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van den Broek WWA, Gimbel ME, Chan Pin Yin DRPP, Azzahhafi J, Hermanides RS, Runnett C, Storey RF, Austin D, Oemrawsingh R, Cooke J, Galasko G, Walhout RJ, Schellings DAAM, Brinckman SL, The HK, Stoel MG, Heestermans AACM, Nicastia D, Emans ME, van ’t Hof AWJ, Alber H, Gerber R, van Bergen PFMM, Aksoy I, Nasser A, Knaapen P, Botman CJ, Liem A, Kelder JC, ten Berg JM. Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry. J Clin Med 2023; 12:5450. [PMID: 37685517 PMCID: PMC10487667 DOI: 10.3390/jcm12175450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.
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Affiliation(s)
- Wout W. A. van den Broek
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Marieke E. Gimbel
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Dean R. P. P. Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Renicus S. Hermanides
- Department of Cardiology, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands;
| | - Craig Runnett
- Department of Cardiology, Northumbria Healthcare NHS Foundation Trust, 8 Silver Fox Way, Newcastle upon Tyne NE27 0QJ, UK;
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2TN, UK;
| | - David Austin
- Academic Cardiovascular Unit, The James Cook University Hospital, Marton Rd., Middlesbrough TS4 3BW, UK;
| | - Rohit Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands;
| | - Justin Cooke
- Department of Cardiology, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield Rd., Calow, Chesterfield S44 5BL, UK;
| | - Gavin Galasko
- Department of Cardiology, Blackpool Teaching Hospital NHS Foundation Trust, Whinney Heys Rd., Blackpool FY3 8NR, UK;
| | - Ronald J. Walhout
- Department of Cardiology, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP Ede, The Netherlands;
| | - Dirk A. A. M. Schellings
- Department of Cardiology, Slingeland Hospital, Kruisbergseweg 25, 7009 BL Doetinchem, The Netherlands;
| | - Stijn L. Brinckman
- Department of Cardiology, Tergooi MC, Rijksstraatweg 1, 1261 AN Blaricum, The Netherlands;
| | - Hong Kie The
- Department of Cardiology, Treant Zorggroep, Boermarkeweg 60, 7824 AA Emmen, The Netherlands;
| | - Martin G. Stoel
- Department of Cardiology, Medisch Spectrum Twente, Koningstraat 1, 7512 KZ Enschede, The Netherlands;
| | | | - Debby Nicastia
- Department of Cardiology, Gelre Hospital, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, The Netherlands;
| | - Mireille E. Emans
- Department of Cardiology, Ikazia Hospital, Montessoriweg 1, 3083 AN Rotterdam, The Netherlands;
| | - Arnoud W. J. van ’t Hof
- Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Henri Dunantstraat 5, 6419 PC Heerlen, The Netherlands
| | - Hannes Alber
- Department for Internal Medicine and Cardiology, KABEG Klinikum, Feschnigstraße 11, 9020 Klagenfurt am Wörthersee, Austria;
| | - Robert Gerber
- Department of Cardiology, East Sussex Healthcare NHS Foundation Trust, Dane Rd., Seaford BN25 1DH, UK;
| | | | - Ismail Aksoy
- Department of Cardiology, Admiraal de Ruyter Hospital, ‘s-Gravenpolderseweg 114, 4462 RA Goes, The Netherlands;
| | - Abdul Nasser
- Department of Cardiology, South Tyneside and Sunderland NHS Foundation Trust, Harton Ln., South Shields NE34 0PL, UK;
| | - Paul Knaapen
- Department of Cardiology, Amsterdam University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands;
| | - Cees-Joost Botman
- Department of Cardiology, Sint Jans Gasthuis, Vogelsbleek 5, 6001 BE Weert, The Netherlands;
| | - Anho Liem
- Department of Cardiology, Franciscus Gasthuis, Kleiweg 500, 3045 PM Rotterdam, The Netherlands;
| | - Johannes C. Kelder
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
| | - Jurriën M. ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (M.E.G.); (D.R.P.P.C.P.Y.); (J.A.); (J.C.K.); (J.M.t.B.)
- Cardiovascular Research Institute Maastricht, Universiteitssingel 50, 6229 ER Maastricht, The Netherlands
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Hu M, Li X, Yang Y. Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years. Arq Bras Cardiol 2023; 120:e20220658. [PMID: 37255135 PMCID: PMC10484564 DOI: 10.36660/abc.20220658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous. OBJECTIVES To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA). METHODS Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant. RESULTS Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%). CONCLUSIONS Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.
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Affiliation(s)
- Mengjin Hu
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
- Xuanwu HospitalCapital Medical UniversityBeijingChinaXuanwu Hospital, Capital Medical University, Beijing – China
| | - Xiaosong Li
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
| | - Yuejin Yang
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
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Dakhil ZA, Farhan HA. Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective. Egypt Heart J 2021; 73:33. [PMID: 33788051 PMCID: PMC8012438 DOI: 10.1186/s43044-021-00155-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 03/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background As the elderly represent a substantial proportion of medical care beneficiaries, and there is limited data about age disparity in emerging countries, this study sought to investigate the impact of age on the management in patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Results Two hundred patients with NSTE-ACS enrolled prospectively, patients’ data, pharmacotherapy, management strategy as well timing to catheterization were documented. Patients grouped into ≥ 65 years versus < 65 years; 32.5% were ≥ 65-year-old. The older group presented as high GRACE risk (Global Registry of Acute Coronary Events) (67.7% versus 15.6%). Elderly patients were less likely to be referred for catheterization compared with younger counterparts (55.4% versus 76.3%, p = 0.003). Within low risk class patients, none of the elderly versus 9.33% of younger patients were catheterized within 2 h; in the same line, none of the elderly versus 16% of younger patients were catheterized within 24 h. Alternatively, at high risk class, 6.81% of the elderly and none of the younger patients were catheterized within 2 h. On the univariate analysis of variables to predict invasive strategy, presence of history of prior IHD, diabetes, absent in-hospital acute heart failure or atrial fibrillation/flutter, higher haemoglobin and lower creatinine levels predicted the use of invasive strategy, while on multivariate analysis, acute heart failure (95% CI − 0.38 to − 0.41, p = 0.01), lower haemoglobin (95% CI 0.002–0.07, p = 0.03), and atrial fibrillation/flutter (95% CI − 0.48 to − 0.02, p = 0.03) predicted conservative strategy. The elderly were more likely to have acute heart failure (32.3% versus 14.8%, p = 0.004), same as stroke (3.1% versus none, p = 0.04). Conclusions Less-invasive strategy used in the elderly with NSTE-ACS compared with younger counterparts, yet age was not a predictor of catheterization underuse on multivariate analysis. It is crucial to bridge the age gap in the healthcare system in setting of ACS management by grasping the attention of decision makers and emphasizing on the adherence of healthcare providers to the guidelines to improve cardiovascular care and outcomes.
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Affiliation(s)
| | - Hasan Ali Farhan
- Scientific Council of Cardiology, Iraqi Board for Medical Specializations, Baghdad, Iraq
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Guo Q, Huang J, Shen Y, Tong G, Li H, Meng S. The role of late reperfusion in ST-segment elevation myocardial infarction: a real-world retrospective cohort study. BMC Cardiovasc Disord 2020; 20:207. [PMID: 32345243 PMCID: PMC7189551 DOI: 10.1186/s12872-020-01479-0] [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: 01/16/2020] [Accepted: 04/12/2020] [Indexed: 11/10/2022] Open
Abstract
Background Early reperfusion of the coronary artery has become the first choice for patients with ST-segment elevation myocardial infarction (STEMI). How to deal with patients who miss the time window for early reperfusion is still controversial. Based on real-world data, this study was conducted to explore whether percutaneous coronary intervention (PCI) has an advantage over standard drug therapy in patients who miss the optimal treatment window. Methods Consecutive patients who were diagnosed with STEMI and met the inclusion criteria between 2009 and 2018 in our center were retrospectively included in this cohort study. The primary endpoint events were major adverse cardiac events (MACEs), including heart failure, sudden cardiac death, malignant arrhythmia, thrombi and bleeding events during the period of admission. Secondary endpoint events were components of MACEs. At the same time, we also evaluated angina pectoris at admission and discharge through Canadian Cardiovascular Society (CCS) grading. Results This study enrolled 417 STEMI patients and divided them into four groups (PCI < 3 days, 14.87%; 3 days<PCI < 7 days, 21.104%; PCI > 7 days, 34.29%; MED, 29.74%). During the period of admission, MACEs occurred in 52 cases. The incidence of MACEs was 11.29, 7.95, 4.20 and 25.81% in the four respective groups (p < 0.0001). The MED group had higher rates of MACEs (OR = 3.074; 95% CI 0.1.116–8.469, p = 0.03) and cardiac death (OR = 3.027; 95% CI 1.121–8.169, p = 0.029) compared to the PCI group. Although both treatments were effective in improving CCS grade at discharge, the PCI group improved more significantly (p < 0.0001). Conclusions In the real world, delayed PCI can be more effective in patients with angina symptoms at discharge and reduce the incidence of MACEs and cardiac death during hospitalization. The timing of intervention was independent of the occurrence of MACEs during hospitalization and of improvement in symptoms.
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Affiliation(s)
- Qixin Guo
- Nanjing Medical University, 818 East Tian Yuan Road, Jiang Ning District, Nanjing City, Jiangsu Province, China
| | - Jinyu Huang
- Nanjing Medical University, 818 East Tian Yuan Road, Jiang Ning District, Nanjing City, Jiangsu Province, China.
| | - Yong Shen
- Zhejiang University of Traditional Chinese Medicine, Hangzhou City, Zhejiang Province, China
| | - Guoxin Tong
- Hangzhou First People's Hospital, Hangzhou City, Zhejiang Province, China
| | - Hong Li
- Hangzhou First People's Hospital, Hangzhou City, Zhejiang Province, China
| | - Shasha Meng
- Hangzhou First People's Hospital, Hangzhou City, Zhejiang Province, China
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