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Komatsu J, Nishimura YK, Sugane H, Hosoda H, Imai RI, Nakaoka Y, Nishida K, Mito S, Seki SI, Kubo T, Kitaoka H, Kubokawa SI, Kawai K, Hamashige N, Doi YL. Early Invasive Strategy for Octogenarians and Nonagenarians With Acute Myocardial Infarction. Circ Rep 2024; 6:263-271. [PMID: 38989106 PMCID: PMC11233166 DOI: 10.1253/circrep.cr-24-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 05/08/2024] [Indexed: 07/12/2024] Open
Abstract
Background: Older adults with acute myocardial infarction (AMI) are currently a rapidly growing population. However, their clinical presentation and outcomes remain unresolved. Methods and Results: A total of 268 consecutive AMI patients were analyzed for clinical characteristics and outcomes with major adverse cardiovascular events (MACE) and all-cause mortality within 1 year. Patients aged ≥80 years (Over-80; n=100) were compared with those aged ≤79 years (Under-79; n=168). (1) Primary percutaneous coronary intervention (PCI) was frequently and similarly performed in both the Over-80 group and the Under-79 group (86% vs. 89%; P=0.52). (2) Killip class III-IV (P<0.01), in-hospital mortality (P<0.01), MACE (P=0.03) and all-cause mortality (P<0.01) were more prevalent in the Over-80 group than in the Under-79 group. (3) In the Over-80 group, frail patients showed a significantly worse clinical outcome compared with non-frail patients. (4) Multivariate analysis revealed Killip class III-IV was associated with MACE (odds ratio [OR]=3.51; P=0.02) and all-cause mortality (OR=9.49; P<0.01) in the Over-80 group. PCI was inversely associated with all-cause mortality (OR=0.13; P=0.02) in the Over-80 group. Conclusions: The rate of primary PCI did not decline with age. Although octogenarians/nonagenarians showed more severe clinical presentation and worse short-term outcomes compared with younger patients, particularly in those with frailty, the prognosis may be improved by early invasive strategy even in these very old patients.
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Affiliation(s)
- Junya Komatsu
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Hiroki Sugane
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Hayato Hosoda
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoko Nakaoka
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Koji Nishida
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shinji Mito
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Shu-Ichi Seki
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | - Toru Kubo
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Aging Science, Kochi Medical School Kochi Japan
| | | | - Kazuya Kawai
- Department of Cardiology, Chikamori Hospital Kochi Japan
| | | | - Yoshinori L Doi
- Department of Cardiology, Chikamori Hospital Kochi Japan
- Cardiomyopathy Institute, Chikamori Hospital Kochi Japan
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Kolarczyk E, Kohanová D, Witkowska A, Szymiczek M, Młynarska A. The factors of quality of life among patients after myocardial infarction in Poland: a cross-sectional study. The quality of life among patients after myocardial infarction. Sci Rep 2024; 14:15925. [PMID: 38987281 PMCID: PMC11237104 DOI: 10.1038/s41598-024-65525-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 06/20/2024] [Indexed: 07/12/2024] Open
Abstract
The quality of life (QoL) is now recognised as a central indicator of the effectiveness of interventions especially in patients after myocardial infarction (MI). The QoL may be important predict poor outcomes in cardiac patients.The present work aims to increase knowledge of the level of QoL in patients after MI. Moreover, the paper analyses the QoL in relation to sociodemographic factors and the degree of functioning in chronic disease. The study was conducted among 231 patients who were hospitalized due to MI within the period of June 2021 to June 2022 in the Hospital in Racibórz in Poland. The WHO Quality of Life Questionnaire and the Chronic Disease Functioning Scale were used. The analysis showed a statistically significant correlation (coefficient value 0.5 <|r/rho|≤ 0.7) between general functioning in chronic disease and the average QoL (rho = 0.56; p < 0.001)and somatic QoL levels(rho = 0.52; p < 0.001), as well as a moderately strong positive correlation with the QoL level on the psychological domain (rho = 0.50; p < 0.001), social domain(rho = 0.48; p < 0.001) and environmental domain (rho = 0.43; p < 0.001). The results of this study suggested that healthcare workers adopts appropriate policies for the implementation of quality of life, which can reduce the number of repetitive referrals to the hospital and costs imposed on the health system.
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Affiliation(s)
- Ewelina Kolarczyk
- Department of Gerontology and Geriatric Nursing, Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland.
| | - Dominika Kohanová
- Department of Nursing, Faculty of Social Sciences and Health Care, Constantine the Philosopher University, Nitra, Slovak Republic
| | - Agnieszka Witkowska
- Department of Cardiology, Electrotherapy and Angiology, Scanmed S.A. Racibórz Medical Center, 47-400, Racibórz, Poland
| | - Marek Szymiczek
- Department of Cardiology, Electrotherapy and Angiology, Scanmed S.A. Racibórz Medical Center, 47-400, Racibórz, Poland
| | - Agnieszka Młynarska
- Department of Gerontology and Geriatric Nursing, Faculty of Health Sciences, Medical University of Silesia, Katowice, Poland
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Pavasini R, Biscaglia S, Kunadian V, Hakeem A, Campo G. Coronary artery disease management in older adults: revascularization and exercise training. Eur Heart J 2024:ehae435. [PMID: 38985545 DOI: 10.1093/eurheartj/ehae435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/10/2024] [Accepted: 06/23/2024] [Indexed: 07/12/2024] Open
Abstract
The mean age of patients with coronary artery disease (CAD) is steadily increasing. In older patients, there is a tendency to underutilize invasive approach, coronary revascularization, up-to-date pharmacological therapies, and secondary prevention strategies, including cardiac rehabilitation. Older adults with CAD commonly exhibit atypical symptoms, multi-vessel disease involvement, complex coronary anatomy, and a higher presence of risk factors and comorbidities. Although both invasive procedures and medical treatments are characterized by a higher risk of complications, avoidance may result in a suboptimal outcome. Often, overlooked factors, such as coronary microvascular disease, malnutrition, and poor physical performance, play a key role in determining prognosis, yet they are not routinely assessed or addressed in older patients. Historically, clinicians have relied on sub-analyses or observational findings to make clinical decisions, as older adults were frequently excluded or under-represented in clinical studies. Recently, dedicated evidence through randomized clinical trials has become available for older CAD patients. Nevertheless, the management of older CAD patients still raises several important questions. This review aims to comprehensively summarize and critically evaluate this emerging evidence, focusing on invasive management and coronary revascularization. Furthermore, it seeks to contextualize these interventions within the framework of improved risk stratification tools for older CAD patients, through user-friendly scales along with emphasizing the importance of promoting physical activity and exercise training to enhance the outcomes of invasive and medical treatments. This comprehensive approach may represent the key to improving prognosis in the complex and growing patient population of older CAD patients.
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Affiliation(s)
- Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Abdul Hakeem
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Via Aldo Moro 8, 44124 Ferrara, Italy
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4
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Campo G, Guiducci V, Escaned J, Moreno R, Casella G, Cavazza C, Cerrato E, Contarini M, Arena M, Iniguez Romo A, Gutiérrez Ibañes E, Scarsini R, Vadalà G, Andò G, Pilato G, Musto d'Amore S, Capecchi A, Trillo Nouche R, Moscarella E, Gambino A, Pavani M, Zanetti A, Pesenti N, Dudek D, Barbato E, Tebaldi M, Biscaglia S. Health-Status Outcomes in Older Patients With Myocardial Infarction: Physiology-Guided Complete Revascularization Versus Culprit-Only Strategy. Circ Cardiovasc Qual Outcomes 2024; 17:e010490. [PMID: 38887951 DOI: 10.1161/circoutcomes.123.010490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 03/11/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The FIRE trial (Functional Assessment in Elderly Myocardial Infarction Patients With Multivessel Disease) enrolled 1445 older (aged ≥75 years) patients with myocardial infarction and multivessel disease in Italy, Spain, and Poland. Patients were randomized to physiology-guided complete revascularization or treatment of the only culprit lesion. Physiology-guided complete revascularization significantly reduced ischemic adverse events at 1 year. This prespecified analysis investigated the changes between the 2 study groups in angina status, quality of life, physical performance, and frailty. METHODS Patients underwent validated scales at hospital discharge (baseline) and 1 year later. Angina status was evaluated using the Seattle Angina Questionnaire, health-related quality of life by EQ visual analog scale, physical performance by short physical performance battery, and frailty by the clinical frailty scale. Mixed models for repeated measures analysis were used to study the association between the treatment arms, time, and scales. RESULTS Baseline and 1-year Seattle Angina Questionnaire, EQ visual analog scale, short physical performance battery, and clinical frailty scale were collected in around two-thirds of the entire FIRE study population. The mean age was 80.9±4.6 years (female sex, 35.9%). Overall, 35.3% were admitted for ST-segment-elevation myocardial infarction, whereas the others were admitted for non-ST-segment-elevation myocardial infarction. Physiology-guided complete revascularization, compared with culprit-only revascularization, was associated with greater improvement in terms of angina status (Seattle Angina Questionnaire summary score, 7.3 [95% CI, 6.1-8.6] points), health-related quality of life (EQ visual analog scale, 6.2 [95% CI, 4.4-8.1] points), and physical performance (short physical performance battery, 1.1 [95% CI, 0.9-1.3] points). After 1 year, patients randomized to culprit-only revascularization experienced a deterioration in frailty status (clinical frailty scale, 0.2 [95% CI, 0.1-0.3] points), which was not observed in patients randomized to physiology-guided complete revascularization. CONCLUSIONS The present analysis suggested that a physiology-guided complete revascularization is associated with consistent benefits in terms of angina status, quality of life, physical performance, and the absence of further deterioration of the frailty status. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03772743.
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Affiliation(s)
- Gianluca Campo
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Italy (G. Campo, S.B.)
| | - Vincenzo Guiducci
- Cardiology Unit, Azienda Unità Sanitaria Locale - Istituto di Ricovero e Cura a Carattere Scientifico Reggio Emilia, S. Maria Nuova Hospital, Italy (V.G., S.M.d.)
| | - Javier Escaned
- Hospital Clínico San Carlos Istituto de Investigacion Sanitaria Hospital San Carlos, Complutense University of Madrid, Spain (J.E.)
| | - Raul Moreno
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares, Madrid, Spain (R.M.)
- Instituto de Investigación Hospital La Paz, University Hospital La Paz, Madrid, Spain (R.M.)
| | - Gianni Casella
- Cardiology Unit, Ospedale Maggiore, Bologna, Italy (G. Casella, A.C.)
| | - Caterina Cavazza
- Cardiovascular Department, Infermi Hospital, Rimini, Italy (C.C.)
| | - Enrico Cerrato
- Interventional Cardiology Unit, San Luigi Gonzaga University Hospital, Orbassano, and Rivoli Infermi Hospital ASLTO3, Turin, Italy (E.C.)
| | | | - Marco Arena
- S.C. Cardiologia, Ospedale Sant'Andrea, La Spezia, Italy (M.A.)
| | | | | | - Roberto Scarsini
- Azienda Ospedaliero Universitaria Integrata di Verona, Italy (R.S.)
| | - Giuseppe Vadalà
- Azienda Ospedaliero Universitaria Policlinico Paolo Giaccone, Italy (G.V.)
| | - Giuseppe Andò
- Azienda Ospedaliero Universitaria Policlinico Gaetano Martino, Messina, Italy (G.A.)
| | - Gerlando Pilato
- Hospital San Giovanni di Dio, Azienda Sanitaria Provinciale Agrigento, Italy (G.P.)
| | - Sergio Musto d'Amore
- Cardiology Unit, Azienda Unità Sanitaria Locale - Istituto di Ricovero e Cura a Carattere Scientifico Reggio Emilia, S. Maria Nuova Hospital, Italy (V.G., S.M.d.)
| | | | - Ramiro Trillo Nouche
- Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain (R.T.N.)
| | | | | | - Marco Pavani
- Ospedale Santissima Annunziata, Savigliano, Italy (M.P.)
| | - Anna Zanetti
- We4 Clinical Research, Milan, Italy (A.Z., N.P.)
| | | | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland (D.D.)
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Italy (E.B.)
| | - Matteo Tebaldi
- Cardiology Unit, Ospedale "Degli Infermi" di Faenza, Italy (M.T.)
| | - Simone Biscaglia
- Cardiology Unit, Azienda Ospedaliero Universitaria di Ferrara, Italy (G. Campo, S.B.)
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Kotanidis CP, Mills GB, Bendz B, Berg ES, Hildick-Smith D, Hirlekar G, Milasinovic D, Morici N, Myat A, Tegn N, Sanchis J, Savonitto S, De Servi S, Fox KAA, Pocock S, Kunadian V. Invasive vs. conservative management of older patients with non-ST-elevation acute coronary syndrome: individual patient data meta-analysis. Eur Heart J 2024; 45:2052-2062. [PMID: 38596853 PMCID: PMC11177715 DOI: 10.1093/eurheartj/ehae151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/30/2024] [Accepted: 02/28/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND AND AIMS Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients. METHODS MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819). RESULTS Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality. CONCLUSIONS No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.
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Affiliation(s)
- Christos P Kotanidis
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Gregory B Mills
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Erlend S Berg
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - David Hildick-Smith
- Sussex Cardiac Centre, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Geir Hirlekar
- Department of Molecular and Clinical Medicine, Institute of Medicine, Gothenburg University, Gothenburg, Sweden
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | | | | | - Nicolai Tegn
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Juan Sanchis
- Department of Cardiology, Hospital Clinico Universitario, INCLIVA, Universitat de Valencia, CIBER-Cardiovascular, Valencia, Spain
| | | | - Stefano De Servi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, High Heaton NE7 7DN, United Kingdom
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Nilsson T, Mokhtari A, Sandgren J, Lundager Forberg J, Olsson de Capretz P, Ekelund U. Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care. Cardiology 2024:1-10. [PMID: 38599184 DOI: 10.1159/000538637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.
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Affiliation(s)
- Tsvetelina Nilsson
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Sandgren
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | | | | | - Ulf Ekelund
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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Lawless M, Damluji A, Dirjayanto VJ, Mills G, Pompei G, Rubino F, Kunadian V. Differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years following acute coronary syndromes: a prospective multicentre study. Open Heart 2023; 10:e002418. [PMID: 38151262 PMCID: PMC10753737 DOI: 10.1136/openhrt-2023-002418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/08/2023] [Indexed: 12/29/2023] Open
Abstract
OBJECTIVE This study describes the differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years presenting with acute coronary syndrome (ACS) and undergoing invasive management. METHODS A large-scale cohort study of patients with ST-elevation/non-ST-elevation myocardial infarction (MI)/unstable angina underwent coronary angiography (January 2015-December 2019). Patients were classified as older (≥75 years) and younger (≤74 years). Regression analysis was used to yield adjusted risks of mortality for older versus younger patients (adjusted for history of heart failure, hypercholesterolaemia, peripheral vascular disease, chronic obstructive pulmonary disease, ischaemic heart disease, presence of ST-elevation MI on presenting ECG, female sex and cardiogenic shock at presentation). RESULTS In total, 11 763 patients were diagnosed with ACS, of which 39% were aged ≥75 years. Percutaneous coronary intervention was performed in fewer older patients than younger patients (81.2% vs 86.2%, p<0.001). At discharge, older patients were prescribed less secondary-prevention medications than younger patients. Median follow-up was 4.57 years. Older patients had a greater risk of in-hospital mortality than younger patients (adjusted OR (aOR) 2.12, 95% CI 1.62 to 2.78, p<0.001). Older patients diagnosed with ST-elevation MI had greater adjusted odds of dying in-hospital (aOR 2.47, 95% CI 1.79 to 3.41, p<0.001). Older age was not an independent prognostic factor of mortality at 1 year (adjusted HR (aHR) 0.95, 95% CI 0.82 to 1.09, p=0.460) and at longer term (aHR 0.98, 95% CI 0.87 to 1.10, p=0.684). CONCLUSIONS Older patients are discharged with less secondary prevention. Patients aged ≥75 years are more likely to die in-hospital than younger patients.
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Affiliation(s)
- Michael Lawless
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Abdulla Damluji
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Gregory Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Graziella Pompei
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Francesca Rubino
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Cardiothoracic Directorate, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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9
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 549] [Impact Index Per Article: 549.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Cartlidge T, Kovacevic M, Navarese EP, Werner G, Kunadian V. Role of percutaneous coronary intervention in the modern-day management of chronic coronary syndrome. Heart 2023; 109:1429-1435. [PMID: 36928242 DOI: 10.1136/heartjnl-2022-321870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/06/2023] [Indexed: 03/18/2023] Open
Abstract
Contemporary randomised trials of percutaneous coronary intervention (PCI) in chronic coronary syndrome (CCS) demonstrate no difference between patients treated with a conservative or invasive strategy with respect to all-cause mortality or myocardial infarction, although trials lack power to test for individual endpoints and long-term follow-up data are needed. Open-label trials consistently show greater improvement in symptoms and quality of life among patients with stable angina treated with PCI. Further studies are awaited to clarify this finding. In patients with severe left ventricular (LV) systolic dysfunction and obstructive coronary artery disease in the Revascularization for Ischemic Ventricular Dysfunction trial, PCI has not been found to improve all-cause mortality, heart failure hospitalisation or recovery of LV function when compared with medical therapy. PCI was, however, performed without additional hazard and so remains a treatment option when there are favourable patient characteristics. The majority of patients reported no angina, and the low burden of angina in many of the randomised PCI trials is a widely cited limitation. Despite contentious evidence, elective PCI for CCS continues to play a significant role in UK clinical practice. While PCI for urgent indications has more than doubled since 2006, the rate of elective PCI remains unchanged. PCI remains an important strategy when symptoms are not well controlled, and we should maximise its value with appropriate patient selection. In this review, we provide a framework to assist in critical interpretation of findings from most recent trials and meta-analysis evidence.
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Affiliation(s)
- Timothy Cartlidge
- Cardiothoracic Directorate, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mila Kovacevic
- Cardiovascular Diseases of Vojvodina, Cardiology Clinic, Sremska Kamenica, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Eliano Pio Navarese
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Nicolaus Copernicus University in Toruń Ludwik Rydygier Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
- Klinikum Darmstadt GmbH, Medizinische Klinik I (Cardiology and Intensive Care), Darmstadt, Germany
- SIRIO MEDICINE Research Network, Bydgoszcz, Poland
| | - Gerald Werner
- Klinikum Darmstadt GmbH, Medizinische Klinik I (Cardiology and Intensive Care), Darmstadt, Germany
| | - Vijay Kunadian
- Cardiothoracic Directorate, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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11
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Nakao K, Dafaalla M, Nakao YM, Wu J, Nadarajah R, Rashid M, Mohammad H, Sumita Y, Nakai M, Iwanaga Y, Miyamoto Y, Noguchi T, Yasuda S, Ogawa H, Mamas MA, Gale CP. Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan. ESC Heart Fail 2023; 10:1372-1384. [PMID: 36737048 PMCID: PMC10053358 DOI: 10.1002/ehf2.14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/23/2022] [Accepted: 12/15/2022] [Indexed: 02/05/2023] Open
Abstract
AIMS Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts. METHODS AND RESULTS We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P < 0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P < 0.001). CONCLUSIONS Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.
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Affiliation(s)
- Kazuhiro Nakao
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- National Cerebral and Cardiovascular CenterSuitaJapan
| | - Mohamed Dafaalla
- Keele Cardiovascular Research Group, Institute for Prognosis ResearchUniversity of KeeleNewcastle upon TyneUK
| | - Yoko M. Nakao
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- National Cerebral and Cardiovascular CenterSuitaJapan
| | - Jianhua Wu
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- School of DentistryUniversity of LeedsLeedsUK
| | - Ramesh Nadarajah
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- Department of CardiologyLeeds Teaching Hospitals NHS TrustLeedsUK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Institute for Prognosis ResearchUniversity of KeeleNewcastle upon TyneUK
| | - Haris Mohammad
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- Department of CardiologyBlackpool Teaching Hospitals NHS TrustBlackpoolUK
| | - Yoko Sumita
- National Cerebral and Cardiovascular CenterSuitaJapan
| | | | | | | | - Teruo Noguchi
- National Cerebral and Cardiovascular CenterSuitaJapan
| | - Satoshi Yasuda
- National Cerebral and Cardiovascular CenterSuitaJapan
- Tohoku University Graduate School of MedicineSendaiJapan
| | | | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Institute for Prognosis ResearchUniversity of KeeleNewcastle upon TyneUK
| | - Chris P. Gale
- Leeds Institute for Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
- Leeds Institute of Data AnalyticsUniversity of LeedsLeedsUK
- Department of CardiologyLeeds Teaching Hospitals NHS TrustLeedsUK
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12
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Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V. Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart 2023; 109:504-510. [PMID: 36104217 DOI: 10.1136/heartjnl-2022-321470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.
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Affiliation(s)
| | - Greg B Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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13
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Beska B, Ratcovich H, Bagnall A, Burrell A, Edwards R, Egred M, Jordan R, Khan A, Mills GB, Morrison E, Raharjo DE, Singh F, Wilkinson C, Zaman A, Kunadian V. Angiographic and Procedural Characteristics in Frail Older Patients with Non-ST Elevation Acute Coronary Syndrome. Interv Cardiol 2023; 18:e04. [PMID: 37614703 PMCID: PMC10442670 DOI: 10.15420/icr.2022.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/10/2022] [Indexed: 08/25/2023] Open
Abstract
Background Angiographic and procedural characteristics stratified by frailty status are not known in older patients with non-ST elevation acute coronary syndrome (NSTEACS). We evaluated angiographic and procedural characteristics in older adults with NSTEACS by frailty category, as well as associations of baseline and residual SYNTAX scores with long-term outcomes. Methods In this study, 271 NSTEACS patients aged ≥75 years underwent coronary angiography. Frailty was assessed using the Fried criteria. Angiographic analysis was performed using QAngio® XA Medis in a core laboratory. Major adverse cardiovascular events (MACE) consisted of all-cause mortality, MI, stroke or transient ischaemic attack, repeat unplanned revascularisation and significant bleeding. Results Mean (±SD) patient age was 80.5 ± 4.9 years. Compared with robust patients, patients with frailty had more severe culprit lesion calcification (OR 5.40; 95% CI [1.75-16.8]; p=0.03). In addition, patients with frailty had a smaller mean improvement in culprit lesion stenosis after percutaneous coronary intervention (50.6%; 95% CI [45.7-55.6]) than robust patients (58.6%; 95% CI [53.5-63.7]; p=0.042). There was no association between frailty phenotype and completeness of revascularisation (OR 0.83; 95% CI [0.36-1.93]; p=0.67). A high baseline SYNTAX score (≥33) was associated with adjusted (age and sex) 5-year MACE (HR 1.40; 95% CI [1.08-1.81]; p=0.01), as was a high residual SYNTAX score (≥8; adjusted HR 1.22; 95% CI [1.00-1.49]; p=0.047). Conclusion Frail adults presenting with NSTEACS have more severe culprit lesion calcification. Frail adults were just as likely as robust patients to receive complete revascularisation. Baseline and residual SYNTAX score were associated with MACE at 5 years.
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Affiliation(s)
- Benjamin Beska
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Hanna Ratcovich
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Department of Cardiology, Rigshospitalet, Copenhagen University HospitalCopenhagen, Denmark
| | - Alan Bagnall
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Amy Burrell
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | - Richard Edwards
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Mohaned Egred
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | | | - Amina Khan
- Leeds Teaching Hospitals NHS TrustLeeds, UK
| | - Greg B Mills
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | - Emma Morrison
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
| | | | - Fateh Singh
- Sandwell and West Birmingham Hospitals NHS TrustBirmingham, UK
| | - Chris Wilkinson
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle UniversityNewcastle, UK
| | - Azfar Zaman
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle UniversityNewcastle, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle, UK
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14
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Damluji AA, Forman DE, Wang TY, Chikwe J, Kunadian V, Rich MW, Young BA, Page RL, DeVon HA, Alexander KP. Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e32-e62. [PMID: 36503287 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.
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15
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Pavasini R, Sanguettoli F, Zanarelli L, Deserio MA, Bianchi N, Fabbri G, Tebaldi M, Biscaglia S, Campo G. Unsolved Questions in the Revascularization of Older Myocardial Infarction Patients with Multivessel Disease. Rev Cardiovasc Med 2022; 23:344. [PMID: 39077134 PMCID: PMC11267381 DOI: 10.31083/j.rcm2310344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/05/2022] [Accepted: 07/22/2022] [Indexed: 07/31/2024] Open
Abstract
Background In cardiology, the global phenomenon of population ageing poses new major challenges, ranging from more comorbid and frail patients to the presence of complex, calcified and multiple coronary lesions. Considering that elderly patients are under-represented in randomized clinical trials (RCT), the aim of this systematic review is to summarize the current knowledge on the revascularization of the elderly patient with myocardial infarction and multivessel coronary artery disease. Methods A systematic review following PRISMA guidelines has been performed. The search was conducted on Pubmed (Medline), Cochrane library, Google Scholar and Biomed Central databases between January and February 2022. We selected the articles focusing on patients hospitalized for myocardial infarction (MI) with multivessel disease and aged 75 years or older. A total of 36 studies have been included. Results Multivessel coronary artery disease is present in around 50-60% of older patients with MI. The in-hospital mortality rate of patients older than 75 years is double compared to their younger counterpart, and the most prevalent complications after revascularization are bleeding and renal failure. In the treatment of patients with ST elevation MI (STEMI), primary percutaneous coronary intervention should be the first choice over fibrinolysis. However, it is not clear whether this population would benefit from complete revascularization or not. In patients with non-ST elevation MI (NSTEMI), an invasive approach with either percutaneous coronary intervention or coronary artery bypass graft may be chosen, but a conservative strategy is also accepted. There are no data from large trials about the comparison of possible revascularization strategies in NSTEMI patients. Conclusions This systematic review shows that this field of research lacks randomized clinical trials to guide revascularization strategy in older STEMI or NSTEMI patients with MI. New results are expected from ongoing trials.
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Affiliation(s)
- Rita Pavasini
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Federico Sanguettoli
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Luca Zanarelli
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Maria Angela Deserio
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Nicola Bianchi
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Gioele Fabbri
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Matteo Tebaldi
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Simone Biscaglia
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Gianluca Campo
- UO Cardiologia, Azienda Ospedaliero Universitaria di Ferrara, 44124 Ferrara, Italy
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16
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Kunadian V. The ongoing conundrum of the best care for patients presenting with non-ST-segment elevation acute coronary syndrome. EUROINTERVENTION 2022; 18:531-533. [PMID: 36134686 PMCID: PMC10241284 DOI: 10.4244/eij-e-22-00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundations Trust, Newcastle upon Tyne, UK
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Hanna JM, Nanna MG. An age-old dilemma: Defining the optimal revascularization approach in older adults. J Am Geriatr Soc 2022; 70:2205-2208. [PMID: 35596677 PMCID: PMC9378558 DOI: 10.1111/jgs.17831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/17/2022] [Accepted: 04/23/2022] [Indexed: 01/09/2023]
Affiliation(s)
- Jonathan M. Hanna
- Department of Internal Medicine, Yale School of Medicine,
New Haven, Connecticut, USA
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Department of Internal
Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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18
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Ratcovich H, Beska B, Mills G, Holmvang L, Adams-Hall J, Stevenson H, Veerasamy M, Wilkinson C, Kunadian V. Five-year clinical outcomes in patients with frailty aged ≥75 years with non-ST elevation acute coronary syndrome undergoing invasive management. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac035. [PMID: 35919345 PMCID: PMC9242041 DOI: 10.1093/ehjopen/oeac035] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/27/2022] [Accepted: 05/12/2022] [Indexed: 01/05/2023]
Abstract
Aim Frailty is associated with adverse outcomes in older patients with acute coronary syndrome (ACS). The impact of frailty on long-term clinical outcomes following invasive management of non-ST elevation ACS (NSTEACS) is unknown. Methods and results The multi-centre Improve Clinical Outcomes in high-risk patieNts with ACS 1 (ICON-1) prospective cohort study consisted of patients aged >75 years undergoing coronary angiography following NSTEACS. Patients were categorized by frailty assessed by Canadian Study of Health and Ageing Clinical Frailty Scale (CFS) and Fried criteria. The primary composite endpoint was all-cause mortality, unplanned revascularization, myocardial infarction, stroke, and bleeding. Of 263 patients, 33 (12.5%) were frail, 152 (57.8%) were pre-frail, and 78 (29.7%) were robust according to CFS. By Fried criteria, 70 patients (26.6%, mean age 82.1 years) were frail, 147 (55.9%, mean age 81.3 years) were pre-frail, and 46 (17.5%, mean age 79.9 years) were robust. The composite endpoint was more common at 5 years among patients with frailty according to CFS (frail: 22, 66.7%; pre-frail: 81, 53.3%; robust: 27, 34.6%, P = 0.003), with a similar trend when using Fried criteria (frail: 39, 55.7%; pre-frail: 72, 49.0%; robust: 16, 34.8%, P = 0.085). Frailty measured with both CFS and Fried criteria was associated with the primary endpoint [age and sex-adjusted hazard ratio (HR) compared with robust groups. CFS: 2.22, 95% confidence interval (CI) 1.23–4.02, P = 0.008; Fried: HR 1.81, 95% CI 1.00–3.27, P = 0.048]. Conclusion In older patients who underwent angiography following NSTEACS, frailty is associated with an increased risk of the primary composite endpoint at 5 years. Registration: Clinicaltrials.gov NCT01933581
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Affiliation(s)
- Hanna Ratcovich
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building Newcastle upon Tyne, UK
| | - Benjamin Beska
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building Newcastle upon Tyne, UK
| | - Greg Mills
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building Newcastle upon Tyne, UK
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jennifer Adams-Hall
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hannah Stevenson
- Cardiovascular and Transplant Research, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Murugapathy Veerasamy
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Chris Wilkinson
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building Newcastle upon Tyne, UK
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