Changing Trends in, and Characteristics Associated with, Not Undergoing Cardiac Catheterization in Elderly Adults Hospitalized with ST-Segment Elevation Acute Myocardial Infarction

Effect of Age on Clinical Outcomes in Elderly Patients (>80 Years) Undergoing Percutaneous Coronary Intervention: Insights From a Multi-Centre Australian PCI Registry

OBJECTIVES

To evaluate the effect of age in an all-comers population undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Age is an important consideration in determining appropriateness for invasive cardiac assessment and perceived clinical outcomes.

METHODS

We analysed data from 29,012 consecutive patients undergoing PCI in the Melbourne Interventional Group (MIG) registry between 2005 and 2017. 25,730 patients <80 year old (78% male, mean age 62±10 years; non-elderly cohort) were compared to 3,282 patients ≥80 year old (61% male, mean age 84±3 years; elderly cohort).

RESULTS

The elderly cohort had greater prevalence of hypertension, diabetes and previous myocardial infarction (all p<0.001). Elderly patients were more likely to present with acute coronary syndromes, left ventricular ejection fraction <45% and chronic kidney disease (p<0.0001). In-hospital, 30-day and long-term all-cause mortality (over a median of 3.6 and 5.1 years for elderly and non-elderly cohorts, respectively) were higher in the elderly cohort (5.2% vs. 1.9%; 6.4% vs. 2.2%; and 43% vs. 14% respectively, all p<0.0001). In multivariate Cox regression analysis, estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m² (HR 3.8, 95% CI: 3.4-4.3), cardiogenic shock (HR 3.0, 95% CI: 2.6-3.4), ejection fraction <30% (HR 2.5, 95% CI: 2.1-2.9); and age ≥80 years (HR 2.8, 95% CI: 2.6-3.1) were independent predictors of long-term all-cause mortality (all p<0.0001).

CONCLUSION

The elderly cohort is a high-risk group of patients with increasing age being associated with poorer long-term mortality. Age, thus, should be an important consideration when individualising treatment in elderly patients.

Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

BACKGROUND

Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

OBJECTIVES

The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.

METHODS

We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).

RESULTS

Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).

CONCLUSIONS

This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

Association Between Mobility Measured During Hospitalization and Functional Outcomes in Older Adults With Acute Myocardial Infarction in the SILVER-AMI Study

Importance

Many older survivors of acute myocardial infarction (AMI) experience functional decline, an outcome of primary importance to older adults. Mobility impairment has been proposed as a risk factor for functional decline but has not been evaluated to date in older patients hospitalized for AMI.

Objective

To examine the association of mobility impairment, measured during hospitalization, as a risk marker for functional decline among older patients with AMI.

Design, Setting, and Participants

Prospective cohort study among 94 academic and community hospitals in the United States. Participants were 2587 hospitalized patients with AMI who were 75 years or older. The study dates were January 2013 to June 2017.

Main Outcomes and Measures

Mobility was evaluated during AMI hospitalization using the Timed "Up and Go," with scores categorized as preserved mobility (≤15 seconds to complete), mild impairment (>15 to ≤25 seconds to complete), moderate impairment (>25 seconds to complete), and severe impairment (unable to complete). Self-reported function in activities of daily living (ADLs) (bathing, dressing, transferring, and walking around the home) and walking 0.4 km (one-quarter mile) was assessed at baseline and 6 months after discharge. The primary outcomes were worsening of 1 or more ADLs and loss of ability to walk 0.4 km from baseline to 6 months after discharge. The association between mobility impairment and risk of functional decline was evaluated with multivariable-adjusted logistic regression.

Results

Among 2587 hospitalized patients with AMI, the mean (SD) age was 81.4 (4.8) years, and 1462 (56.5%) were male. More than half of the cohort exhibited mobility impairment during AMI hospitalization (21.8% [564 of 2587] had mild impairment, 16.0% [414 of 2587] had moderate impairment, and 15.2% [391 of 2587] had severe impairment); 12.8% (332 of 2587) reported ADL decline, and 16.7% (431 of 2587) reported decline in 0.4-km mobility. Only 3.8% (30 of 800) of participants with preserved mobility experienced any ADL decline compared with 6.9% (39 of 564) of participants with mild impairment (adjusted odds ratio [aOR], 1.24; 95% CI, 0.74-2.09), 18.6% (77 of 414) of participants with moderate impairment (aOR, 2.67; 95% CI, 1.67-4.27), and 34.7% (136 of 391) of participants with severe impairment (aOR, 5.45; 95% CI, 3.29-9.01). Eleven percent (90 of 800) of participants with preserved mobility declined in ability to walk 0.4 km compared with 15.2% (85 of 558) of participants with mild impairment (aOR, 1.51; 95% CI, 1.04-2.20), 19.0% (78 of 411) of participants with moderate impairment (aOR, 2.03; 95% CI, 1.37-3.02), and 24.6% (95 of 386) of participants with severe impairment (aOR, 3.25; 95% CI, 2.02-5.23).

Conclusions and Relevance

This study's findings suggest that mobility impairment assessed during hospitalization may be a potent risk marker for functional decline in older survivors of AMI. These findings also suggest that brief, validated assessments of mobility should be part of the care of older hospitalized patients with AMI to identify those at risk for this important patient-centered outcome.

Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set

Background:

We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years.

Methods:

We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization.

Results:

We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001).

Conclusions:

Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.

Gender-related differences in elderly patients with myocardial infarction in a European Centre

BACKGROUND

Weighing the benefit of revascularization procedures against the risk of adverse events is particularly challenging in elderly patients suffering acute myocardial infarction (AMI). Based on a general gender gap in coronary interventions, the restraint in invasive procedures may be particularly high in elderly women. We therefore investigated gender-related differences in the frequency of coronary interventions as well as gender- and age-specific outcomes after coronary interventions in patients with AMI.

DESIGN

We included 906 AMI patients in the final analysis. Among patients ≥ 80 years (n = 453), the intention to intervention (lysis and/or coronary angiography) for women was significantly lower compared to men (65·7% vs. 80·8%; P < 0·001), whereas in patients < 80 years (n = 453), the rate was similar between both genders (94·8% vs. 95·1%, P = 0·89). However, the assessment of potential risk factors for adverse events did not explain the gender gap. When assessing the benefit of any coronary intervention (stenting and/or lysis and/or coronary artery bypass graft), elderly women benefited at least as much with a hazard ratio (HR) for cardiovascular mortality of 0·56 (95% confidence interval [CI] 0·37-0·84, P = 0·005) compared to a HR of 0·96 (95% CI 0·76-1·23, P = 0·766) in elderly men.

CONCLUSION

We observed a lower intention to coronary intervention in elderly women compared with men. However, the distribution of risk factors in elderly women and men who did not undergo coronary intervention was similar and therefore seemed not to be causal for the gender gap although the benefit of any coronary interventions was even higher in elderly women.