Percutaneous coronary interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors' safety profile

Antiplatelet Therapy for Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

The elderly represent an increasing proportion of patients presenting with acute coronary syndrome (ACS). Various data have shown that the benefits of percutaneous coronary revascularization are maintained in elderly patients presenting with ACS. Conversely, the management of antiplatelet therapy remains challenging and controversial, because older patients are usually at a high risk of both ischemia and bleeding. Moreover, the recommended ischemic and bleeding risk scores in patients with ACS were developed from studies with a low representation of older patients. New antiplatelet strategies have been developed, but their evidence in elderly patients is limited because they are usually underrepresented in randomized clinical trials due to their clinical complexity. The aim of this review is to summarize the different factors associated with increased ischemic and/or bleeding risk and the scientific evidence about the different antiplatelet strategies in elderly patients presenting with ACS and undergoing percutaneous coronary revascularization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Percutaneous Coronary Intervention in Elderly Patients with Coronary Chronic Total Occlusions: Current Evidence and Future Perspectives

The proportion of the elderly in the total population of the world is growing, and the number of elderly patients with coronary chronic total occlusions (CTO) is huge. The elderly patients often have more extensive coronary artery disease, more severe ischemic burden and higher risk of cardiovascular events, as compared to younger patients, and thereby they might greatly benefit from coronary revascularization, even though they may have higher risk of operative complications. Most interventional cardiologists are more likely to be reluctant to operate complex percutaneous coronary intervention (PCI) in elderly patients. The latest refinements in dedicated CTO-PCI equipment and techniques have led to high rates of success and low complications rates and have made the CTO-PCI procedures safe and effective among the elderly patients. However, up to now, there is no widely recognized consensus or guideline on treatment strategy of elderly CTO patients, and the prognosis in this population is unknown. In this review, we aim to provide an overview of the current evidence and future perspectives on PCI in elderly patients with CTOs.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Comparison of Outcomes of Patients With ST-Segment Elevation Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention Analyzed by Age Groups (<75, 75 to 85, and >85 Years); (Results from the Bremen STEMI Registry)

As old patients, who were treated by percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), are regularly excluded or underrepresented in randomized trials, data on treatment and outcomes of this patient group at high risk have to be collected by registries. The study population of the German Bremen STEMI Registry was divided into the age groups G1: <75 years (n = 4,108, young), G2: 75 to 85 years (n = 1,032, old), and G3: >85 years (n = 216, very old) and was evaluated for clinical management and course. PCI failure (Thrombolysis In Myocardial Infarction flow 0 or 1 after PCI) was observed more often with increasing age. Patients >85 years without successful PCI had a very high inhospital mortality (40.0% without PCI success vs 18.1% with PCI success, p <0.05). Despite a reduced rate of periinterventional treatment with glycoprotein IIb/IIIa inhibitors in elderly patients of G2 and G3, inhospital bleedings (Thrombolysis In Myocardial Infarction/Bleeding Academic Research Consortium ≥2) occurred more frequently in these patients (G1: 5.4% vs G2: 11.0% vs G3: 19.6%, p <0.0001). Mortality rates during inhospital and long-term course increased with increasing age. In a multivariate analysis successful PCI was associated with improved outcomes in all age groups; even in very old patients successful PCI was associated with a significantly lower inhospital mortality rate (odds ratio 0.26, 95% confidence interval 0.08 to 0.81) and a trend toward a lower 1-year mortality. In conclusion, the present "real-world" data demonstrate an elevated rate of PCI failure, bleeding complications, and mortality in elderly patients treated by primary PCI for STEMI. However, a beneficial effect of successful PCI on mortality was observed in all age groups, even in very old patients, indicating the crucial role of revascularization therapy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The clinical value of single photon emission computed tomography myocardial perfusion imaging in cardiac risk stratification of very elderly patients (≥80 years) with suspected coronary artery disease

BACKGROUND

The role of single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) in cardiac evaluation of the very elderly patients is unclear. We investigated the clinical value of SPECT MPI in very elderly patients (≥80 years) with suspected coronary artery disease (CAD) as well as in comparison to younger patients.

METHODS AND RESULTS

A retrospective analysis of prospectively collected data from 8,864 patients [1,093 patients ≥80 years (very elderly), 3,369 patients 65-79 years (elderly), and 4,402 patients 50-64 years (middle-aged)] with suspected CAD who underwent exercise and/or pharmacologic stress testing with SPECT MPI between 1996 and 2005 was performed. Clinical and SPECT MPI characteristics, cardiac event rates, early (≤60 days) cardiac catheterization and revascularization rates of very elderly patients were compared to that of younger patients. Mean follow-up for cardiac events (cardiac death or non-fatal myocardial infarction) was 1.9 ± 0.9 years. Very elderly patients with moderate to severely abnormal SSS had a significantly higher annualized cardiac event rate than those with mildly abnormal or normal study (9.6% vs 3.4% and 2.5% respectively, P < .001). Across all categories of SSS, very elderly patients had a significantly higher cardiac event rate as compared to younger patients (P < .001). Early cardiac catheterization and revascularization referrals in very elderly patients increased as a function of severity of ischemia on SPECT MPI (P < .001), although these referral rates were significantly lower in very elderly patients with mild to moderate and severe ischemia as compared to younger patients (P < .05).

CONCLUSIONS

In very elderly patients (≥80 years) with suspected CAD, SPECT MPI has prognostic and incremental value in the noninvasive cardiovascular assessment for risk stratification and may influence medical decisions.

Age related issues in reperfusion of myocardial infarction

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.

The Role of Glycoprotein IIb/IIIa Inhibitors- A Promise Not Kept?

For over one decade Glycoproteins IIb/IIIa inhibitors (GPI) have been administered to prevent coronary artery thrombosis. Initially these agents were used for acute coronary syndromes and subsequently as adjunctive pharmacotherapy for percutaneous coronary interventions (PCIs).

Most benefit of GPI emerged from reduction of ischemic events: mostly non-q-wave myocardial infarctions (NQWMIs) during PCI. However, individual randomized clinical trials could not demonstrate that any of these agents could significantly reduce mortality in any clinical subset of patients. Studies of employing prolonged oral GPI administration resulted in excessive death. The non-homogenous statistically-significant reduction of ischemic endpoints was accompanied by an excess of bleeding, vascular complications, and thrombocytopenia. The clinical and ecomomic burden of major bleeding and thrombocytopenia is substantial. The ACUITY trial has initiate a new debate regarding the efficacy and safety of GPI.

Selective “patient-tailored” use of GPI limited to moderate-high risk PCI patients with low bleeding propensity is suggested. Research of new algorithms emphasizing abbreviated GPI administration, careful access site and bleeding surveillance, in conjunction with lower doses of unfractionated heparin or new and safer anti-thrombins may further enhance patient safety.

[ST-elevation myocardial infarction in octogerians]

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

Acute coronary syndrome in the elderly

The spectrum of acute coronary syndrome (ACS) including unstable angina, non-ST-elevation myocardial infarction and ST-elevation myocardial infarction accounts for increasing numbers of deaths among persons age > or = 65 years in the US. This is important given demographic changes involving falling birth rates and increasing life expectancy. Elderly patients are likely to benefit the most from treatment of ACS, even though community practice still demonstrates less use of cardiac medications as an early-invasive approach among this population.

Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in elderly patients transferred with ST-elevation myocardial infarction: data from the EUROTRANSFER registry

BACKGROUND

Limited data are available concerning benefits and risks of early abciximab (EA) administration before primary percutaneous coronary intervention (PPCI) in elderly ST-segment elevation myocardial infarction (STEMI) patients. The objective of the study was to assess the impact of EA before PPCI in elderly (>or=65 years) patients.

METHODS AND RESULTS

We identified 545 patients <65 years (354 with EA administration (>30 min before PPCI), 191 late abciximab (LA)), and 541 patients >or=65 years of age (373 EA, 168 LA) in the EUROTRANSFER Registry database. Elderly patients were more likely to have comorbidities, angiographic PCI complications, and bleeding events. EA promotes infarct-related artery patency before PPCI and improves myocardial reperfusion after PPCI in both age groups, but the risk of 30-day death (EA vs. LA: <65 years, 2.0% vs. 1.6%; p=0.999; >or=65 years, 5.9% vs. 14.3%; p=0.001) and 30-day death+reinfarction (EA vs. LA: <65 years, 2.5% vs. 2.1%; p=0.999; >or=65 years, 7.5% vs. 17.3%; p=0.001) was reduced in elderly patients only. There was no difference in bleedings, especially major bleedings requiring transfusion (EA vs. LA: patients <65 years, 2.3% vs. 0%, p=0.055; >or=65 years, 2.4% vs. 3%; p=0.448) between groups.

CONCLUSIONS

Patients >or=65 years of age have a substantially increased risk of angiographic PCI complications, death and bleeding events compared with their younger counterparts. Strategy of EA before PPCI improves reperfusion parameters and clinical outcome in elderly patients and is not associated with elevated risk of major bleeding.

Benefit of standard versus low-dose tirofiban for percutaneous coronary intervention in very elderly patients with high-risk acute coronary syndrome

AIM

This study aimed to compare the efficacy and safety between standard and low-dose tirofiban in the treatment of elderly high-risk non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients who underwent percutaneous coronary intervention (PCI).

METHODS

Ninety-four very elderly (>or=80 years) high-risk patients with NSTE-ACS were randomly assigned to the standard or the low-dose group. Upstream tirofiban was administered intravenously with a bolus dose of 0.4 microg x kg(-1) x min(-1) over a period of 30 min after the diagnosis had been confirmed, and was followed by a 36-48 h infusion of 0.10 microg x kg(-1) x min(-1) or 0.075 microg x kg(-1) x min(-1). PCI was performed within 24 h of admission. Platelet aggregation inhibition and thrombolysis in myocardial infarction (TIMI) grade flow were assessed. The major adverse cardiac events (MACEs), including death, myocardial infarction, recurrent angina and urgent target-vessel revascularization (TVR), were documented at 7 d, 30 d, and 6 months, and bleeding events were recorded at 7 d.

RESULTS

Although a significantly higher inhibition of platelet aggregation was observed in the standard-dose group (P<0.05), angiographic PCI success was similar between the two groups (P>0.05). The rate of MACEs was not significantly different at 7 days (2.1% vs 4.4%, P=0.61), 30 days (6.3% vs 8.7%, P=0.71) and 6 months (14.6% vs 17.4%, P=0.71). Major bleeding events were significantly higher in the standard-dose group (10.4% vs 0.0%, P=0.03).

CONCLUSION

In very elderly high-risk patients with NSTE-ACS undergoing PCI, low-dose tirofiban offered about the same level of protection from major ischemic events that standard doses did, with less associated bleeding.

Transfusion associated microchimerism: a heretofore little-recognized complication following transfusion

Potent antiplatelet and antithrombotic agents have significantly reduced mortality in the setting of acute coronary syndromes and percutaneous coronary intervention. However these agents are associated with increased bleeding which is in turn associated with adverse clinical outcomes. In many centers, transfusion is often used to correct for blood loss. Blood transfusion in the setting of acute coronary syndrome has been associated with adverse clinical outcomes including increased mortality. Transfusion associated microchimerism (TA-MC) is a newly recognized complication of blood transfusion. There is engraftment of the donor's hematopoietic stem cells in patients who then develop microchimerism. This article discusses the association of bleeding/blood transfusion with adverse outcomes and the potential role of TA-MC in clinical outcomes.

Abciximab in elderly with acute coronary syndrome invasively treated: effect on outcome

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77+/-1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77+/-2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p=0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p=0.0001), and pre-PCI (5.7% vs 13.4%; p=0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394-0.976, p=0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

Intracoronary abciximab use in patients undergoing PCI at a community hospital: a single operator experience

OBJECTIVE

To evaluate the safety of intracoronary (IC) abciximab during percutaneous coronary intervention (PCI).

BACKGROUND

Adjunctive treatment with glycoprotein IIb/IIIa inhibitors, especially abciximab, during PCI has been shown to improve clinical and procedural outcomes in numerous studies. However, significant bleeding complications exist with its use and this has limited its standard use. Interest has grown in local (IC) use with studies showing safety and long-term effectiveness, especially in patients with high thrombus loads.

METHODS

A retrospective review of records in a database of patients who had PCI by a single operator at the Easton Hospital.

RESULTS

611 patients received IC abciximab, and there were no complications in 610 (98.3%) patients; only 1 had an allergic reaction.

CONCLUSIONS

IC abciximab is safe and has a unique role in the catheterization lab and in patients at high risk of bleeding complications who would benefit from its limited use.

Impact of acute blood loss anemia and red blood cell transfusion on mortality after percutaneous coronary intervention

The clinical impact of increasing levels of blood loss has been shown to increase morbidity and mortality after percutaneous coronary intervention (PCI). The impact of red blood cell (RBC) transfusion for severe bleeding is unknown. We systematically collected baseline and 8-h postprocedure hematocrit (HCT) values on patients undergoing PCI. The incidence of adverse events, including death and recurrent myocardial infarction, was correlated to increasing blood loss. A total of 6,799 patients undergoing PCI (January 2000 to April 2002) had serial HCT levels. Negligible, mild, moderate, and severe blood loss occurred in 43, 25, 25, and 8% of patients, respectively. In-hospital mortality was 0.3, 0.5, 1.4, and 5.7% (p < 0.0001) with increasing severity of blood loss. Blood transfusion was independently associated with mortality (relative risk [RR] 2.03, p = 0.028). A case-controlled analysis of 146 transfused patients versus 292 nontransfused patients with severe bleeding found an independent association between RBC transfusion and increased risk of 1-year mortality (RR 2.42, p = 0.0045). Patients receiving blood >35 days old had significantly worse 1-year survival rates compared with patients receiving blood <35 days old and patients not transfused (36 vs. 24 vs. 10%, p < 0.0001). In a general PCI population, increasing levels of blood loss are associated with an increased incidence of major adverse cardiac events and in-hospital mortality. RBC transfusion in the setting of severe bleeding is associated with an increased risk of 1-year mortality. Transfusion of aged RBCs may also be detrimental in this setting.

Glycoprotein IIb/IIIa inhibitors: questioning indications and treatment algorithms

Glycoprotein inhibitors (GPI) are viewed as beneficial adjunctive pharmacotherapy agents for percutaneous coronary interventions (PCIs). The major benefit of GPI is derived from the reduction of ischemic events (mostly non-Q-wave myocardial infarctions) during PCI. There is no single randomized clinical trial demonstrating that any of these agents significantly reduces mortality in any clinical subset of patients. Studies of sustained oral GPI resulted in excessive death and myocardial infarctions. Reduction of ischemic end points was counteracted by excessive bleeding, vascular complications, and thrombocytopenia. These complications bear considerable medical and economic impact. The Acute Catheterization and Early Intervention Triage Strategy trial demonstrated that GPI, when added to heparin, enoxaparine, or bivalirudin, do not reduce mortality or ischemic events but significantly increase bleeding complications. Major bleeding resulted in threefold mortality at 1 year. In view of available data, the use of GPI should be limited to moderate-risk to high-risk PCI patients with low bleeding propensity. Protocols of abbreviated GPI administration and careful bleeding surveillance, in conjunction with lower doses of unfractionated heparin or new and possibly safer antithrombins, can potentially improve patient safety.

Coronary angiography in the elderly with acute myocardial infarction

BACKGROUND

Despite the high mortality rate in elderly patients with acute myocardial infarction (AMI), the value of coronary angiography (CA) in the elderly has been questioned due to a less favorable outcome. The aim of the study was to determine the prognostic significance of CA on mortality of elderly patients AMI in "real world" practice.

METHODS

The study cohort comprised 1009 elderly (age > or = 75 years) patients with AMI who were derived from three prospective national surveys between 1996 and 2000 in all 25 CCUs operating in Israel. Baseline characteristics, hospital course, management and outcome of 274 (27%) elderly patients who underwent CA during the index hospitalization were compared with 735 (73%) counterpart patients who did not.

RESULTS

Patients who underwent CA were on average 2.2 years younger, and were more often with hyperlipidemia (p<0.0001 for each) and with a history of previous percutaneous coronary intervention (p<0.03) than the control group. They had a more favorable clinical presentation: a higher systolic blood pressure (p<0.04), a better Killip class (p<0.03) and an increased frequency of non-Q wave MI (p<0.03). They developed more often recurrent MI (p=0.002) and re-ischemia (p<0.0001). Variables associated with CA use during the index hospitalization were re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a catheterization laboratory in the hospital, while a higher age and fibrinolytic therapy decreased the likelihood of CA use. Of the patients who underwent CA, 67% underwent coronary revascularization (either PCI and/or CABG). Crude and adjusted mortality rates at 1 year were significantly lower in patients who underwent CA, as compared to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio=0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted in a wide range of subgroups analyzed.

CONCLUSIONS

In "real world" practice, elderly patients with AMI who undergo CA during hospitalization have a better prognosis at 1 year. Age alone should not be a deterrent to performing CA in elderly patients with AMI. Further large randomized trials are needed to confirm that an invasive approach is beneficial in high-risk elderly patients with AMI.

CONDENSED ABSTRACT

To determine the prognostic significance of coronary angiography (CA) during the course of acute myocardial infarction (AMI) in "real world" practice on mortality of elderly patients, 1009 such patients were studied. Re-infarction, re-ischemia, the year of the index AMI and the availability of an on-site a Cath. Lab. were variables which increased the likelihood of undergoing CA, while a higher age and fibrinolytic therapy decreased this likelihood. The crude and covariate adjusted mortality rates at 1 year were significantly lower in patients who underwent CA in comparison to counterparts who did not: 21% vs. 37.3%, respectively (p<0.0001), hazard ratio 0.52 (95% confidence interval 0.38-0.71). The benefit of CA was noted across a wide range of subgroups analyzed.

Current issues in coronary artery stenting in the elderly

The aim of this review is to present current trends and outcomes among elderly patients undergoing coronary stenting for treatment of symptomatic coronary artery disease. Elderly patients are at higher risk for morbidity and mortality after coronary revascularization procedures. Acute and long-term outcomes relative to increased baseline risk factors and other competing mortality risks are reviewed for stenting and the alternatives of medical or surgical treatment. Improvement in quality of life is discussed as an outcome that some have regarded as more germane than simple survival in this population. Caution is urged for the often avoidable complications related to vascular injury, bleeding and contrast nephropathy, which are more common in the elderly after stenting and are independently associated with increased mortality. The authors also review the increasing relevance of coronary stent outcomes among the elderly in the context of the newer drug-eluting stents that have revolutionized percutaneous revascularization strategies.

Age-Dependent Effect of Abciximab in Patients With Acute Coronary Syndromes Treated With Percutaneous Coronary Interventions

Background— No studies have specifically performed an age-based analysis of the efficacy of abciximab in patients with non–ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention (PCI). The aim of the study was to assess whether there are age-dependent differences in the clinical benefit of abciximab in patients with acute coronary syndrome treated with PCI.

Methods and Results— We performed this retrospective analysis of 2022 patients with acute coronary syndrome enrolled in the Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment (ISAR-REACT 2) study and randomized to receive abciximab or placebo during a PCI procedure. The incidence of major adverse cardiac events (MACE) during the 30 days after PCI was the primary end point of the study. On the basis of the cutoff age value provided by logistic regression in connection with bootstrap resampling, patients were divided into those younger (n=1220) and older (n=802) than 70 years. Among younger patients, the incidence of MACE was 7.7% in the abciximab group versus 13.3% in the placebo group (relative risk 0.57, 95% confidence interval 0.40 to 0.80, P =0.001). In contrast, no difference was observed among older patients: The incidence of MACE was 10.9% in the abciximab group versus 9.9% in the placebo group (relative risk 1.10, 95% confidence interval 0.72 to 1.69, P =0.65). After adjustment for other variables, including cardiac troponin, there was a significant interaction between age and abciximab ( P =0.04) with respect to MACE reduction, with abciximab being more effective in younger patients.

Conclusions— In patients with non–ST-elevation acute coronary syndromes undergoing PCI, the efficacy of abciximab appears to be age-dependent, with greater benefit among younger 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.

Special issues when caring for the older person with acute coronary syndromes

Persons 75 years of age or older constitute 6% of the US population but account for more than one third of those with acute coronary syndromes (ACS). Unfortunately, most randomized clinical trials have enrolled few older persons, and, as a result, few data are available to guide clinical practice. As in younger patients, aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and angiotensin-converting enzyme inhibitors are useful, beginning with lower doses and carefully observing the patient for symptoms of toxicity. Similarly, older patients should not be denied the benefit of reperfusion therapy and early invasive strategy because of their age. Although primary angioplasty is an optimal reperfusion strategy, thrombolytic therapy is a beneficial alternative in carefully selected older patients. Although glycoprotein IIb/IIIa inhibitors appear to be beneficial in select cases, bleeding concerns exist. Despite a growing body of evidence in support of aggressive ACS care in older persons, evidence-based therapy is underused in older patients. Continued efforts are required to improve the quality of care to this high-risk cohort of ACS patients.

Predictors and 1-year outcome of major bleeding in patients with non-ST-elevation acute coronary syndromes: insights from the Canadian Acute Coronary Syndrome Registries

BACKGROUND

Bleeding is the major noncardiac adverse consequence of treatment in patients with non-ST-elevation (NSTE) acute coronary syndromes (ACS). The aims were to identify predictors of major bleeding in patients with NSTE ACS and to evaluate in-hospital and 1-year outcomes.

METHODS

We evaluated 5842 patients with NSTE-ACS included in the multicenter Canadian ACS Registries.

RESULTS

Patients with in-hospital major bleeding (n = 79, 1.4%) were older (75 vs 66 years, P < .001), with higher baseline creatinine (1.17 vs 1.02 mg/dL, P < .002), more diabetes (36% vs 25%, P = .04), hypertension (73% vs 54%, P < .002), previous stroke (20% vs 9%, P < .002), Killip class > or = II (P < .01), and ST-depression (37% vs 18%, P < .001). Antiplatelet/thrombotic therapies did not differ between patients with and without major bleeding. Crude event rates were significantly higher in patients with major bleeding: in-hospital death 19.2% vs 1.5% (P < .001), myocardial infarction (MI) 15.4% vs 3.8% (P < .001), and death or MI 26.9% vs 4.9% (P < .001). One-year event rates were also higher: death 35.9% vs 7.4% (P < .0001), MI 15.6% vs 6.2% (P = .0021), and death or MI 40.6% vs 12.6% (P < .0001). In multivariable analysis, independent predictors for major bleeding were age (OR 1.03, 95% CI 1.03-1.09), hypertension (1.72, 1.0-2.97), previous stroke (1.84, 1.0-3.37), and in-hospital catheterization (1.93, 1.06-3.53) or bypass surgery (2.18, 1.0-4.76). Major bleeding was an independent predictor of 1-year death (OR 3.92, 2.07-7.41) and death or MI (2.51, 1.41-4.48).

CONCLUSIONS

In patients with NSTE-ACS, major bleeding is associated with increased short- and long-term rates of death and MI, and is predicted by simple clinical characteristics.

Comparison of transradial and transfemoral approaches for coronary angiography and angioplasty in octogenarians (the OCTOPLUS study)

This prospective multicenter study was conducted to compare the incidence of significant vascular complications delaying hospital discharge after coronary angiography and percutaneous coronary intervention (PCI) between the radial approach (n = 192) and the femoral approach (n = 185) in octogenarians, a rapidly growing population with numerous risk factors for complications. By intention-to-treat analysis, the incidence of vascular complications was found to be significantly less in the radial group (1.6% vs 6.5%, p = 0.03), without any decrease in the efficacy of PCI and only a slight increase in procedure duration for coronary angiography. All vascular complications, except for 1, occurred in patients treated with the transfemoral approach.

State of the science for care of older adults with heart disease

This article provided an overview of the current state of knowledge related to cardiovascular disease in elders. Some depth has been provided related to CHD and HF, two common diagnoses in older persons. The most striking finding is that although trials are increasingly including older cohorts of patients, research specifically testing known therapies in older patients is essential. In particular, research testing the safety, efficacy, and acceptability of therapies in the oldest old is greatly needed.