included in RCTs reporting on pharmaceutical interventions with patients from everyday clinical practice. The review focused on publications in the fields of cardiology, mental health, and oncology. A range of databases were interrogated (MEDLINE; EMBASE; Science Citation Index; Cochrane Methodology Register). Double-abstract review and data extraction were performed as per protocol specifications. Out of 5,456 de-duplicated abstracts, 52 studies met the inclusion criteria (cardiology, n = 20; mental health, n = 17; oncology, n = 15). Studies either performed an analysis of the baseline characteristics (demographic, socioeconomic, and clinical parameters) of RCT-enrolled patients compared with a real-world population, or assessed the proportion of real-world patients who would have been eligible for RCT inclusion following the application of RCT inclusion/exclusion criteria. Many of the included studies concluded that RCT samples are highly selected and have a lower risk profile than real-world populations, with the frequent exclusion of elderly patients and patients with co-morbidities. Calculation of ineligibility rates in individual studies showed that a high proportion of the general disease population was often excluded from trials. The majority of studies (n = 37 [71.2 %]) explicitly concluded that RCT samples were not broadly representative of real-world patients and that this may limit the external validity of the RCT. Authors made a number of recommendations to improve external validity. Findings from this review indicate that there is a need to improve the external validity of RCTs such that physicians treating patients in real-world settings have the appropriate evidence on which to base their clinical decisions. This goal could be achieved by trial design modification to include a more representative patient sample and by supplementing RCT evidence with data generated from observational studies. In general, a thoughtful approach to clinical evidence generation is required in which the trade-offs between internal and external validity are considered in a holistic and balanced manner.
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Affiliation(s)
- Tessa Kennedy-Martin
- Kennedy-Martin Health Outcomes Ltd, 3rd Floor, Queensberry House, 106 Queens Road, Brighton, BN1 3XF, UK.
| | - Sarah Curtis
- Eli Lilly and Company, Indianapolis, Indiana, USA.
| | | | - Susan Robinson
- Kennedy-Martin Health Outcomes Ltd, 3rd Floor, Queensberry House, 106 Queens Road, Brighton, BN1 3XF, UK.
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Feinstein AJ, Long J, Soulos PR, Ma X, Herrin J, Frick KD, Chagpar AB, Krumholz HM, Yu JB, Ross JS, Gross CP. Older Women With Localized Breast Cancer: Costs And Survival Rates Increased Across Two Time Periods. Health Aff (Millwood) 2015; 34:592-600. [DOI: 10.1377/hlthaff.2014.1119] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron J. Feinstein
- Aaron J. Feinstein is a resident in head and neck surgery at the University of California, Los Angeles, and a researcher at the Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, in New Haven, Connecticut
| | - Jessica Long
- Jessica Long is a researcher at the COPPER Center
| | | | - Xiaomei Ma
- Xiaomei Ma is an associate professor of epidemiology at the Yale University School of Public Health
| | - Jeph Herrin
- Jeph Herrin is an assistant professor of medicine (cardiology) at the Yale University School of Medicine
| | - Kevin D. Frick
- Kevin D. Frick is a professor and vice dean for education at the Johns Hopkins Carey Business School, in Baltimore, Maryland
| | - Anees B. Chagpar
- Anees B. Chagpar is an associate professor of surgery at the Yale University School of Medicine
| | - Harlan M. Krumholz
- Harlan M. Krumholz is the Harold H. Hines Jr. Professor of Medicine and Epidemiology and Public Health at the Yale University School of Medicine
| | - James B. Yu
- James B. Yu is an assistant professor of therapeutic radiology at the Yale University School of Medicine
| | - Joseph S. Ross
- Joseph S. Ross is an associate professor of internal medicine at the Yale University School of Medicine
| | - Cary P. Gross
- Cary P. Gross ( ) is a professor of medicine at the Yale University School of Medicine
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Ariza-Solé A, Formiga F, Lorente V, Sánchez-Salado JC, Sánchez-Elvira G, Roura G, Sánchez-Prieto R, Vila M, Moliner P, Cequier A. Eficacia de los scores de riesgo hemorrágico en el paciente anciano con síndrome coronario agudo. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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19
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Ariza-Solé A, Formiga F, Lorente V, Sánchez-Salado JC, Sánchez-Elvira G, Roura G, Sánchez-Prieto R, Vila M, Moliner P, Cequier A. Efficacy of Bleeding Risk Scores in Elderly Patients with Acute Coronary Syndromes. ACTA ACUST UNITED AC 2014; 67:463-70. [DOI: 10.1016/j.rec.2013.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Accepted: 10/02/2013] [Indexed: 10/25/2022]
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20
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Ariza-Solé A, Formiga F, Bernal E, Sánchez-Prieto R. [Prediction of risk in the elderly patient with acute coronary syndrome]. Rev Esp Geriatr Gerontol 2014; 49:150. [PMID: 24513437 DOI: 10.1016/j.regg.2013.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 12/23/2013] [Indexed: 06/03/2023]
Affiliation(s)
- Albert Ariza-Solé
- Unidad Coronaria, Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - Francesc Formiga
- Unidad de Geriatría, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Eva Bernal
- Servicio de Cardiología, Hospital Universitario Germans Trias i Pujol, Badalona, Barcelona, España
| | - Remedios Sánchez-Prieto
- Unidad Coronaria, Servicio de Cardiología, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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21
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Ariza-Solé A, Formiga F, Vidán MT, Bueno H, Curós A, Aboal J, Llibre C, Rueda F, Bernal E, Cequier A. Impact of frailty and functional status on outcomes in elderly patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: rationale and design of the IFFANIAM study. Clin Cardiol 2013; 36:565-9. [PMID: 24114768 DOI: 10.1002/clc.22182] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Revised: 07/01/2013] [Indexed: 11/12/2022] Open
Abstract
The IFFANIAM study (Impact of frailty and functional status in elderly patients with ST segment elevation myocardial infarction undergoing primary angioplasty) is an observational multicenter registry to assess the impact of frailty and functional status on outcomes of elderly patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary angioplasty. STEMI patients age 75 years or older undergoing primary angioplasty will be extensively studied during admission in 4 tertiary care Hospitals in Spain, assessing their baseline functional status (Barthel index, Lawton-Brody index), frailty (Fried criteria, FRAIL scale [fatigue, resistance, ambulation, illnesses, and loss of weight]), comorbidities (Charlson index), nutritional status (Mini Nutritional Assessment-Short Form), and quality of life (Seattle Angina Questionnaire). Participants will be managed according current recommendations. The primary outcome will be the description of 1-year mortality, its causes, and associated factors. Secondary outcomes will be functional capacity and quality of life. Results will help to better understand the impact of frailty and functional ability on outcomes in elderly STEMI patients undergoing primary angioplasty, thus potentially contributing to improving their clinical management. Higher life expectancy has resulted in a large segment of elderly population and an increase in myocardial infarction in these patients. This calls attention to healthcare systems to focus on promoting methods to improve the clinical management of this population.
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Affiliation(s)
- Albert Ariza-Solé
- Cardiology Department, Internal Medicine Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Geller AI, Nopkhun W, Dows-Martinez MN, Strasser DC. Polypharmacy and the role of physical medicine and rehabilitation. PM R 2012; 4:198-219. [PMID: 22443958 DOI: 10.1016/j.pmrj.2012.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 02/08/2012] [Accepted: 02/10/2012] [Indexed: 02/07/2023]
Abstract
Polypharmacy and inappropriate prescribing practices lead to higher rates of mortality and morbidity, particularly in vulnerable populations, such as the elderly and those with complex medical conditions. Physical medicine and physiatrists face particular challenges given the array of symptoms treated across a spectrum of conditions. This clinical review focuses on polypharmacy and the associated issue of potentially inappropriate prescribing. The article begins with a review of polypharmacy along with relevant aspects of pharmacokinetics and pharmacodynamics in the elderly. The adverse effects and potential hazards of selected medications commonly initiated and managed by rehabilitation specialists are then discussed with specific attention to pain medications, neurostimulants, antipsychotics, antidepressants, antispasmodics, sleep medications, and antiepileptics. Of particular concern is the notion that an adverse effect of one medication can mimic an indication for another and lead to a prescribing cascade and further adverse medication events. Appropriate prescribing practices mandate an accurate, current medication list, yet errors and inaccuracies often plague such lists. The evidence to support explicit (medications to avoid) and implicit (how to evaluate) criteria is presented along with the role of physicians and patients in prescribing medications. A brief discussion of "medication debridement" or de-prescribing strategies follows. In the last section, we draw on the essence of physiatry as a team-based endeavor to discuss the potential benefits of collaboration. In working to optimize medication prescribing, efforts should be made to collaborate not only with pharmacists and other medical specialties but with members of inpatient rehabilitation teams as well.
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Affiliation(s)
- Andrew I Geller
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA, USA
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Schmidt M, Jacobsen JB, Lash TL, Bøtker HE, Sørensen HT. 25 year trends in first time hospitalisation for acute myocardial infarction, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity: a Danish nationwide cohort study. BMJ 2012; 344:e356. [PMID: 22279115 PMCID: PMC3266429 DOI: 10.1136/bmj.e356] [Citation(s) in RCA: 343] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To examine 25 year trends in first time hospitalisation for acute myocardial infarction in Denmark, subsequent short and long term mortality, and the prognostic impact of sex and comorbidity. DESIGN Nationwide population based cohort study using medical registries. SETTING All hospitals in Denmark. SUBJECTS 234,331 patients with a first time hospitalisation for myocardial infarction from 1984 through 2008. MAIN OUTCOME MEASURES Standardised incidence rate of myocardial infarction and 30 day and 31-365 day mortality by sex. Comorbidity categories were defined as normal, moderate, severe, and very severe according to the Charlson comorbidity index, and were compared by means of mortality rate ratios based on Cox regression. RESULTS The standardised incidence rate per 100,000 people decreased in the 25 year period by 37% for women (from 209 to 131) and by 48% for men (from 410 to 213). The 30 day, 31-365 day, and one year mortality declined from 31.4%, 15.6%, and 42.1% in 1984-8 to 14.8%, 11.1%, and 24.2% in 2004-8, respectively. After adjustment for age at time of myocardial infarction, men and women had the same one year risk of dying. The mortality reduction was independent of comorbidity category. Comparing patients with very severe versus normal comorbidity during 2004-8, the mortality rate ratio, adjusted for age and sex, was 1.96 (95% CI 1.83 to 2.11) within 30 days and 3.89 (3.58 to 4.24) within 31-365 days. CONCLUSIONS The rate of first time hospitalisation for myocardial infarction and subsequent short term mortality both declined by nearly half between 1984 and 2008. The reduction in mortality occurred for all patients, independent of sex and comorbidity. However, comorbidity burden was a strong prognostic factor for short and long term mortality, while sex was not.
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Affiliation(s)
- Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark.
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Abstract
Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.
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Affiliation(s)
- Amelia Carro
- Cardiovascular Sciences Research Centre, Division of Clinical Sciences, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
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Kuch B, Wende R, Barac M, von Scheidt W, Kling B, Greschik C, Meisinger C. Prognosis and outcomes of elderly (75–84 years) patients with acute myocardial infarction 1–2 years after the event — AMI-elderly study of the MONICA/KORA Myocardial Infarction Registry. Int J Cardiol 2011; 149:205-210. [DOI: 10.1016/j.ijcard.2010.01.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 12/18/2009] [Accepted: 01/18/2010] [Indexed: 10/19/2022]
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Newell MC, Henry JT, Henry TD, Duval S, Browning JA, Christiansen EC, Larson DM, Berger AK. Impact of age on treatment and outcomes in ST-elevation myocardial infarction. Am Heart J 2011; 161:664-72. [PMID: 21473964 DOI: 10.1016/j.ahj.2010.12.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Accepted: 12/06/2010] [Indexed: 12/22/2022]
Abstract
OBJECTIVES We hypothesized that older patients in a regional ST-elevation myocardial infarction (STEMI) transfer program would attain comparable treatment to younger patients. BACKGROUND Older patients have been either excluded or underrepresented in STEMI clinical trials. Observational studies suggest that these patients are less likely to receive adjunctive pharmacologies and reperfusion therapy-thrombolysis or percutaneous coronary intervention (PCI)-and therapy is frequently delayed. METHODS We identified a consecutive series of 2,262 STEMI patients (March 2003-December 2008) who either presented or were transferred to Abbott Northwestern Hospital for PCI (<65 years [n = 1285], 65-74 years [n = 436], 75-84 years [n = 381], and ≥85 years [n = 160]). Main outcome measures included time-to-reperfusion therapy, adjunctive medications received, and all-cause mortality. RESULTS Overall time-to-reperfusion therapy was similar across age strata-94 minutes (<65 years), 101 minutes (65-74 years), 106 minutes (75-84 years), and 103 minutes (≥85 years). No difference in adjunctive antiplatelet or anticoagulant medications was seen at hospital admission, and only slight differences in standard post-myocardial infarction medication use were seen by age at hospital discharge. Age was an independent predictor of in-hospital and yearly mortality up to 5 years (1-year mortality 3.4% [<65 years], 9.2% [65-74 years], 15.2% [75-84 years], and 28.9% [≥85 years]; P < .0001). CONCLUSIONS Older patients receive similar care to younger patients when treated in a regional STEMI transfer program. Although all-cause mortality in the elderly is increased, the absolute rates are lower than previously established. Our data suggest primary PCI (including transfer) can be applied to all appropriate STEMI patients, regardless of age.
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Gottlieb S, Behar S, Schwartz R, Harpaz D, Shotan A, Zahger D, Hod H, Tzivoni D, Moriel M. Age differences in the adherence to treatment guidelines and outcome in patients with ST-elevation myocardial infarction. Arch Gerontol Geriatr 2011; 52:118-24. [PMID: 20399515 DOI: 10.1016/j.archger.2010.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 02/15/2010] [Accepted: 02/25/2010] [Indexed: 11/28/2022]
Abstract
The aim of this study was to assess age differences in the utilization of class-I treatment guidelines and its effect on mortality in patients with ST-elevation myocardial infarction (STEMI). The study included 1026 consecutive patients from the prospective nationwide Acute Coronary Syndrome Israeli Survey (ACSIS). Primary reperfusion was used less often among elderly (age>75 years) patients than among those aged 65-74 and <65 years (46%, 63%, 64%, respectively, p (for trend)=0.004). Class-I evidence-based medications (EBM) at discharge (aspirin, β-blockers, angiotensin converting-enzyme inhibitors=ACEI, angiotensin receptor-blockers=ARBs and statins) were less frequently prescribed to elderly compared to younger age-subgroup (44%, 61%, 57%, respectively; adjusted odds ratio (OR)=0.62; 0.40-0.97 for age ≥ 75 vs. age<65 years). Early and 1-year mortality rates were 3-5-fold higher among the elderly compared to patients <65 years. In the entire cohort use of primary reperfusion was associated with lower 1-year mortality (OR=0.69; 0.47-1.01), as was the use of EBM (OR=0.26; 0.17-0.41). These effects were similar across all age-subgroups but with a greater impact among the elderly, as the number of patients needed to treat (NNT) was significantly lower with advancing age. Better adherence to treatment guidelines may improve the prognosis of elderly patients with STEMI.
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Affiliation(s)
- Shmuel Gottlieb
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer 52621, Israel.
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Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, García EJ, López-Sendón JL, Macaya C, Hernández-Antolín R. Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies. Eur Heart J 2010; 32:51-60. [PMID: 20971744 PMCID: PMC3013200 DOI: 10.1093/eurheartj/ehq375] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aims To compare primary percutaneous coronary intervention (pPCI) and fibrinolysis in very old patients with ST-segment elevation myocardial infarction (STEMI), in whom head-to-head comparisons between both strategies are scarce. Methods and results Patients ≥75 years old with STEMI <6 h were randomized to pPCI or fibrinolysis. The primary endpoint was a composite of all-cause mortality, re-infarction, or disabling stroke at 30 days. The trial was prematurely stopped due to slow recruitment after enroling 266 patients (134 allocated to pPCI and 132 to fibrinolysis). Both groups were well balanced in baseline characteristics. Mean age was 81 years. The primary endpoint was reached in 25 patients in the pPCI group (18.9%) and 34 (25.4%) in the fibrinolysis arm [odds ratio (OR), 0.69; 95% confidence interval (CI) 0.38–1.23; P = 0.21]. Similarly, non-significant reductions were found in death (13.6 vs. 17.2%, P = 0.43), re-infarction (5.3 vs. 8.2%, P = 0.35), or disabling stroke (0.8 vs. 3.0%, P = 0.18). Recurrent ischaemia was less common in pPCI-treated patients (0.8 vs. 9.7%, P< 0.001). No differences were found in major bleeds. A pooled analysis with the two previous reperfusion trials performed in older patients showed an advantage of pPCI over fibrinolysis in reducing death, re-infarction, or stroke at 30 days (OR, 0.64; 95% CI 0.45–0.91). Conclusion Primary PCI seems to be the best reperfusion therapy for STEMI even for the oldest patients. Early contemporary fibrinolytic therapy may be a safe alternative to pPCI in the elderly when this is not available. Clinicaltrials.gov # NCT00257309.
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Affiliation(s)
- Héctor Bueno
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Dr Esquerdo 46, Madrid, Spain.
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Shelton RJ, Crean AM, Somers K, Priestley C, Hague C, Blaxill JM, Wheatcroft SB, McLenachan JM, Greenwood JP, Blackman DJ. Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service. Am Heart J 2010; 159:956-63. [PMID: 20569706 DOI: 10.1016/j.ahj.2010.02.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 02/24/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged > or =80 before and after the introduction of routine 24/7 PPCI. METHODS Retrospective observational analysis of all patients aged > or =80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis. RESULTS Two hundred fifty-six STEMI patients aged > or =80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis. CONCLUSIONS Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.
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Cohen M, Boiangiu C, Abidi M. Therapy for ST-segment elevation myocardial infarction patients who present late or are ineligible for reperfusion therapy. J Am Coll Cardiol 2010; 55:1895-906. [PMID: 20430260 DOI: 10.1016/j.jacc.2009.11.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 11/18/2009] [Accepted: 11/19/2009] [Indexed: 10/19/2022]
Abstract
Despite the wide contemporary availability of pharmacological and mechanical means of reperfusion, a very significant proportion of ST-segment elevation myocardial infarction (STEMI) patients are still not offered any reperfusion therapy, and some of them are considered "ineligible for reperfusion." Spontaneous reperfusion and contraindications to the use of fibrinolytics and/or mechanical reperfusion methods account only for a small part of these clinical situations. The boundary between "timely" and "late" presentation in STEMI, the appropriateness of percutaneous intervention in patients presenting late after onset of symptoms, and the impact of sex and age on the eligibility and/or choice of reperfusion therapy continue to be challenged by the most recent published data. In the current invasive-driven reperfusion era, if scientific evidence and clinical guidelines are applied diligently, the vast majority of eligible STEMI patients should receive reperfusion therapy. Pharmacological nonlytic therapy of patients with STEMI, regardless of the choice of reperfusion strategy or the absence of it, is clearly defined by the current practice guidelines. Available data suggest that for patients who do not receive any form of reperfusion, anticoagulation therapy with low molecular weight heparin provides a clear additional mortality benefit versus placebo. Fondaparinux as compared with usual care (unfractionated heparin infusion or placebo) significantly reduces the composite of death or myocardial reinfarction without increasing severe bleeding or number of strokes. In the treatment of late-presenting patients with STEMI (beyond the first 12 h after onset of symptoms), clinical evaluation and risk stratification represent the crucial elements helping in decision making between therapeutic interventions.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey 07112, USA.
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Wang OJ, Krumholz HM. Clinical trial participation: are we studying the patients we are trying to treat? Eur J Heart Fail 2010; 11:1021-2. [PMID: 19875402 DOI: 10.1093/eurjhf/hfp137] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Sardella G, De Luca L, De Persio G, Colantonio R, Petrolini A, Conti G, Fedele F. Benefits on coronary restenosis from elective paclitaxel-eluting stent implantation in patients aged 75 years and older. J Cardiovasc Med (Hagerstown) 2007; 8:494-8. [PMID: 17568281 DOI: 10.2459/01.jcm.0000278442.81741.d2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Elderly patients are increasingly referred for revascularisation yet have been underrepresented in some large clinical trials. Although the advent of drug-eluting stents has dramatically reduced clinical events related to restenosis, older age remains one of the most important correlates of adverse outcome, even after an elective percutaneous coronary intervention (PCI). We sought to evaluate the impact of paclitaxel-eluting stents on coronary restenosis in elderly patients undergoing elective PCI. METHODS Patients undergoing successful elective PCI with stenting of de novo coronary artery lesions were identified and screened for participation in this study. All patients included in our analysis were divided into two cohort groups: patients aged <75 years (younger cohort) and patients aged >or=75 years (elderly cohort). We evaluated the six-month incidence of target lesion revascularisation (TLR) and major adverse cardiac events, which included TLR, death and myocardial infarction. RESULTS A total of 171 (58 aged >or=75 years) consecutive patients were enrolled in the study. At six months, TLR rate was similar in both groups [1.77 vs. 1.72%, odds ratio (OR) 0.97, 95% confidence interval (CI) 0.08-10.9, P = 0.98, in the younger and elderly group, respectively]. Even the rate of major adverse cardiac events was comparable between the two groups (7.96 vs. 8.62%, OR 1.09, 95% CI 0.34-3.41, P = 0.88, in the younger and elderly group, respectively). Also the angiographic restenosis rates were comparable between patients <75 or >or=75 years (4.42 vs. 3.46%, P = 0.76). CONCLUSIONS After elective paclitaxel-eluting stent implantation, there is no difference in coronary restenosis in younger and elderly patients, suggesting an age-independent efficacy.
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Affiliation(s)
- Gennaro Sardella
- Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy.
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36
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Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM. Acute Coronary Care in the Elderly, Part II. Circulation 2007; 115:2570-89. [PMID: 17502591 DOI: 10.1161/circulationaha.107.182616] [Citation(s) in RCA: 369] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background—
Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status.
Methods and Results—
Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment–elevation myocardial infarction in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment–elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A “one-size-fits-all” approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients.
Conclusions—
Few trials have adequately described treatment effects in older patients with ST-segment–elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.
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Weir RAP, McMurray JJV. Epidemiology of heart failure and left ventricular dysfunction after acute myocardial infarction. Curr Heart Fail Rep 2007; 3:175-80. [PMID: 17129511 DOI: 10.1007/s11897-006-0019-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The development of heart failure and/or left ventricular systolic dysfunction has long been regarded as an ominous complication, significantly increasing the morbidity and short- and long-term mortality of survivors of acute myocardial infarction. Although the incidence of heart failure after myocardial infarction has fallen over the last few decades, it remains common, complicating up to 45% of infarcts. Moreover, up to 60% of myocardial infarcts will result in left ventricular systolic dysfunction, depending on the exact definition used. Those at greatest risk of developing heart failure are the elderly, females, and those with prior myocardial infarction. Advances in the management of acute myocardial infarction have led to reduced in-hospital mortality (even when complicated by heart failure), but longer-term mortality remains high in these patients.
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Affiliation(s)
- Robin A P Weir
- Department of Cardiology, Western Infirmary, Glasgow, G11 6NT, United Kingdom
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Graff LG, Wang Y, Borkowski B, Tuozzo K, Foody JM, Krumholz HM, Radford MJ. Delay in the diagnosis of acute myocardial infarction: effect on quality of care and its assessment. Acad Emerg Med 2006; 13:931-8. [PMID: 16894002 DOI: 10.1197/j.aem.2006.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delay in diagnosis of acute myocardial infarction (AMI) may affect quality of care and its assessment. OBJECTIVES To examine over time the frequency of delay in AMI diagnosis and the effect of this delay on the quality of patient care and its assessment. METHODS The authors examined the trend in coded admission diagnosis, age, comorbidities, procedures during hospitalization, and discharge status for 42,406 Connecticut Medicare cases with the principal discharge diagnosis of AMI for the time period 1992 through 2001. For 2,583 cases discharged in 1992 and 1993 and for 1,398 cases discharged in 1998 through 2001, the rates of administration of aspirin (ASA) and beta blocker (BB) on admission and discharge, by admission diagnosis, were ascertained. RESULTS For patients discharged with the principal diagnosis of AMI over the decade examined, the proportion with this diagnosis on admission fell (59% to 40%, p < 0.001), the proportion with a non-acute coronary syndrome (ACS) admission diagnosis rose (18% to 26%, p < 0.001), and the population aged (proportion older than 85 years of age increased from 16% to 28%, p < 0.001). Patients with ACS as the admission diagnosis more frequently received cardiac catheterization (during 2000-2001, 39% versus 17%, p < 0.001), percutaneous coronary intervention (19% versus 4%, p < 0.001), and evidence-based therapy; during 1998-2001, opportunities to give ASA or BB on admission were fulfilled for 88% versus 73% (p < 0.001), and on discharge, for 87% versus 74% (p < 0.005). CONCLUSIONS The diagnosis of AMI is delayed after admission for a significant proportion of cases who receive care that is measured to be of lower quality. There is a need to more effectively diagnose and treat these cases with delayed diagnosis and to develop new quality measures to address changes in the characteristics of patients who are hospitalized with AMI.
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Weir RAP, McMurray JJV, Velazquez EJ. Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance. Am J Cardiol 2006; 97:13F-25F. [PMID: 16698331 DOI: 10.1016/j.amjcard.2006.03.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The development of heart failure and/or left ventricular systolic dysfunction (LVSD) in the setting of acute myocardial infarction (AMI) results in significant risk far above that of AMI independently. In patients admitted to the hospital for AMI, concomitant heart failure and/or LVSD on hospital admission or development of either or both of these conditions during admission are among the strongest predictors of inhospital death and are associated with significant increases in inhospital, 30-day, and long-term mortality and rehospitalization rates. Given the high risks in this population, aggressive treatment, comprising early initiation and sustained use of evidence-based treatments, is essential for improving prognosis.
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Affiliation(s)
- Robin A P Weir
- Department of Cardiology, Western Infirmary, Glasgow, United Kingdom, and Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Foody JM, Rathore SS, Galusha D, Masoudi FA, Havranek EP, Radford MJ, Krumholz HM. Hydroxymethylglutaryl-CoA reductase inhibitors in older persons with acute myocardial infarction: evidence for an age-statin interaction. J Am Geriatr Soc 2006; 54:421-30. [PMID: 16551308 PMCID: PMC2797316 DOI: 10.1111/j.1532-5415.2005.00635.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To characterize the relationship between hydroxymethylglutaryl-CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI). DESIGN Observational study. SETTING Acute care hospitals in the United States from April 1998 to June 2001. PARTICIPANTS Medicare patients aged 65 and older with a principal discharge diagnosis of AMI (N=65,020) who did and did not receive a discharge prescription for statins. MEASUREMENTS The primary outcome of interest was all-cause mortality at 3 years after discharge. RESULTS Of 23,013 patients with AMI assessed, 5,513 (24.0%) were receiving a statin at discharge. Nearly 40% of eligible patients (n=8,452) were aged 80 and older, of whom 1,310 (15.5%) were receiving a statin at discharge. In a multivariable model taking into account demographic, clinical, physician and hospital characteristics, and propensity score, discharge statin therapy was associated with significantly lower 3-year mortality (hazard ratio (HR)=0.89 (95% confidence interval (CI)=0.83-0.96)). In an analysis stratified by age, discharge statins were associated with lower mortality in patients younger than 80 (HR=0.84, 95% CI=0.76-0.92) but not in those aged 80 and older (HR=0.97, 95% CI=0.87-1.09). CONCLUSION Statin therapy is associated with lower mortality in older patients with AMI younger than 80 but not in those aged 80 and older, as a group. This finding questions whether statin efficacy data in younger patients can be broadly applied to the very old and indicates the need for further study of this group.
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Affiliation(s)
- JoAnne Micale Foody
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520, USA.
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Abstract
Women substantially outnumber men among older Americans. Among the noninstitutionalized U.S. population age 65-74, for every 100 men there are 120 women. Among those age 75-84, for every 100 men there are nearly 150 women, and among those age >/=85, for every 100 men there are nearly 220 women. Among the population of nursing home residents, the sex ratios are even more dramatic. For those age 65-74 who reside in U.S. nursing homes, for every 100 men there are 132 women. Among residents of nursing homes age 75-84, for every 100 men there are 246 women, and among those age >/=85, for every 100 men there are 425 women. Unless gender-based differences in mortality narrow, the age-related demographic shifts that are occurring in the United States will remain overwhelmingly female. In considering any health-related issue in the geriatric patient population, a special focus on women is absolutely required. This is especially true with regard to pharmacotherapy in the geriatric population.
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Affiliation(s)
- Jerry H Gurwitz
- Division of Geriatric Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
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Cowper PA, Udayakumar K, Sketch MH, Peterson ED. Economic effects of prolonged clopidogrel therapy after percutaneous coronary intervention. J Am Coll Cardiol 2005; 45:369-76. [PMID: 15680714 DOI: 10.1016/j.jacc.2004.10.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Revised: 10/17/2004] [Accepted: 10/18/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVES This study examined the incremental cost-effectiveness of extending clopidogrel therapy from one month to one year after percutaneous coronary intervention (PCI) in an unselected, heterogeneous patient population. BACKGROUND Clinical trials suggest that prolonging clopidogrel therapy for up to one year after PCI reduces downstream cardiac events. However, clopidogrel therapy is costly and may increase bleeding risk. METHODS Using decision analysis, we compared the outcomes and cost of prolonging clopidogrel treatment from one month to one year after PCI with the alternative strategy of discontinuing therapy one month after the procedure. Event rates were based on 3,976 PCI patients who were treated between January 1999 and December 2001 at the Duke Medical Center and received no more than one month of clopidogrel after the procedure. Baseline characteristics and event rates were obtained from Duke clinical information systems. The effect of prolonged clopidogrel therapy on event rates was based on the Clopidogrel for the Reduction of Events During Observation (CREDO) trial per-protocol data. Unit costs and the effect of myocardial infarction (MI) on life expectancy were based on published sources. RESULTS Extending clopidogrel therapy from one month to one year after PCI cost USD 879 per patient and reduced the risk of MI by 2.6%. Assuming MI decreases life expectancy by two years, prolonged therapy would cost USD 15,696 per year of life saved. Economic attractiveness of therapy varied with baseline risk, the effect of prolonged therapy on MI risk, and the price of clopidogrel. CONCLUSIONS Prolonging clopidogrel therapy for one year after PCI is economically attractive, particularly in high-risk patients.
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Affiliation(s)
- Patricia A Cowper
- Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
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Kandzari DE, Roe MT, Chen AY, Lytle BL, Pollack CV, Harrington RA, Ohman EM, Gibler WB, Peterson ED. Influence of clinical trial enrollment on the quality of care and outcomes for patients with non-ST-segment elevation acute coronary syndromes. Am Heart J 2005; 149:474-81. [PMID: 15864236 DOI: 10.1016/j.ahj.2004.11.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinical trials provide evidence that is formulated into recommendations for practice guidelines, but it remains uncertain whether patients enrolled in trials are similar to those treated in routine practice and whether trial enrollment influences inhospital treatments and outcomes. METHODS Using data from the CRUSADE quality improvement initiative, we evaluated predictors of trial enrollment, treatment patterns, and clinical outcomes among high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who were and were not enrolled in a clinical trial during hospitalization. RESULTS Among 55,172 high-risk patients presenting with NSTE ACS at 443 US hospitals, 1397 (2.5%) patients were enrolled in a clinical trial during index hospitalization. Significant predictors of trial enrollment included male sex, lack of renal insufficiency, and absence of congestive heart failure on presentation. Acute (<24 hours) and discharge secondary prevention interventions recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were used more commonly in patients enrolled in clinical trials. Cardiac catheterization (84.5% vs 65.8%, P < .0001), percutaneous coronary intervention (48.2% vs 36.3%, P < .0001), and bypass surgery (19.1% vs 11.3%, P < .0001) were also performed more frequently in trial patients. The adjusted risk of inhospital mortality was similar in trial versus nontrial patients (odds ratio 0.86, 95% CI 0.60-1.24). CONCLUSIONS Patients with NSTE ACS participating in clinical trials are more likely to receive beneficial therapies and interventions throughout hospitalization, but preferential recruitment of patients with lower-risk features may limit the external validity of trial results.
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Affiliation(s)
- David E Kandzari
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27705, USA.
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Rumsfeld JS, Peterson ED. Care disparities. J Am Coll Cardiol 2005; 45:79-81. [PMID: 15629378 DOI: 10.1016/j.jacc.2004.10.012] [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] [Indexed: 10/26/2022]
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45
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Núñez JE, Núñez E, Fácila L, Bertomeu V, Llàcer À, Bodí V, Sanchis J, Sanjuán R, Blasco ML, Consuegra L, Martínez Á, Chorro FJ. Prognostic Value of Charlson Comorbidity Index at 30 Days and 1 Year After Acute Myocardial Infarction. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/s1885-5857(06)60649-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Núñez JE, Núñez E, Fácila L, Bertomeu V, Llàcer À, Bodí V, Sanchis J, Sanjuán R, Blasco ML, Consuegra L, Martínez Á, Chorro FJ. Papel del índice de Charlson en el pronóstico a 30 días y 1 año tras un infarto agudo de miocardio. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77204-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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