Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic

Utilization Rate and Outcomes of Intravascular Imaging in Elderly Patients Presenting With ST-Elevation Myocardial Infarction

BACKGROUND

Elderly patients presenting with ST-elevation myocardial infarction (STEMI) represent a vulnerable population with comorbid conditions and complex coronary anatomy. We aimed to describe the utilization rate and outcomes of intravascular imaging to guide percutaneous coronary intervention (PCI) in this population.

METHODS

The Nationwide Readmissions Database was queried for all hospitalizations for STEMI involving PCI from 2018 to 2019. Hospitalizations were stratified by patient age into a younger cohort <75 years (mean age 58.7 ± 9.5 years) and an older cohort ≥75 years. Propensity score-weighed regression analysis was used to identify the association of intravascular imaging with in-hospital mortality, 90-day all-cause readmission, and readmission for myocardial infarction (MI).

RESULTS

A total of 299,619 STEMI PCI hospitalizations were included. Intravascular imaging was utilized less frequently in the older cohort (6.8 % vs 7.8 %, odds ratio [OR] 0.87, 95 % CI 0.82-0.92, p < 0.001). In both cohorts, intravascular imaging was more likely to be used with anterior STEMI, complex PCI, mechanical support, and thrombectomy. Propensity score analysis showed the use of intravascular imaging was associated with lower in-hospital mortality in both cohorts (OR 0.60, 95 % CI 0.52-0.68, p < 0.001 in the younger cohort and OR 0.61, 95 % CI 0.51-0.72, p < 0.001 in the older cohort). There was no difference in 90-day all-cause readmission or readmission for MI with intravascular imaging.

CONCLUSIONS

Intravascular imaging during STEMI PCI is associated with lower in-hospital mortality regardless of age. Further studies are needed to understand the low utilization rates especially among elderly patients.

Percutaneous Coronary Intervention Outcomes Based on Decision-Making Capacity

Background

Long‐term outcomes of percutaneous coronary intervention (PCI) based on patients’ decision‐making ability have not been studied. Our objective was to assess long‐term outcomes after PCI in patients who provided individual versus surrogate consent.

Methods and Results

Data were collected retrospectively for patients who underwent PCI at Cleveland Clinic between January 1, 2015 and December 31, 2016. Inclusion criteria consisted of hospitalized patients aged ≥20 years who had PCI. Patients with outpatient PCI, or major surgery 30 days before or 90 days after PCI, were excluded. Patients who underwent PCI with surrogate consent versus individual consent were matched using the propensity analysis. Kaplan–Meier, log rank, t‐statistic, and χ² tests were used for statistical analysis. The study was approved by the Institutional Review Board at Cleveland Clinic, Ohio. Of 3136 patients who underwent PCI during the study period, 183 had surrogate consent. Propensity matching yielded 149 patients from each group. Two‐year all‐cause mortality was significantly higher in the surrogate consent group (38 [25.5%] versus 16 [10.7%] deaths, log‐rank χ²=10.16, P<0.001). The 2‐year major adverse cardiac events rate was also significantly higher in the surrogate consent group (60 versus 36 events, log‐rank χ²=8.36, P=0.003).

Conclusions

Patients with surrogate consent had significantly higher all‐cause mortality and higher major adverse cardiac events when compared with patients with individual consent. This study emphasizes the fact that patients with an inability to give consent are at high risk and may need special attention in postprocedural and postdischarge care.

Predictive values of sST2 and IL-33 for heart failure in patients with acute myocardial infarction

Timely prediction of the risk of heart failure in acute myocardial infarction patients is critical for better prognosis. This article aims to evaluate the predictive value of serum soluble growth stimulation expressed gene 2 (sST2) and interleukin-33 in patients with acute myocardial infarction complicated by heart failure. A total of 42 healthy controls and 144 acute myocardial infarction patients were recruited in the study. According to Killip cardiac function classification as the basis for concurrent heart failure, they were distributed into non-heart failure group (n = 76) and heart failure group (n = 68). ELISA was utilized to determine the serum sST2 and interleukin-33 levels, and the diagnostic efficiency was evaluated by receiver operating characteristics curve. sST2 and interleukin-33 levels in patients with acute myocardial infarction were significantly increased when compared with normal healthy controls, and were further enhanced in the heart failure group. With the increased Killip cardiac function classification, interleukin-33 and sST2 levels were gradually elevated. Multivariate analysis indicated that interleukin-33 and sST2 could be used as independent predictors for heart failure combined with acute myocardial infarction.

C-Reactive Protein/Albumin Ratio Predicts Acute Kidney Injury in Patients With Moderate to Severe Chronic Kidney Disease and Non-ST-Segment Elevation Myocardial Infarction

In this study, we aimed to evaluate the predictive value of admission C-reactive protein/albumin ratio (CAR) for acute kidney injury (AKI) in cases with moderate to severe chronic kidney disease (CKD) not on dialysis who presented with non-ST-segment elevation myocardial infarction (NSTEMI) and underwent coronary angiography (CAG). This cross-sectional and observational study included 420 NSTEMI patients. The study population was categorized based on the CAR tertiles as groups T1, T2, and T3. The primary outcome of the study was AKI development; 92 (21.9%) cases developed AKI. The frequency of AKI was significantly higher in the T3 group compared with the T2 and T1 groups (34% vs 17% vs 14%, P < .001). Age, estimated glomerular filtration rate, contrast media volume, and CAR (odds ratio: 1.36; 95% CI: 1.17-1.57; P < .01) were significant predictors of AKI. In a receiver operating characteristic curve analysis, CAR levels >0.20 predicted AKI development with a sensitivity of 74% and a specificity of 45%. We observed that the CAR may be a promising inflammatory parameter for AKI in NSTEMI patients with moderate to severe CKD after CAG.

Predictors of suboptimal coronary blood flow after primary angioplasty and its implications on short-term outcomes in patients with acute anterior STEMI

BACKGROUND

Suboptimal coronary blood flow after primary percutaneous coronary intervention (PCI) is a complex multifactorial phenomenon. Although extensively studied, defined modifiable risk factors and efficient management strategy are lacking. This study aims to determine the potential causes of suboptimal flow and associated impact on 30-day outcomes in patients presenting with anterior ST-elevation myocardial infarction (STEMI).

METHODS

We evaluated a total of 1104 consecutive patients admitted to our hospital from January 2016 to December 2018 with the diagnosis of anterior wall STEMI who had primary PCI.

RESULTS

Overall, 245 patients (22.2%) had final post-PCI TIMI flow ≤2 in the LAD (suboptimal flow group) and 859 (77.8%) had final TIMI-3 flow (optimal flow group). The independent predictors of suboptimal flow were thrombus burden grade (Odds ratio (OR) 1.848; p < 0.001), age (OR 1.039 per 1-year increase; p < 0.001), low systolic blood pressure (OR 1.017 per 1 mmHg decrease; p < 0.001), total stent length (OR 1.021 per 1 mm increase; p < 0.001), and baseline TIMI flow ≤1 (OR 1.674; p = 0.018). The 30-day rates of major adverse cardiovascular events (MACE) and cardiac mortality were significantly higher in patients with TIMI flow ≤2 compared to those with TIMI-3 flow (MACE: adjusted risk ratio [RR] 2.021; P = 0.025, cardiac mortality: adjusted RR 2.931; P = 0.031).

CONCLUSION

Failure to achieve normal TIMI-3 flow was associated with patient-related (age) and other potentially modifiable risk factors (thrombus burden, admission systolic blood pressure, total stent length, and baseline TIMI flow). The absence of final TIMI-3 flow carried worse short-term clinical outcomes.

Percutaneous coronary intervention of unprotected left main and bifurcation in octogenarians: Subanalysis from RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life)

OBJECTIVE

Outcomes of complex percutaneous coronary interventions (PCIs) in older patients are still debated. The aim of the study was to evaluate clinical outcomes of Octogenarian patients treated with ultrathinstents on left main or on coronary bifurcations, compared with younger patients.

METHODS

All consecutive patients presenting a critical lesion of an unprotected left main (ULM) or a bifurcation and treated with very thin stents were included in the RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry and divided into octogenarians group (OG, 551 patients) and nonoctogenarians (NOGs, 2,453 patients). Major adverse cardiovascular event (MACE), a composite end point of all-cause death, nonfatal myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST), was the primary endpoint, while MACE components, cardiovascular (CV) death, and target vessel revascularization (TVR) were the secondary ones.

RESULTS

Indication for PCI was acute coronary syndrome in 64.7% of the OG versus 53.1% of the NOG. Severe calcifications and a diffuse disease were significantly more in OG. After a follow-up of 15.2 ± 10.3 months, MACEs were higher in the OG than in the NOG patients (OG 19.1% vs. NOG 11.2%, p < .001), along with MI (OG 6% vs. NOG 3.4%, p = .002) and all-cause death (OG 14% vs. NOG 4.3%, p < .001). In contrast, no significant difference was detected in CV-death (OG 5.1% vs. NOG 4%, p = .871), TVR/TLR, or ST. At multivariate analysis, age was not an independent predictor of MACE (OR 1.02 CI 95% 0.76-1.38), while it was for all-cause death, along with diabetes, GFR < 60 ml/min, and ULM disease.

DISCUSSION

Midterm outcomes of complex PCI in OG are similar to those of younger patients. However, due to the higher non-CV death rate, accurate patient selection is mandatory.

Effect of coronary collateral circulation on the prognosis of elderly patients with acute ST-segment elevation myocardial infarction treated with underwent primary percutaneous coronary intervention

Investigate the effect of coronary collateral circulation (CCC) on the prognosis of elderly patients with acute ST-segment elevation myocardial infarction (STEMI) and acute total occlusion (ATO) of a single epicardial coronary artery.Three hundred forty-six advanced-age patients (age ≥60 years) with STEMI and ATO who underwent primary percutaneous coronary intervention (PCI) were enrolled in this study. According to the Rentrop grades, the patients were assigned to the poor CCC group (Rentrop grade 0-1) and good CCC group (Rentrop grade 2-3).Multivariate logistic regression analysis revealed that poor coronary collateral circulation was an independent factor for Killip class ≥2 (odds ratio [OR]: -1.559; 95% confidence interval [CI]: 1.346-2.378; P = .013), the use of an intra-aortic balloon pump (IABP) (OR: -1.302; 95% CI: 0.092-0.805; P = .019), and myocardial blush grade (MBG) 3 (OR: 1.516; 95% CI: 2.148-9.655; P < .001). We completed a 12-month follow-up, during which 52 patients (15.0%) were lost to follow-up and 19 patients (5.5%) died. Univariate analysis (Kaplan-Meier and log-rank tests) suggested that poor CCC had a significant effect on all-cause mortality (P = .046), while multivariate analysis (Cox regression analysis) indicated that CCC had no statistically significant effect on all-cause mortality (P = .089) after the exclusion of other confounding factors. After excluding the influence of other confounding factors, this study showed that the mortality rate increased by 26.9% within 1 year for every 1-hour increment of time of onset. The mortality rate in patients with Killip class ≥2 was 8.287 times higher than that in patients with Killip class 0 to 1. The mortality rate in patients over 75 years was 8.25 times higher than that in patients aged 60 to 75 years. The mortality rate in patients with myocardial blush grade 3 (MBG 3) was 5.7% higher than that in patients with MBG 0-2.The conditions of CCC in the acute phase had no significant direct effect on all-cause mortality in patients, but those with good CCC had a higher rate of MBG 3 after primary PCI and a lower rate of Killip ≥2.

Total and Cause-Specific Mortality After Percutaneous Coronary Intervention: Observations From the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease Registry

Background

Patients undergoing percutaneous coronary intervention (PCI) are increasingly older and have a higher comorbidity burden. This study evaluated trends in 30-day, 1-year, and 2-year total and cause-specific mortality using a large, contemporary cohort of patients who underwent PCI in Alberta, Canada.

Methods

We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry to identify patients aged ≥ 20 years who underwent PCI between 2005 and 2013. All patients were followed until death or being censored by August 2016. Cause of death was from the Vital Statistics database and classified as cardiac or noncardiac. Multivariable logistic regression was used to calculate predicted mortality at 30 days, 1 year, and 2 years post-PCI.

Results

Of the 35,602 patients who underwent PCI, 5284 (14.8%) had died. Mean (standard deviation) follow-up was 74.9 (35.1) months. Over the study period, patients were older and more likely to undergo PCI for an acute coronary syndrome indication. Thirty-day (2005: 1.3%; 2013: 3.2%; P < 0.001), 1-year (2005: 2.7%; 2013: 5.7%; P < 0.001), and 2-year (2005: 4.5%; 2013: 7.5%; P < 0.001) predicted mortality after PCI increased over the study period. Cardiac cause of death dominated in the short-term, but the proportion of noncardiac deaths increased as time from PCI to death increased (30 days = 11.5%, 1 year = 31.5%, 2 years = 39.6%; P < 0.001).

Conclusions

In this population-based study, we found all-cause mortality at 30 days, 1 year, and 2 years after PCI increased over time. Cardiac causes of death dominate in the short-term after PCI; however, noncardiac cause becomes a major driver of mortality in the long-term.

Life Expectancy and Years of Potential Life Lost After Acute Myocardial Infarction by Sex and Race: A Cohort-Based Study of Medicare Beneficiaries

BACKGROUND

Most studies of sex and race differences after acute myocardial infarction (AMI) have not taken into account differences in life expectancy in the general population. Years of potential life lost (YPLL) is a metric that takes into account the burden of disease and can be compared by sex and race.

OBJECTIVES

This study sought to determine sex and race differences in long-term survival after AMI using life expectancy and YPLL to account for differences in population-based life expectancy.

METHODS

Using data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized for AMI between 1994 and 1995 (N = 146,743), we calculated life expectancy and YPLL using Cox proportional hazards regression with extrapolation using exponential models.

RESULTS

Of the 146,743 patients with AMI, 48.1% were women and 6.4% were black; the average age was 75.9 years. Post-AMI life expectancy estimates were similar for men and women of the same race but lower for black patients than white patients. On average, women lost 10.5% (SE 0.3%) more of their expected life than men, and black patients lost 6.2% (SE 0.6%) more of their expected life than white patients. After adjustment, women still lost an average of 7.8% (0.3%) more of their expected life than men, but black race became associated with a survival advantage, suggesting that racial differences in YPLL were largely explained by differences in clinical presentation and treatment between black and white patients.

CONCLUSIONS

Women and black patients lost more years of life after AMI, on average, than men and white patients, an effect that was not explained in women by clinical or treatment differences.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

Clinical outcomes following percutaneous coronary intervention before and after introduction of drug-eluting stent

Drug-eluting stents (DES) have demonstrated safety and efficacy in clinical outcomes, especially reduced rate of revascularization. However, it remains unknown whether clinical outcomes related to mortality improved after the introduction of DES. We sought to examine clinical outcomes including all-cause mortality, cardiovascular and non-cardiovascular death in pre-DES and DES eras. This was a single-center retrospective study including patients who underwent percutaneous coronary intervention (PCI) from August 1997 and June 2011. Study population was divided into two groups according to the time period of PCI (August 1997 to July 2004; pre-DES era, August 2004 to June 2011; DES era). The primary endpoint was all-cause mortality and secondary endpoints were cardiovascular and non-cardiovascular mortality. These endpoints were evaluated 3 years after PCI. A total of consecutive 3361 patients from our PCI cohort were analyzed. Patients in DES era were more likely to have traditional risk factors and angiographic disadvantages. The incidence of the primary endpoint was comparable between the two groups (p = 0.053). Cardiovascular and non-cardiovascular mortality were also similar between the groups (p = 0.1 and p = 0.2, respectively). Importantly, non-cardiovascular mortality accounted for over 60% of all-cause mortality in both eras. DES era was not associated with 3-year all-cause mortality, whereas DES use was associated with a reduction in 3-year cardiovascular mortality (HR 0.16, 95% CI 0.010-0.9, p = 0.035). All-cause mortality, cardiovascular and non-cardiovascular mortality at three years were comparable between pre-DES and DES era, despite the higher risk profiles of patients in DES era.

Association of various risk factors with prognosis and hospitalization cost in Chinese patients with acute myocardial infarction: A clinical analysis of 627 cases

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality in the developed world and is becoming increasingly more common in developing countries. The risk factors affecting the prognosis of Chinese patients may differ from those in other populations. This study was conducted to investigate the potential risk factors that may correlate with prognosis and hospitalization costs of Chinese AMI patients. A total of 627 hospitalized AMI patients were recruited and their general information and relevant laboratory parameters were collected. Accordingly, the patients were grouped into different subgroups and potential risk factors and their correlations with prognosis and hospitalization costs were analyzed. Age, high blood pressure, infarct location and percutaneous coronary intervention (PCI) were the variables significantly associated with the differences in the prognosis of AMI patients (P<0.05), whereas times and duration of hospitalization, high blood pressure, infarct location and PCI treatment were found to be significantly associated with the cost of hospitalization (P<0.05). However, the AMI patients enrolled in this study may not be representative of all AMI patients in China. In addition, the prognosis of these patients was limited to their hospital stay. Therefore, long-term follow-up requires careful assessment.

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

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

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Combination of angiographic and clinical characteristics for the prediction of clinical outcomes in elderly patients undergoing multivessel PCI

BACKGROUND

Risk stratification is essential for the clinical decision-making process in elderly patients undergoing multivessel revascularization, since the optimal revascularization strategy remains subject of ongoing debate.

AIMS

To assess the prognostic value of angiographic versus clinical characteristics for the prediction of a first adverse cardiac and cerebrovascular events (MACCE) (all-cause mortality, non-fatal myocardial infarction, stroke, and target lesion revascularization) and to develop a combined risk model.

METHODS

After multivessel percutaneous coronary intervention (MV-PCI), SYNTAX score and EuroSCORE were calculated as combined risk model in 328 elderly patients who were followed up for a first MACCE.

RESULTS

328 patients with a mean age of 77.5 ± 5.1 years were followed up for 2.7 ± 1.5 years. A first MACCE occurred in 50.0 % (164/328) of the patients. To improve predictability, a combined risk score model with receiver operating characteristic curve validated cut-off values for EuroSCORE (>5 %) and SYNTAX score (>25) was developed. High risk patients had a 3.5-fold higher risk for MACCE after 3 years (HR 7.1, 95 % CI 1.9-6.5; p < 0.001).

CONCLUSIONS

For adequate risk assessment in elderly patients undergoing MV-PCI, consideration of both comorbidities and coronary anatomic complexity is essential. A combined angiographic and clinical risk score provides superior prediction of 3-year MACCE risk in elderly patients.

Development and validation of a clinical risk score predicting the no-reflow phenomenon in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVE

The 'no-reflow' phenomenon after a primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is a strong predictor of both short- and long-term mortality. We therefore developed and prospectively validated a risk score system in order to identify STEMI patients at high risk in terms of no-reflow after primary PCI.

METHODS

The first part of our study used data from 1,615 STEMI patients who underwent primary PCI within 12 h from symptom onset. Using logistic regression, we derived a risk score to predict angiographic no-reflow using baseline clinical variables. From this score, we developed a simplified fast-track screen that can be used before reperfusion. In the second part of our study, we prospectively validated the score system using receiver-operating characteristic (ROC) curves with data from 692 STEMI patients.

RESULTS

The model included six clinical items: age, neutrophil count, admission plasma glucose, β-blocker treatment, time-to-hospital admission and Killip classes. The risk score system demonstrated a good risk prediction with a c-statistic of 0.757 (95% CI 0.732-0.781) based on ROC analysis.

CONCLUSION

A simple risk score system based on clinical variables is useful to predict the risk of developing no-reflow after pPCI in patients with STEMI.

Thirty-year trends in outcomes of percutaneous coronary interventions in diabetic patients

OBJECTIVE

To characterize in-hospital and long-term outcomes after percutaneous coronary interventions (PCIs) in patients with diabetes mellitus (DM).

PATIENTS AND METHODS

Patients who underwent PCIs were grouped by era: group 1, October 9, 1979, to December 31, 1989 (408 with DM and 2684 without DM); group 2, January 1, 1990, to December 31, 1996 (1170 and 4664); group 3, January 1, 1997, to December 31, 2003 (2032 and 6584); and group 4, January 1, 2004, to December 31, 2008 (1412 and 4141). The main outcome measures were in-hospital mortality, major adverse cardiovascular events, long-term mortality, composites of mortality with revascularization, and ischemic events.

RESULTS

Patients with DM had significant declines in in-hospital adverse outcomes over time. These declines were similar to those observed in patients without DM. After adjusting for baseline risk, there was no significant change in the association between DM and in-hospital death or in-hospital major adverse cardiovascular events over time. The use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and thienopyridines all increased over time. The effect of DM on long-term survival and survival free of revascularization did not change significantly from group 2 to group 4. However, the effect of DM on survival free of myocardial infarction and stroke was reduced significantly, from a hazard ratio (95% CI) of 1.71 (1.51-1.92) in group 2 to 1.39 (1.20-1.60) in group 4 (P=.04).

CONCLUSION

Over 30 years, the improving outcomes in patients with diabetes who underwent PCIs have been similar to improvements in patients without DM. However, the risk-adjusted association of DM with long-term death, myocardial infarction, and stroke has decreased in the current era (group 4) compared with the bailout stent era (group 2).

Procedural and long-term outcome of primary percutaneous coronary intervention in octogenarians

Background/objectives. To investigate the procedural and long-term outcome of primary percutaneous coronary intervention (PCI) in octogenarians with an acute myocardial infarction.Methods. We performed a retrospective analysis of all consecutive octogenarian patients (n=98) with an acute myocardial infarction treated with primary PCI in the Catharina Hospital in the year 2006. We compared procedural results and outcome with a matched control group composed of non-octogenarians undergoing primary PCI. Follow-up period was one year.Results. The initial success rate of PCI was similar in the two groups but short-term mortality was higher among the elderly patients: 30-day mortality 26.3 vs. 9.6%. Age-adjusted mortality between 30 days and one year was comparable in the two groups and similar to natural survival in the Netherlands. Octogenarians were less likely to have a normal left ventricular function during follow-up (48.3 vs. 66.7%). New York Heart Association (NYHA) class and recurrence rate of myocardial infarction was higher among octogenarians.Conclusion. Technical success rate during primary PCI was as good for octogenarians as in younger patients, but 30-day mortality, though acceptable, was higher among the elderly. After 30 days, age-adjusted mortality was comparable in both groups. (Neth Heart J 2010;18:129-34.).

Changing nature of cardiac interventions in older adults

Older adults represent a rapidly growing segment of the population in developed countries. Advancing age is the most powerful risk factor for the development of cardiovascular disease (CVD), and CVD-related mortality increases markedly in older individuals. Procedures for patients with CVD, including percutaneous coronary intervention, aortic valve replacement and implantable cardioverter defibrillators were all initially validated in younger individuals but are increasingly being applied in older adults who for the most part have been significantly understudied in clinical trials. While advanced age alone is not a contraindication to these procedures, with the advent of less invasive methods to manage CVD including percutaneous techniques to treat both coronary artery disease and valvular heart disease, future research will need to weigh the potential harms of intervention in a population of older adults with multiple medical comorbidities and complex physiologic phenotypes against outcomes that include preventing functional decline and improving quality of life.

A no-reflow prediction model in patients with ST-elevation acute myocardial infarction and primary drug-eluting stenting

OBJECTIVES

This study was undertaken to assess independent no-reflow predictors in patients with ST-elevation acute myocardial infarction (STEMI) and primary drug-eluting stenting in the current interventional strategies.

DESIGN

One thousand four hundred and thirteen patients with STEMI were successfully treated with primary drug-eluting stenting within 12 h after AMI. All clinical, angiographic and procedural data were collected. Univariate and multivariate logistic regression was used to identify independent no-reflow predictors.

RESULTS

The no-reflow was found in 297 (21%) of 1413 patients. Univariate and multivariate logistic regression identified that age (>65 years, OR 1.47, 95% CI 1.46-1.49; p = 0.007), long time-to-reperfusion (>6 h, OR 1.27, 95% CI 1.16-1.40; p = 0.001), admission plasma glucose (>13.0 mmol/L, OR 1.27, 95% CI 1.16-1.40; p = 0.027), collateral circulation (0-1, OR 1.69, 95% CI 1.25-2.29; p = 0.001), pre-PCI thrombus score (≥4, OR 1.36, 95% CI 1.16-1.79; p = 0.011), and IABP use before PCI (OR 2.89, 95% CI 1.65-5.05; p < 0.0001) were independent no-reflow predictors. The no-reflow rate significantly increased as the number of independent predictors increased (0%, 6%, 15%, 25%, 40%, 50% and 100% in patients with 0, 1, 2, 3, 4, 5, and 6 independent predictors, respectively; p < 0.0001).

CONCLUSIONS

The prediction model consisted of six no-reflow predictors in patients with STEMI and primary drug-eluting stenting and should be confirmed in large-scale prospective studies.

Percutaneous coronary intervention in the elderly: results from the Thai National Percutaneous Coronary Intervention Registry (TPCIR)

AIMS

The objective of this study was to evaluate the outcomes and identify the risk factors of in-hospital mortality among elderly patients undergoing PCI in Thailand.

METHODS AND RESULTS

Included in this study were 4,156 consecutive patients (comprising 639 elderly [age ≥ 75 years] and 3,517 non-elderly [age < 75 years]) undergoing PCI between May 2006 and October 2007. The success rate of PCI was less favourable among elderly compared to the non-elderly patients (91.2% vs. 87.5%; p=0.003). Elderly patients had higher rate of post PCI renal failure (3.9% vs. 1.8%; p=0.001), Q-wave myocardial infarction (3.0 vs. 1.4%, p=0.003), and unadjusted in-hospital mortality (5.3% vs. 2.4%, p ≤ 0.001), compared with non-elderly patients. After adjustment for baseline variables, acute coronary syndrome and heart failure were the two variables most associated with increased mortality (OR=5.95, 95% CI=3.22-11.01), p<0.001 and OR=5.73,95% CI=3.80-8.63), p<0.001, respectively). According to the multivariate analysis, age was not significantly related with increased mortality (OR=1.37, 95% CI=0.87-2.16, p=0.174).

CONCLUSIONS

Our study highlights the safety and effectiveness of PCI in elderly patients since advanced age is not a predictor of in-hospital mortality.

Outcomes of a system-wide protocol for elective and nonelective coronary angioplasty at sites without on-site surgery: the Mayo Clinic experience

OBJECTIVE

To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital).

PATIENTS AND METHODS

Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site.

RESULTS

Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge.

CONCLUSION

Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.

Outcomes of a system-wide protocol for elective and nonelective coronary angioplasty at sites without on-site surgery: the Mayo Clinic experience

OBJECTIVE

To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital).

PATIENTS AND METHODS

Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site.

RESULTS

Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge.

CONCLUSION

Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.

Trends in the Association Between Age and In-Hospital Mortality After Percutaneous Coronary Intervention

Background— Temporal trends and contemporary data characterizing the impact of patient age on in-hospital outcomes of percutaneous coronary interventions are lacking. We sought to determine the importance of age by assessing the in-hospital mortality of stratified age groups in the National Cardiovascular Data Registry.

Methods and Results— In-hospital mortality after percutaneous coronary intervention on 1 410 069 patients was age stratified into 4 groups—group 1 (age <40, n=25 679), group 2 (40 to 59, n=496 204), group 3 (60 to 79, n=732 574), and group 4 (≥80, n=155 612)—admitted from January 1, 2001, to December 31, 2006. Overall in-hospital mortality was 1.22%; in-hospital mortality was 0.60%, 0.59%, 1.26%, and 3.16% in groups 1 to 4, respectively, P <0.0001. Overall temporal improvement per calendar year in the adjusted in-hospital mortality after percutaneous coronary intervention was noted in most groups; however, this finding was significant only in the 2 older age groups, group 3 (odds ratio, 0.94; 95% CI, 0.92 to 0.96) and group 4 (odds ratio, 0.95; 95% CI, 0.92 to 0.97). The absolute mortality reduction was greatest in the most elderly group, those over the age of 80 years.

Conclusions— In-hospital mortality after percutaneous coronary intervention has fallen for all age groups over the past 6 years. However, the largest absolute reduction was seen among patients 80 years of age or older.

Clinical and procedural predictors of no-reflow phenomenon after primary percutaneous coronary interventions: experience at a single center

BACKGROUND

The aim of the study was to identify clinical factors, angiographic findings, and procedural features that predict no-reflow phenomenon (Thrombolysis In Myocardial Infarction (TIMI) flow grade < or =2) in patients with acute myocardial infarction (AMI) who undergo primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A series of 382 consecutive patients with AMI underwent primary PCI within 12 h of symptom onset. Patients with ischemic symptoms continuing for more than 12 h were also included. Clinical, angiographic and procedural data were collected for each subject. Ninety-three (24.3%) of the patients developed no-reflow phenomenon, and their findings were compared with those of the reflow group. Univariate analysis showed that advanced age (>60 years), delayed reperfusion (> or =4 h), low (< or =1) TIMI flow prior to PCI, cut-off type total occlusion, high thrombus burden on baseline angiography, long target lesion (>13.5 mm) and large vessel diameter all correlated with no-reflow (p<0.05 for all). Multiple logistic regression analysis identified that advanced age (odds ratio (OR) 1.04, p=0.001), delayed reperfusion (OR 1.4, p=0.0004), low TIMI flow before primary PCI (OR 1.1, p=0.0002), target lesion length (OR 5.1, p=0.0003) and high thrombus burden (OR 1.6, p=0.03) on angiography as independent predictors of no-reflow phenomenon.

CONCLUSION

The occurrence of no-reflow phenomenon after primary PCI can be predicted using simple clinical, angiographic and procedural features. In this selected group of patients, adjunctive pharmacotherapy and/or distal protection device may be of value.

Drug-eluting stents in octogenarians: early and intermediate outcome

BACKGROUND

Large randomized controlled trials have demonstrated that percutaneous coronary intervention with the routine use of drug-eluting stents is safe and effective. However, octogenarians are usually excluded from these trials.

METHODS

We analyzed 2453 consecutive patients who underwent DES implantation at the Mayo Clinic (Rochester, MN). The patients were classified in 2 age groups: patients > or = 80 years of age < or = 79 years of age.

RESULTS

Patients > or = 80 years old had significantly more adverse baseline characteristics including more comorbid conditions and more severe extensive coronary artery disease. Procedural success was high irrespective of the age group--97% in patients > or = 80 years of age versus 98% in the younger patients. Multivariate analysis demonstrated that age of > or = 80 years was significantly associated with inhospital major adverse cardiac events (MACEs) (P = .004). In addition, among inhospital survivors, octogenarians also had higher follow-up MACE rates (P < .001). At 12 months of follow-up, patients > or = 80 years of age had a mortality of 8.9% versus 3.0% for the younger patients (P < .001). The older patients also had more recurrent myocardial infarction (5.2% vs 2.6%, P = .019). However, there was no significant difference in 12-month target lesion revascularization (4.5% vs 4.9% [> or = 80 years of age vs < or = 79 years of age]) or coronary artery bypass grafting (1.8% vs 1.3% [> or = 80 years of age vs < or = 79 years of age]). After age-sex adjustment, life expectancy of octogenarians was similar to that of the general population (P = .78).

CONCLUSION

This study showed that drug-eluting stent implantation in octogenarians has high initial procedural success rates compared with the younger patients despite having more severe baseline risk characteristics. During follow-up, death and overall MACE rates remain higher in octogenarians but target lesion revascularization rates are similar.

Minimally Invasive Video-Assisted Thyroidectomy: The Learning Curve

<i>Background:</i> MIVAT (minimally invasive video-assisted thyroidectomy) is a recent technique that requires a learning curve. <i>Materials and Methods:</i> From July 2005 to December 2006, we treated 100 from a total of 467 thyroidectomy patients with MIVAT. We divided the patients into 3 groups. The first 2 groups consisted of 25 patients each: group A (cases 1–25) and group B (26–50). We also divided patients into 2 groups based on our surgical experience: group A + B (cases 1–50) and group C (cases 51–100). <i>Results:</i> The operative times for groups A and B were 101.7 and 84.6 min, respectively (p < 0.03); those for groups A + B and C were 91.07 and 63.06 min, respectively (p < 0.004). Complications of hypocalcemia were observed in 6 cases (4 in the first 50 cases and 2 in the second 50), and complications of nerve palsy were observed in 2 cases from group A. <i>Conclusions:</i> After 25 cases, we observed that the MIVAT procedure allows for a lower mean operative time and a reduction of complications.

Twenty-Five–Year Trends in In-Hospital and Long-Term Outcome After Percutaneous Coronary Intervention

Background— Little is known about the impact of technological and pharmacological advances on long-term outcome after percutaneous coronary intervention in general clinical practice.

Methods and Results— We analyzed in-hospital and long-term outcome of 24 410 percutaneous coronary interventions among 18 575 unique patients who underwent percutaneous coronary intervention at Mayo Clinic over 25 years. The study population was divided into group 1 (n=3708), coronary interventions from 1979 to 1989; group 2 (n=7020), interventions from 1990 to 1996; group 3 (n=10 952), interventions from 1996 to 2003; and group 4 (n=2730), interventions from 2003 to 2004. Despite the fact that patients in groups 3 and 4 were significantly older, sicker, and had greater prevalence of comorbid conditions, heart failure, and previous revascularization than those in groups 1 and 2, procedural success in groups 3 and 4 improved significantly (94%) versus groups 2 (89%) and 1 (78%) ( P <0.001). Significant reduction in in-hospital mortality (groups 4 to 1: 1.8%, 1.7%, 2.6%, 3.0%; P <0.001) and need for emergency bypass surgery (groups 4 to 1: 0.4%, 0.5%, 1.6%, 5%; P <0.001) was noted in groups 3 and 4 compared with groups 1 and 2. Better adherence to currently recommended evidence-based medications for secondary prevention was seen in the recent time periods. After adjustment, significant reduction in follow-up mortality (hazard ratio, 0.81 and 0.74 for groups 3 and 4, respectively); death or myocardial infarction (hazard ratio, 0.80 and 0.75 for groups 3 and 4, respectively); death, myocardial infarction, or revascularization (hazard ratio, 0.76 and 0.58 for groups 3 and 4, respectively) was noted in recent time periods.

Conclusions— Despite higher-risk profiles of patients who underwent percutaneous coronary intervention in recent time periods, procedural success as well as in-hospital and long-term outcomes improved significantly over the last 25 years.

Letalidade hospitalar nas angioplastias coronárias no Estado do Rio de Janeiro, Brasil, 1999-2003

O estudo analisa a letalidade hospitalar nas angioplastias coronárias, pagas pelo Sistema Único de Saúde (SUS), realizadas nos hospitais do Estado do Rio de Janeiro, Brasil, de 1999 até 2003. As informações sobre as angioplastias coronárias provieram do banco de Autorizações de Internações Hospitalares da Secretaria de Estado de Saúde do Estado do Rio de Janeiro. As taxas de letalidade foram estimadas segundo faixas etárias, sexo, diagnósticos e hospitais. A letalidade geral foi de 1,9% em 8.735 angioplastias coronárias. A taxa mais baixa ocorreu nas anginas (0,8%), as mais elevadas nos infartos agudos do miocárdio (6%) e em outros diagnósticos (7%). A letalidade foi menor nas mulheres na faixa etária entre 50 e 69 anos, e a partir dos setenta anos foi quase três vezes maior que a dos mais jovens (de 1,4 a 4%), em ambos os sexos. Ocorreu grande variabilidade entre as taxas de letalidade nas angioplastias coronárias nos diferentes hospitais (entre 0 e 6,5%). Portanto, é necessário acompanhar de modo contínuo a adequação da utilização da angioplastia coronária. Em conclusão, a performance deste procedimento no âmbito da modalidade de atenção pelo SUS nos hospitais, dentro do período estudado, não foi satisfatória.

An Invasive Strategy Is Associated With Decreased Mortality in Patients 80 Years and Older With Acute Myocardial Infarction

The value of invasive therapy in elderly patients with acute myocardial infarction is controversial. The authors performed a retrospective chart review of 140 consecutive patients 80 years and older who were hospitalized with acute myocardial infarction. Hospital outcomes and long-term survival were compared in 79 patients referred for cardiac catheterization during hospitalization with outcomes in 61 patients managed conservatively. Vital status as of December 2003 was determined from the Social Security Death Index. Propensity analysis was used to limit confounding from 13 variables. After a mean follow-up of 333 days, unadjusted mortality was lower in the invasive group (16.5% vs 50.8%; P<.001). The multivariable propensity-adjusted hazard ratio for death was 0.30 (95% confidence interval, 0.11-0.76; P=.01), favoring the invasive group. These data suggest that in patients 80 years and older who are hospitalized with acute myocardial infarction, an invasive strategy confers a significant survival advantage during the first year after hospital discharge.

Primary percutaneous interventions for acute myocardial infarction in octogenarians: a single-center experience

BACKGROUND

The majority of cardiovascular deaths occur in the elderly. The safety and results of primary infarct intervention in octogenarians is not well characterized.

HYPOTHESIS

The purpose of this study was to compare the results of primary infarct intervention in octogenarians with those in younger patients during 1997-1998 and to compare these results to those obtained in octogenarians treated in 1991-1994.

METHODS

During 1997-1998, 40 octogenarians were treated with primary infarct intervention and were compared with 60 randomly selected patients aged < 80 years treated during the same time period. The results in octogenarians were compared with the results in a group of 37 patients of similar age treated in 1991-1994. The baseline characteristics, procedural results, and hospital outcome were obtained from a prospectively designed interventional database at a busy single-center program.

RESULTS

There was no significant difference in hospital survival between the two groups of patients treated in 1997-1998 although there was a trend toward higher mortality in the octogenarian group. Length of stay and use of intra-aortic balloon pumps were greater in the octogenarian group. When the results in octogenarians treated in 1997-1998 were compared with the group of 37 patients treated in 1991-1994, the hospital mortality declined from 27 to 10% (p = 0.05).

CONCLUSIONS

There has been improvement in hospital mortality over the past decade for patients aged > or = 80 years treated with primary infarct intervention. Hospital resources and length of stay are greater for the octogenarian group. Ongoing research studies are comparing the results of thrombolytic therapy and primary intervention in aged patients.

Survival in octogenarians receiving implantable defibrillators

BACKGROUND

Although clinical trials have expanded implantable defibrillator (ICD) indications, octogenarians have been poorly represented in these studies. Overall, survival in this subgroup is ill-defined.

METHODS

Consecutive patients > or = 80 years of age at ICD implant between July 1995 and September 2003 were retrospectively analyzed. Kaplan-Meier survival analysis was performed, and mortality predictors were identified. Consecutive nonelderly patients aged 60 to 70 years (60-70 group) who received ICDs over the same period were analyzed as a reference. Mortality predictors in the > or = 80 group were compared to the 60-to-70 group.

RESULTS

A total of 348 patients (age, > or = 80 years [n = 107]; age, 60-70 years [n = 241]) were included. Mean follow-up time for the entire cohort was 3.3 +/- 2.2 years. Other than the estimated glomerular filtration rate (eGFR) (58 +/- 22 vs 66 +/- 22 mL/min) in the > or = 80 group versus the 60-to-70 group, no other differences in baseline characteristics were observed. Median survival was 4.2 years after implant in the > or = 80 group versus 7 years in the 60-to-70 group (P < .01). Mortality predictors in the > or = 80 group included ejection fraction (EF) < or = 30% (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.3-4.0) and eGFR < 60 mL/min (HR, 2.2; 95% CI, 1.3-3.7). In the 60-to-70 group, EF < or = 30% (HR, 2.7; 95% CI, 1.6-4.5), eGFR < 60 mL/min (HR, 3.4; 95% CI, 2.2-5.3), diabetes (HR, 1.8; 95% CI, 1.9-2.9), and QRS width > 120 ms (HR, 2.1; 95% CI, 1.4-3.3) predicted mortality. QRS > 120 ms and diabetes were not predictors in octogenarians (HR, 1.1 and 1.5, respectively; 95% CI, 0.7-1.9 and 0.8-2.7, respectively). Analysis of octogenarians subgrouped by EF < or = 30% and eGFR < 60 mL/min identified patients whose median survival was 6.1 years (neither predictor present; n = 28), 4.7 years (either predictor present; n = 46), and 19 months (both predictors present; n = 33) (P < .01 between groups). Survival analysis in the > or = 80-year-old cohort grouped by eGFR quartile identified groups with median survival of 5.6, 4.7, 3.5 years, and 18 months, respectively, in the highest to the lowest eGFR quartile (> 75, 61-75, 41-60, and < 41 mL/min).

CONCLUSIONS

Median survival in octogenarian ICD recipients is greater than 4 years. In addition to baseline EF, eGFR is a strong predictor of mortality in elderly ICD candidates. These easily identifiable clinical variables may assist clinical decision making and help to provide appropriate post-ICD implant survival expectations in this elderly patient group.

Aging Adversely Affects Postinfarction Inflammatory Response and Early Left Ventricular Remodeling after Reperfused Acute Anterior Myocardial Infarction

BACKGROUND AND AIMS

We have demonstrated that an increased peak serum C-reactive protein (CRP) level after acute myocardial infarction (AMI) was a major predictor of left ventricular (LV) remodeling. We sought to clarify the effect of aging on the postinfarction inflammatory response and LV remodeling.

METHODS

We studied 102 patients who underwent primary angioplasty for a first anterior Q-wave AMI. Serum CRP levels, plasma neurohormones and interleukin-6 (IL-6) levels, and LV volume by left ventriculography were serially measured. Patients were divided into two groups according to their age (>or=70 years, n=33; <70 years, n=69).

RESULTS

There was no difference in use of cardiovascular drugs and coronary angiographic findings. Older patients had a greater increase in LV end-diastolic volume during 2 weeks after AMI (p=0.0007) and a higher peak CRP level (12.4+/-7.3 vs. 5.5+/-4.2 mg/dl, p<0.0001), although peak CK level was comparable between the two groups. Plasma atrial natriuretic peptide, brain natriuretic peptide and IL-6 levels were higher in older patients at 2 weeks and 6 months after AMI.

CONCLUSIONS

Augmented and prolonged activation of the inflammatory system after AMI was observed in older patients, in association with exaggerated LV remodeling. Aging may adversely affect LV remodeling through modification of the inflammatory response after AMI.

Outcome of Primary Percutaneous Coronary Intervention in Octogenarians with Acute Myocardial Infarction

BACKGROUND/PURPOSE

Acute myocardial infarction (AMI) results in more complications and increased mortality in octogenarians compared to patients in younger age groups. This study investigated the short- and long-term outcomes in octogenarians after primary percutaneous coronary intervention (PCI).

METHODS

During the study period from May 1997 to August 2004, 54 patients > or = 80 years old with ST-elevation myocardial infarction (STEMI) were eligible for primary PCI. Data collected included baseline clinical characteristics and usage of cardiovascular medications. Diagnostic coronary angiography and revascularization procedures were performed using standard practices. During hospitalization, the clinical course including serial changes in cardiac enzymes, adverse events associated with myocardial infarction or treatment, and inhospital or long-term mortality of patients were recorded.

RESULTS

The mean age of the 54 patients (35 men, 19 women) was 82.8 +/- 2.5 years (range, 80-89 years). Among them, 27 (50%) had anterior infarction, six (11%) had anterolateral infarction, and 21 (39%) had inferior infarction, inclusive of three patients with accompanying right ventricular infarction. Among them, 20 (37%) patients were in Killip class I, nine (17%) were in class II, two (4%) in class III, and 23 (43%) in class IV. The mean delay from onset of symptoms to arrival in hospital was 220 +/- 167 minutes, and 189 +/- 169 minutes from hospital arrival to reperfusion. Diagnostic coronary angiography revealed that 48 (89%) patients had multivessel disease. Inhospital death occurred in 23 (43%) patients, with the leading causes of death being profound cardiogenic shock (61%), and free wall rupture (26%).

CONCLUSION

Octogenarian patients who developed STEMI tended to have multivessel disease. These patients had a high inhospital mortality rate that was most likely to be due to cardiogenic shock.

Prediction of complications following nonemergency percutaneous coronary interventions

Previous models for prediction of complications after percutaneous coronary interventions (PCIs) have included in-hospital mortality and major in-hospital complications. In general, these models have excluded elevated cardiac biomarkers as a complication. We sought to determine whether a risk model could predict complications, including biomarker elevation, in patients undergoing nonemergency PCI. We examined the outcomes of nonemergency PCI performed on patients at Mayo Clinic from 2000 to 2003. The primary end point was in-hospital complications of death, myocardial infarction (MI) (Q-wave MI, or post-PCI creatine kinase-MB elevation >or=3 times the upper limit of normal), emergency coronary artery bypass grafting, or stroke. We used the Hosmer-Lemeshow test to demonstrate the adequacy of the model fit, and the c-index for discriminatory ability of the model. Of 2,894 nonemergency PCIs, the end point was noted in 232 (8%). The final prediction model included vein graft intervention (odds ratio [OR] 2.19), angiographic thrombus (OR 2.12), preprocedure stenosis of a minor (OR 1.98) or major (OR 1.62) side branch, and type C lesion (OR 1.48). The model had modest ability to discriminate between event and nonevent patients (c = 0.641). In the 500 bootstrap samples for internal validation, the c-index was 0.642 +/- 0.020, indicating only fair discriminatory ability. The average number of observed events was 232.0 +/- 14.7 compared with 232.1 +/- 2.5 expected events (average difference -0.06 +/- 14.5). In conclusion, the 5 risk variables associated with an increased risk of complications in patients undergoing elective PCI included vein graft intervention, presence of angiographic thrombus, stenosis of a major or minor side branch, and type C lesion; however, the discriminatory ability of the model derived from the variables was only modest.

Reperfusion treatment of ST-elevation acute myocardial infarction

Reperfusion treatment of ST-segment elevation myocardial infarction (STEMI) is one of the medical interventions with the largest potential for saving human lives, independently of age and gender. An attempt to reopen an acutely occluded coronary artery can be done within a wide array of possibilities, from the simple administration of aspirin to the combination of drugs and complex coronary artery interventions. Fibrinolytic drugs and aspirin represent the easiest way to attempt reperfusion and together offer an acceptable compromise between opportunity for treatment and efficacy. Other drugs and the use of invasive revascularization alternatives yield further advantages, and in some high-risk subgroups may be the most rational treatment approach. Beyond investigator's bias and dedication to either form of reperfusion treatment, interventions and/or drugs should be used as needed (and as possible) to increase the overall impact of reperfusion treatment in the community, taking advantage of the best potential of each approach. Most resources have been directed toward the improvement of reperfusion rates with the combination of fibrinolytic and antiplatelet drugs or with angioplasty. These efforts have certainly raised costs, but have not decisively improved clinical outcome nor have they broadened the impact of reperfusion treatment in the community. Indeed, the main shortcoming of reperfusion therapy is that the cohort of untreated patients is still larger than the cohort of treated patients. At a time when mortality of patients with STEMI reaching the hospital and receiving treatment has decreased significantly, the prehospital diagnosis and treatment of STEMI with the objective of enlarging the treated population and shortening the pretreatment delays is likely the best strategy to further reduce mortality. The need for a population approach to treatment of STEMI is even more obvious when considering the expanding patient load that continuously worsens its clinical risk profile, together with the increasing incidence of diabetes, obesity, hypertension, and smoking habits. The target for improving reperfusion treatment of STEMI in the future, and thereby saving more lives, seems now to involve a cultural change and fulfillment of an organizational mission more than an incremental improvement in the current pharmacologic or interventional approach. These epidemiologic and social aspects of contemporary medicine deserve full attention at a time when researchers, clinicians, and health care providers tend to focus primarily on technological advances.

Comparison of Mayo Clinic risk score and American College of Cardiology/American Heart Association lesion classification in the prediction of adverse cardiovascular outcome following percutaneous coronary interventions

OBJECTIVES

We compared American College of Cardiology/American Heart Association (ACC/AHA) lesion classification with the recently proposed Mayo Clinic risk score to predict complications following percutaneous coronary intervention (PCI).

BACKGROUND

The ability of the ACC/AHA classification system to predict complications following PCI has been modest. With the inclusion of patient demographics, acuity of presentation, and measure of left ventricular function, models with better discriminatory accuracy are presently available.

METHODS

The Mayo Clinic risk score is constructed by adding integer scores for the presence of eight variables. We mapped the lesion-specific risk levels to a patient level by counting the number of lesions in each class (A, B1, B2, C, and unknown).

RESULTS

In 5,064 PCIs, 183 patients (4%) had the primary end point (death, Q-wave myocardial infarction, stroke, emergency coronary artery bypass graft). Of the 7,632 treated lesions, 891 (12%) were unsuccessfully treated with PCI (residual stenosis >20%). The discriminatory ability of the Mayo Clinic risk score model for prediction of the primary end point, as measured by the c-statistic, was 0.78 (95% confidence interval [CI] 0.74 to 0.81). The Mayo Clinic risk score offered significantly better risk stratification than the ACC/AHA lesion classification counts (95% CI for c-statistic difference: 0.05 to 0.15). Regarding angiographic success, the ACC/AHA lesion classification was a better system (95% CI for c-statistic difference: -0.08 to -0.03 favoring ACC/AHA classification), although its absolute ability was modest (c = 0.58).

CONCLUSIONS

Mayo Clinic risk score offers significantly better prediction for cardiovascular complications than the ACC/AHA classification. However, lesion classification by ACC/AHA classification is a better predictor for angiographic success.

Outcomes of elderly patients with cardiogenic shock treated with early percutaneous revascularization

BACKGROUND

Subgroup analysis from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial indicated that patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) who were > or =75 years old did not benefit from early revascularization and may have been harmed; their mortality rate at 30 days was 75%. The applicability of this subset analysis from a select patient population enrolled in a randomized trial to the general population is unclear.

METHODS

At the Mayo Clinic between 1991 and 2000, we evaluated the outcome of all patients > or =75 years old with CS caused by MI who underwent urgent percutaneous coronary intervention (PCI).

RESULTS

The study included 61 patients with a mean age of 79.5 +/- 3 years; 21% of these patients had a history of prior coronary artery bypass grafting (CABG), 41% had had a prior MI, 28% had diabetes mellitus, and 18% had a history of a cerebrovascular accident (CVA). PCI was performed 8.0 +/- 7.2 hours after onset of MI. Angiographic success (<50% residual stenosis) was achieved in 91% of the lesions that were dilated. In hospital outcomes included death (44%), CABG (1.6%), and CVA (4.9%). The 30-day mortality rate was 47%. The estimated survival rate 1 year after discharge (Kaplan Meier method) was 75%.

CONCLUSIONS

These data confirm a high early mortality rate among patients > or =75 years old with MI complicated by CS, but suggest that among patients referred for angiography, outcomes may be better than previously believed when early revascularization is performed. In this population, 56% of patients survived to be discharged from the hospital, and of the hospital survivors, 75% were alive at 1 year.