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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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Zhao YJ, Sun Y, Wang F, Cai YY, Alolga RN, Qi LW, Xiao P. Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197451. [PMID: 37745128 PMCID: PMC10516546 DOI: 10.3389/fcvm.2023.1197451] [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: 04/06/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.
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Affiliation(s)
- Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Yangyang Sun
- Department of Pharmacy, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fan Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yuan-Yuan Cai
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N. Alolga
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Lian-Wen Qi
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
- College of Traditional Chinese Medicine and Food Engineering, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Pingxi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Gao H, Bai M, Chu A, Pan C, Zhao J, Zhang Z, Shang X. Safety and efficacy of perioperative continuous renal replacement therapy for percutaneous coronary intervention in severe acute myocardial infarction patients. J Med Life 2023; 16:719-724. [PMID: 37520492 PMCID: PMC10375348 DOI: 10.25122/jml-2022-0270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/27/2023] [Indexed: 08/01/2023] Open
Abstract
This retrospective study aimed to evaluate the safety and efficacy of continuous renal replacement therapy (CRRT) during percutaneous coronary intervention (PCI) in patients with severe acute myocardial infarction (AMI). The study analyzed data from 945 AMI patients hospitalized between January 2016 and December 2017, out of which 21 patients underwent perioperative CRRT for PCI. We assessed the baseline characteristics of severe AMI patients before and after CRRT and examined the effect of CRRT on cardiac, renal, and liver function, as well as other indicators. The heart rate of patients undergoing CRRT was significantly lower at 24 h and 48 h after CRRT than before CRRT (p=0.038). There was a moderate but not significant decrease in the mean systolic blood pressure or diastolic blood pressure (p>0.05). Importantly, we found that significantly more patients showed Killip class I-II and significantly improved cardiac function after CRRT (23.8% vs. 57.1%, p=0.001). The levels of urea nitrogen, creatinine, aspartate aminotransferase, glutamic pyruvic transaminase, and total bilirubin were significantly lowered after CRRT treatment (p<0.05). Perioperative management of CRRT was safe and effective for severe AMI patients.
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Affiliation(s)
- Hanxiang Gao
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Ming Bai
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Aiai Chu
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chenliang Pan
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Jing Zhao
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Zheng Zhang
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaofeng Shang
- Department of Cardiology, Zhangye People's Hospital Affiliated Hexi College, Zhangye, Gansu, China
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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 PMCID: PMC10312228 DOI: 10.1161/cir.0000000000001112] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [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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Management and Outcomes in the Elderly with Non-ST-Elevation Acute Coronary Syndromes Admitted to Spoke Hospitals with No Catheterization Laboratory Facility. J Clin Med 2022; 11:jcm11206179. [PMID: 36294500 PMCID: PMC9605530 DOI: 10.3390/jcm11206179] [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: 07/21/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational−retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82−89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25−87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7−27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0−4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.
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Siddiqui AJ, Omerovic E, Holzmann MJ, Böhm F. Association of coronary angiographic lesions and mortality in patients over 80 years with NSTEMI. Open Heart 2022; 9:openhrt-2021-001811. [PMID: 35101898 PMCID: PMC8804677 DOI: 10.1136/openhrt-2021-001811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 01/09/2022] [Indexed: 01/16/2023] Open
Abstract
Objective Coronary angiography (CA) and percutaneous coronary intervention (PCI) is of great importance during non-ST-segment elevation myocardial infarction (NSTEMI) management. Coronary artery lesions and their association to mortality in elderly patients with NSTEMI was investigated. Methods Patients >80 years of age who underwent CA at index NSTEMI during 2011–2014 were included. Data were collected from the Swedish Coronary Angiography and Angioplasty Registry and Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registries. Coronary lesions were categorised into; one vessel disease (1VD), multi-vessel disease (MVD) and left main disease (LMD) and 0%–49% stenosis grade were considered as controls. Cox regression was used to estimate HRs for all-cause mortality associated with coronary lesions. Survival benefit was determined after PCI and in relation to if revascularisation was complete or incomplete and any complications in the Cath lab was assessed. Results Five thousand seven hundred and seventy patients with history of CA and PCI were included, 10% had normal coronary arteries, 26% had 1VD, 50% MVD and 14% LMD. Mortality was higher in patients with 1VD, MVD and LMD: HR 1.8 (1.3–2.5), HR 2.2 (1.6–3.0) and HR 2.8 (2.1–3.9), respectively. PCI were treated in 84% of 1VD, 73% MVD, and 54% in LMD. Survival was higher with PCI HR 0.85 (0.73–0.99). MVD had lower adjusted mortality HR 0.71 (0.58–0.87) compared with patients with MVD who did not undergo PCI. Complications and mortality were higher in patients with LMD both during CA and PCI, HR 2.9 (1.1–7.6) and HR 4.5 (1.6–12.5). Conclusion Coronary lesions (>50% stenosis) are strong predictors of mortality in elderly patients with NSTEMI. MVD is common and PCI treatment is associated with increased survival.
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Affiliation(s)
- Anwar J Siddiqui
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency and Reparative Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Felix Böhm
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska Institutet, Stockholm, Sweden
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7
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de Belder A, Myat A, Blaxill J, Haworth P, O'Kane P, Hatrick R, Aggarwal R, Davie A, Smith W, Gerber R, Byrne J, Adamson D, Witherow F, Alsanjari O, Wright J, Robinson D, Hildick-Smith D. Revascularisation or medical therapy in elderly patients with acute anginal syndromes: the RINCAL randomised trial. EUROINTERVENTION 2021; 17:67-74. [PMID: 33226000 PMCID: PMC9724962 DOI: 10.4244/eij-d-20-00975] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Historically the elderly have been under-represented in non-ST-elevation myocardial infarction (NSTEMI) management trials. AIMS The aim of this trial was to demonstrate that an intervention-guided strategy is superior to optimal medical therapy (OMT) alone for treating NSTEMI in elderly individuals. METHODS Patients (≥80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an intervention-guided strategy plus OMT versus OMT alone. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial reinfarction at 1 year. Ethics approval was obtained by the institutional review board of every recruiting centre. RESULTS From May 2014 to September 2018, 251 patients (n=125 invasive vs n=126 conservative) were enrolled. Almost 50% of participants were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary endpoint at 1 year (invasive 18.5% [23/124] vs conservative 22.2% [28/126]; p=0.39). No significant difference persisted after Cox proportional hazards regression analysis (hazard ratio 0.79, 95% confidence interval 0.45-1.35; p=0.39). There was greater freedom from angina at 3 months (p<0.001) after early intervention but this was similar at 1 year. Both non-fatal reinfarction (invasive 9.7% [12/124] vs conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs conservative 6.4% [8/126]; p=0.10) occurred more frequently in the OMT alone cohort. CONCLUSIONS An intervention-guided strategy was not superior to OMT alone to treat very elderly NSTEMI patients. The trial was underpowered to demonstrate this definitively. Early intervention resulted in fewer cases of reinfarction and unplanned revascularisation but did not improve survival.
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Affiliation(s)
| | - Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | | | - Peter Haworth
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Peter O'Kane
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, United Kingdom
| | - Robert Hatrick
- Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom
| | | | - Andrew Davie
- Golden Jubilee National Hospital and Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Robert Gerber
- East Sussex Healthcare NHS Trust, Hastings, United Kingdom
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Dawn Adamson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Fraser Witherow
- Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom
| | | | - Juliet Wright
- Brighton and Sussex Medical School, Brighton, United Kingdom
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Zhao X, Wang Y, Liu C, Zhou P, Sheng Z, Li J, Zhou J, Chen R, Chen Y, Zhao H, Yan H. Prognostic Value of Total Bilirubin in Patients With ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Coronary Intervention. Front Cardiovasc Med 2021; 7:615254. [PMID: 33392275 PMCID: PMC7773653 DOI: 10.3389/fcvm.2020.615254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Bilirubin, a natural product of heme catabolism, has antioxidant and anti-inflammatory activities and is inversely associated with stable coronary artery disease. However, the relationship between the bilirubin levels and long-term outcomes in patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PPCI) remains unknown. This study aimed to establish a score model based on bilirubin for predicting major adverse cardiovascular events (MACEs) and stratify patients to the level of care. Methods and Results: Data of 4,151 consecutive patients with STEMI who underwent PPCI were evaluated, and 3,708 cases were analyzed. The total bilirubin (TBil) levels were measured during admission, and the study population was divided into two groups. The high TBil group (n = 143) comprised patients who had a TBil level of ≥22 μmmol/L, and the low TBil group (n = 3,565) comprised patients who had a TBil level of <22 μmmol/L. The median follow-up period was 754 days (2.066 years). The MACE was significantly lower in the high TBil group than in the low TBil group (3.5% vs. 11.0%, p = 0.001). In the multivariate Cox regression analysis, a significant association was noted between the TBil levels and adjusted risk of MACE (hazard ratio, 0.279; 95% confidence interval, 0.088-0.877; p = 0.029). A prediction score model composed of TBil, age, hypertension history, and other eight variables was developed, with scores ranging from 0 to 500. The scores categorized patients into low-, medium-, and high-risk categories. The cumulative survival rate was significantly higher in the low-risk group than in the medium- and high-risk groups for MACE, all-cause death, cardiac death, recurrent myocardial infarction, and ischemic stroke (p < 0.001, p < 0.001, p < 0.001, p = 0.030, and p = 0.001, respectively). The area under the curve of the TBil score was 0.768; this was significantly greater in the pairwise comparison with the Global Registry of Acute Coronary Events score (p = 0.0012). Conclusion: The new prediction score model based on TBil could be used in clinical practice to support risk stratification as recommended in the clinical guidelines.
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Affiliation(s)
- Xiaoxiao Zhao
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Ying Wang
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Chen Liu
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Peng Zhou
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Zhaoxue Sheng
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jiannan Li
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Jinying Zhou
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Runzhen Chen
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Yi Chen
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Hanjun Zhao
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Hongbing Yan
- Department of Cardiology, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China.,Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
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9
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Kaura A, Sterne JAC, Trickey A, Abbott S, Mulla A, Glampson B, Panoulas V, Davies J, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Lord GM, Melikian N, Johnson T, Francis DP, Shah AM, Perera D, Kharbanda R, Patel RS, Mayet J. Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data. Lancet 2020; 396:623-634. [PMID: 32861307 PMCID: PMC7456783 DOI: 10.1016/s0140-6736(20)30930-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI. METHODS Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure. FINDINGS Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93). INTERPRETATION The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. FUNDING NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.
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Affiliation(s)
- Amit Kaura
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan A C Sterne
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Adam Trickey
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Sam Abbott
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Abdulrahim Mulla
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Benjamin Glampson
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Vasileios Panoulas
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jim Davies
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kerrie Woods
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joe Omigie
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Anoop D Shah
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Keith M Channon
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan N Weber
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Mark R Thursz
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Paul Elliott
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Harry Hemingway
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Bryan Williams
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael O'Sullivan
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graham M Lord
- National Institute for Health Research Manchester Biomedical Research Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Narbeh Melikian
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas Johnson
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Darrel P Francis
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Ajay M Shah
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Divaka Perera
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Rajesh Kharbanda
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Riyaz S Patel
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Jamil Mayet
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK.
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10
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Sui YG, Teng SY, Qian J, Wu Y, Dou KF, Tang YD, Qiao SB, Wu YJ. Gender differences in treatment strategies among patients ≥80 years old with non-ST-segment elevation myocardial infarction. J Thorac Dis 2019; 11:5258-5265. [PMID: 32030243 DOI: 10.21037/jtd.2019.11.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background This study aims to investigate the gender differences in treatment strategies among non-ST-segment elevation myocardial infarction (NSTEMI) patients ≥80 years old in China. Methods A total of 190 consecutive NSTEMI patients ≥80 years old in Fuwai Hospital were included from 2014 to 2017. These patients were grouped by gender, and sub-grouped by conservative treatment or invasive treatment. The clinical characteristics, medical history, discharge drug used, and prognosis were collected and compared between these two treatment strategies. Results There were significant differences between these two treatment strategies in terms of GRACE grade, history of myocardial infarction (MI), after coronary artery bypass grafting (CABG), III grade, renal dysfunction, anemia, and use of diuretic (P<0.05). In addition, the age, creatinine and Killip class of female patients, and the death and good prognosis of male patients were found to be significantly different between these two treatment strategies (P<0.05). The multivariate logistic regression analysis revealed that the death of males was significantly associated with treatment strategies in the multivariable logistic regression analysis (P<0.05). In addition, the Kaplan-Meier survival analyses revealed that the survival rates of invasive strategy were significantly higher, when compared to that of conservative strategy in males (P=0.001) and females (P=0.015). Conclusions There were gender differences in treatment strategies among NSTEMI patients ≥80 years old. The difference in treatment strategies in males was more pronounced than in females, in terms of long-term survival rate.
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Affiliation(s)
- Yong-Gang Sui
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Si-Yong Teng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Jie Qian
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Yuan Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Ke-Fei Dou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Yi-Da Tang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Shu-Bin Qiao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
| | - Yong-Jian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing University, Beijing 100037, China
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Merinopoulos I, Gunawardena T, Wickramarachchi U, Ryding A, Eccleshall S, Vassiliou VS. Percutaneous Coronary Intervention in the Elderly: Are Drug-coated Balloons the Future? Curr Cardiol Rev 2018; 14:45-52. [PMID: 29278215 PMCID: PMC5872262 DOI: 10.2174/1573403x14666171226144120] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Balloon angioplasty revolutionised percutaneous treatment for coronary ar-tery disease four decades ago, but vessel-threatening dissections, elastic recoil and restenosis were major drawbacks to an otherwise successful long-lasting intervention. Subsequent advances with bare metal stents and then drug eluting stents followed, aiming to mitigate the risks of acute vessel closure and restenosis. However, stent implantation often necessitates dual antiplatelet therapy for a pro-longed period of time, which in itself can lead to adverse outcomes, especially in the frail elderly pop-ulation at higher risk of bleeding. More recently, bioabsorbable stents have been implemented in clini-cal practice enabling earlier intimal coverage of the stent and apposition. However, another addition to the armamentarium of percutaneous coronary intervention is the use of drug-coated balloons without the need for deploying any coronary stents or scaffolds. Drug-coated balloons are semi-compliant balloons coated with an antiproliferative agent that is rapidly released on contact with the vessel intima exerting an anti-restenotic effect. The absence of a metallic scaffold means that the need for antiplatelet therapy can potentially be negated in the longer term if required. In this article, we will review the history of percutaneous coronary intervention and the available evi-dence for the appropriate use of drug-coated balloons especially in the elderly population. Conclusion: We will conclude this review by demonstrating the potential use of drug-coated balloon rather percutaneous stenting through case examples.
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Affiliation(s)
- Ioannis Merinopoulos
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | | | - Upul Wickramarachchi
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Alisdair Ryding
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Simon Eccleshall
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Vassilios S Vassiliou
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom.,Norwich Medical School, University of East Anglia and Royal Brompton Hospital and Imperial College London, London, United Kingdom
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12
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Leng W, Yang J, Li W, Wang Y, Yang YJ. Rationale and design of the DEAR-OLD trial: Randomized evaluation of routinely Deferred versus EARly invasive strategy in elderly patients of 75 years or OLDer with non-ST-elevation myocardial infarction. Am Heart J 2018; 196:65-73. [PMID: 29421016 DOI: 10.1016/j.ahj.2017.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Comparing with conservative strategy, early invasive approach has been shown to be beneficial for initially stabilized patients with non-ST-elevation myocardial infarction (NSTEMI). However, concerns of increased risk of bleeding and other complications associated with early revascularization in patients aged ≥75 years persist. A routinely deferred invasive strategy aiming to facilitate revascularization after stabilizing the culprit lesion predominates across China. AIM The aim was to compare efficacy and safety of deferred invasive strategy versus guideline-recommended early invasive strategy in initially stabilized Chinese patients aged ≥75 years with NSTEMI. METHODS Twenty qualified centers from 10 different provinces throughout mainland China will contribute to the study. Eligible patients will be central randomized to a routine deferred invasive approach or an early invasive approach (coronary angiography >72 hours or <24 hours of admission and appropriate revascularization). Patients meeting the inclusion criteria but not randomized for any reason will be registered. The primary end point of the present study is a composite of all-cause mortality, nonlethal (re) MI, ischemic stroke, and urgent revascularization at 1 year. Noninferiority design is used, and the inferiority margin was set to be 5%. The goal is to enroll 696 patients with expected primary end point rates of 30%, 2-tailed α of .05, power of 80%, and dropout rate of 5%. CONCLUSIONS The DEAR-OLD trial is a prospective, nationwide, multicenter, noninferiority-designed, open-label randomized clinical trial evaluating efficacy and safety of routinely deferred invasive strategy compared with early invasive strategy in Chinese elderly patients with NSTEMI.
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