Review of the treatment of acute coronary syndrome in elderly patients

Clinical outcomes and associated factors in patients who underwent percutaneous coronary intervention: a multicenter study in Ethiopia

AIMS

This study aimed to evaluate the clinical outcomes and associated factors in patients who underwent percutaneous coronary intervention (PCI).

METHODS

This five-year retrospective cross-sectional study analyzed data from 241 patients who underwent urgent and primary PCI. Outcome measures included in-hospital mortality, major adverse cardiac and cerebrovascular events (MACCEs), postprocedural complications, and survival rates. Data were analysed using the Statistical Package for Social Sciences version 25. Cox proportional hazard regression models were used to assess predictors of in-hospital mortality. Kaplan-Meier analysis and the log-rank test were used to assess the overall survival rates and median survival time and to compare the survival probability curves for independent predictors. Hazard ratios (HRs) and 95% confidence intervals (CIs) were presented.

RESULTS

One hundred forty-two patients underwent elective PCI with drug-eluting stent implantation (75.1%) as the reperfusion method. The in-hospital mortality and non-fatal MACCE rates were 3.7% and 24.1%, respectively. The predictors of in-hospital mortality were female sex (AHR = 8.39, 95% CI: 1.20-58.68, p = 0.03), preprocedural obesity (AHR = 6.54, 95% CI: 1.10-40.60, p = 0.04), previous myocardial infarction (AHR = 9.68, 95% CI: 1.66-56.31, p = 0.01), chronic heart failure (AHR = 9.21, 95% CI: 1.38-61.78, p = 0.02), and a previous history of stroke (AHR = 18.99, 95% CI: 1.59-227.58, p = 0.02). Notably, this study reported a high one-year survival rate.

CONCLUSION

Urgent and primary PCIs are critical interventions for patients with MI in Ethiopia, showing promising outcomes such as low in-hospital mortality and a high one-year survival rate. These findings underscore the importance of optimising access to PCI and related treatments to improve patient outcomes.

Invasive versus Conservative Treatment Approach among Older Adult Patients Admitted with Acute ST-Segment Elevation Myocardial Infarction

BACKGROUND

Primary percutaneous coronary intervention (PCI) is the preferred treatment strategy for patients with ST-elevation myocardial infarction (STEMI); however, its efficacy remains unclear in very older adult patients with STEMI.

METHODS

This retrospective single-center observational study included 530 patients aged >75 years admitted to Tel Aviv Sourasky Medical Center with a diagnosis of acute STEMI. Primary PCI was performed for patients with symptoms ≤12 hours in duration, while the other patients were conservatively treated. We evaluated 30-day mortality and complications occurring during hospitalization based on data from patient records.

RESULTS

Among the study patients, only 28/530 (5%) were conservatively treated. In-hospital complications, including the use of inotropes or intra-aortic balloon counterpulsation and the need for mechanical ventilation, did not differ significantly between the groups. The only parameter that showed a trend toward significance was the incidence of heart failure during hospitalization (p=0.042). The risk for 30-day mortality was substantially higher in the conservative treatment group than in the invasive treatment group (27% vs. 10%; p = 0.02).

CONCLUSION

Our data suggested that despite concerns regarding the safety of the primary PCI strategy in the older adult STEMI population, this treatment strategy was associated with a survival benefit.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered.

STRUCTURE

Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients.

METHODS

A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.

[Complications of coronary invasive procedures in nonagenarians: A case-control study]

INTRODUCTION

Coronary heart disease is the leading cause of morbidity and mortality in nonagenarians, whose numbers have doubled in twenty years. In the absence of recommendations, the place of coronary invasive strategy in this population remains a therapeutic challenge and its interest as well as its risks are poorly established. The aim of our study was to evaluate the safety of coronary invasive practice in the nonagenarian population for all indications.

POPULATION AND METHODS

This was a monocentric case-control study conducted from January 1, 2010 to May 30, 2019. The patients included were all nonagenarians who had undergone coronary angiography at the centre hospitalier de Troyes during this period. For each patient included, two controls matched on sex, date of procedure and procedure were drawn at random. The main judgment criterion was the occurrence of immediate per- or post-procedure complications during the stay in which the procedure was performed. The main secondary outcome measures were average length of stay, occurrence of intercurrent events during the stay (nosocomial infections, confusional syndrome), and loss of autonomy.

RESULTS

In all, 59 nonagenarians and 118 controls were included in our study. We identified 30.5% major complications in the nonagenarians versus 10.2% in the controls (P=0.001; OR=0.26 [0.1-0.6]), with a significant difference in the occurrence of cardiogenic shock (P=0.04), heart failure (P=0.02) and ventricular rhythm disorders (P=0.04). Post-procedure acute renal failure was greater in the nonagenarians (P=0.02; OR=0.20 [0.05-1.57]). The mean length of stay was on average twice as long in the nonagenarians.

CONCLUSION

Nonagenarian patients are subject to more complications when undergoing coronary invasive procedures compared to patients under 75.

Applicability of the PRECISE-DAPT score in elderly patients with myocardial infarction

BACKGROUND

Elderly patients with acute coronary syndromes (ACS) are at higher risk both for ischemic and bleeding complications. Current guidelines recommend the PRECISE-DAPT score for bleeding risk stratification in this setting, but no study assessed its applicability in elderly patients. This study aimed to assess the performance of the PRECISE-DAPT score in a series of non-selected elderly patients with ACS from routine clinical practice.

METHODS

The IFFANIAM registry included prospectively patients aged ≥ 75 years with ST segment elevation myocardial infarction (STEMI). Main outcome measured was the incidence of relevant bleeding after discharge (bleeding leading to hospital readmission, need for transfusion, intervention, stop of antithrombotic drugs or death). Bleeding risk was classified: (A) according to PRECISE-DAPT values above or not the recommended cut-off point (≥ 25); and (B) according to the quartiles of PRECISE-DAPT values observed in the IFFANIAM series (Q1: < 30; Q2: 30-35; Q3: 36-44; Q4: ≥ 45).

RESULTS

A total of 208 patients were included. Mean age was 81.9 ± 4.5 years. Most patients (92.6%) had a PRECISE-DAPT value > 25. A total of 25 patients (12.0%) had bleeding events and 49 patients (23.6%) died. No significant differences regarding the incidence of bleeding were observed according to the recommended cutt of point ≥ 25. However, a progressive increase in the incidence of bleeding was observed across PRECISE-DAPT quartiles observed in this series (P = 0.038).

CONCLUSIONS

The vast majority of elderly patients have PRECISE-DAPT values above the recommended cut-off point for bleeding risk. Using different cut-off points could be a more rational approach for predicting bleeding risk in these complex patients.

Blood pressure target achievement and antihypertensive medication use in women and men after first-ever myocardial infarction: the Tromsø Study 1994-2016

Background

Recurrent cardiovascular events after myocardial infarction (MI) are frequent, and gender differences in blood pressure treatment have been reported. Despite increased focus on secondary prevention, recent reports indicate that treatment targets are not achieved. There is a need for gender-specific analyses of post-MI blood pressure treatment target achievement and antihypertensive medication adherence.

Design

We investigated the change in systolic and diastolic blood pressure and antihypertensive drug use after first-ever MI over two time periods in a Norwegian population-based study.

Methods

We followed 10 089 participants (55% women) attending the Tromsø Study in 1994-1995 (MI-cohort I) and 8412 participants (55% women) attending the Tromsø Study 2007-2008 (MI-cohort II) for first-ever MI up to their participation in 2007-2008 and 2015-2016, respectively. We used linear regression models to investigate sex and age differences in change in blood pressure.

Results

A total of 396 participants in MI-cohort I and 131 participants in MI-cohort II had a first-ever MI in the observation periods. In MI-cohort I, 35% of the women and 52% of the men achieved the treatment targets of blood pressure <140/90 mm Hg (130/80 mm Hg if diabetic), while the proportions for MI-cohort II were 50% and 54% for women and men, respectively. Antihypertensive use was reported in 88% of women and 87% of men in MI-cohort I, and 76% of women and 81% of men in MI-cohort II.

Conclusions

We found an overall low achievement of the treatment target. The findings call for better strategies for secondary prevention for both women and men.

Comparison of 30-Day and Long-Term Outcomes and Hospital Complications Among Patients Aged <75 Versus ≥75 Years With ST-Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Our aim was to evaluate the mortality rate and occurrence of complications in patients aged <75 versus ≥75 years with ST-elevation myocardial infarction (STEMI). We studied 1,657 consecutive patients with STEMI hospitalized in the cardiac intensive care unit during 2008 to 2014. All patients underwent primary percutaneous intervention, of which 292 (18%) were aged ≥75 years. Patient records were evaluated for in-hospital complications, 30-day mortality, and long-term mortality over a mean period of 3.4 ± 2.1 years. Compared with younger patients, patients aged ≥75 years had a significantly higher rate of coronary disease risk factors, prolonged symptom duration (512 ± 640 vs 333 ± 545 minutes, p <0.01) and door-to-balloon time (51.1 ± 24 vs 45.6 ± 38, p = 0.02). Patients aged ≥75 years had more in-hospital noncardiac and cardiac complications, including cardiogenic shock and arrhythmia, and had higher 30-day and long-term mortalities. Cardiogenic shock was associated with increased short- and long-term mortality in the older group but was not incremental over the noncardiogenic shock cohort. In conclusion, in patients aged ≥75 years who underwent primary percutaneous intervention for STEMI, the short- and long-term mortality rate was greater than fourfold higher compared with younger patients.

Efficacy and safety outcomes of ticagrelor compared with clopidogrel in elderly Chinese patients with acute coronary syndrome

Objective

This study was designed to investigate the efficacy and safety outcomes of ticagrelor in comparison with clopidogrel on a background of aspirin in elderly Chinese patients with acute coronary syndrome (ACS).

Patients and methods

A double-blinded, randomized controlled study was conducted, and 200 patients older than 65 years with the diagnosis of ACS were assigned 1:1 to take ticagrelor or clopidogrel. The course of treatment was required to continue for 12 months.

Results

The median age of the whole cohort was 79 years (range: 65–93 years), and females accounted for 32.5% (65 patients). Baseline characteristics and clinical diagnosis had no significant difference between patients taking ticagrelor and clopidogrel; they were also balanced with respect to other treatments (P>0.05 for all). The risk of cardiovascular death was significantly lower in patients taking ticagrelor compared with clopidogrel, as was the risk of myocardial infarction (P<0.05 for all); there was no difference in the risk of stroke (P>0.05). Ticagrelor was more effective than clopidogrel in decreasing the primary efficacy end point (cardiovascular death, myocardial infarction, and stroke, P<0.05). The all-cause mortality was not significantly different between patients taking ticagrelor and clopidogrel (P>0.05). The difference in the risk of bleeding, platelet inhibition and patient outcomes major bleeding (life-threatening bleeding and others), and platelet inhibition and patient outcomes minor bleeding was not evident between patients taking ticagrelor and clopidogrel (P>0.05 for all).

Conclusion

The current study in elderly Chinese patients with ACS demonstrated that ticagrelor reduced the primary efficacy end point at no expense of increased bleeding risk compared with clopidogrel, suggesting that ticagrelor is a suitable alternative for use in elderly Chinese patients with ACS.

Intravenous Enoxaparin Versus Unfractionated Heparin in Elderly Patients Undergoing Primary Percutaneous Coronary Intervention: An Analysis of the Randomized ATOLL Trial

Elderly (≥75 years old) patients with ST-segment elevation myocardial infarction (STEMI) have higher ischemic and bleeding risk compared with those <75 years old. We investigated the efficacy and safety of intravenous (IV) enoxaparin versus IV unfractionated heparin (UFH) in elderly patients undergoing primary percutaneous coronary intervention (PCI) for STEMI. A prespecified analysis of the Acute Myocardial Infarction Treated with Primary Angioplasty and Intravenous Enoxaparin or Unfractionated Heparin to Lower Ischemic and Bleeding Events at Short- and Long-term Follow-up (ATOLL) study was performed examining the 30-day outcomes in the elderly patients. Of the 165 elderly patients in the ATOLL study, 85 patients received IV enoxaparin 0.5 mg/kg and 80 patients received IV UFH. Intravenous enoxaparin did not reduce the primary end point, the main secondary efficacy end point, major bleeding, major or minor bleeding, and all-cause mortality compared with IV UFH. The rate of minor bleeding (5.9% vs 22.8%, P _adjusted = .01) was significantly lower with IV enoxaparin compared with IV UFH. Intravenous enoxaparin appears to be a safe alternative to IV UFH in primary PCI of the elderly patients with STEMI.

Anticoagulant dosing in renal impairment

Anticoagulants are widely used for prophylaxis and treatment of venous thromboembolism in the elderly, who commonly have renal impairment and other comorbidities. Renal impairment is a risk factor for bleeding and thrombosis during anticoagulant therapy and can influence the balance between the safety and efficacy of such agents. Some anticoagulants, such as fondaparinux and the direct acting oral thrombin inhibitor dabigatran etexilate are contraindicated for use in patients with severe renal impairment (eGFR <30 ml/min). However, also the direct acting oral FXa-inhibitors rivaroxaban, edoxaban and apixaban need caution regarding dosing advice or contraindications when used in patients with renal impairment.

Sex differences in the treatment and outcome of patients with acute coronary syndrome after percutaneous coronary intervention: a population-based study

BACKGROUND

This study was performed to assess the influence of sex on drug therapy and long-term outcomes in acute coronary syndrome (ACS) patients who underwent percutaneous coronary intervention (PCI).

METHODS

This is a retrospective cohort study of ACS patients who underwent PCI [women (n=8,884) and men (n=23,937)] between January 1, 2006, and December 31, 2007, with at least a 1-year follow-up, based on the National Health Insurance Research Database in Taiwan. Propensity score was used to identify a 1:1 matched cohort (n=17,768) for multivariable adjustment. The influence of sex on drug therapy and outcomes was examined by multivariate logistic regression and multivariable Cox proportional hazards regression.

RESULTS

Female patients had an 18% and 12% lower likelihood of receiving aspirin (adjusted odds ratio [OR(adj)]=0.82, 95% confidence interval [CI]=0.77-0.88) and clopidogrel (OR(adj)=0.88, 95% CI=0.81-0.95), respectively, than male patients but had a 17% and 22% higher likelihood of receiving beta-blockers (OR(adj)=1.17, 95% CI=1.10-1.24) and statins (OR(adj)=1.22, 95% CI=1.14-1.29), respectively, than male patients in the matched cohort. The adjusted hazard ratio (HR(adj)) of rehospitalization for revascularization in women was 0.84 (95% CI=0.79-0.90) compared with men after at least a 1-year follow-up in the matched cohort.

CONCLUSIONS

Female patients with ACS who underwent PCI were less likely to receive aspirin and clopidogrel but were more likely to receive beta-blockers and statins than male patients. Male sex was associated with a higher risk of rehospitalization for revascularization than female sex.

[Acute myocardial infarction in Charleroi: evolution of risk factors and therapeutic practices]

OBJECTIVES

The aim of the study consists in analyzing the evolution of acute coronary risk factors as well as the 28 days case fatality and the therapeutic practices over 12 years of follow-up in Charleroi. The factors influencing the mortality of these patients are also investigated.

METHODS

The Charleroi register of ischaemic cardiopathies is the oldest register of infarctions in the French-speaking community of Belgium. Analyses presented hereafter relate only patients in the 25-69-year age range over time from 1998 to 2009. Some analysis was extended to 25-74-year range. Treatment and risk factors evolutions over time were analysed using Chi(2) tests. Logistic regression was used to identify factors influencing 28 days mortality.

RESULTS

The analysis shows a significant decline in 28 days mortality. A marked increase in the prevalence of hypertension and hypercholesterolemia is highlighted as well as an increase of utilization of percutaneous transluminal coronary angioplasty (PTCA) between 1998 and 2009. The use of ß-blockers and antiplatelet drugs remained fairly stable between 1998 and 2009 with approximately 75% and 90% of the patients treated, respectively. The factors associated with fatality were specifically age of patients, antecedents of diabetes and antecedents of myocardial infarction, hypercholesterolaemia as well as oral antiplatelet drugs, ß-blockers therapies and PTCA.

CONCLUSIONS

The evolution of the therapeutic data on AMI in this register confirms that PTCA becomes the main coronary reperfusion. Angiotensin-converting enzyme inhibitors were without effect on mortality.

Ticagrelor Versus Clopidogrel in Elderly Patients With Acute Coronary Syndromes

Background—

Elderly patients with acute coronary syndrome are at high risk of recurrent ischemic events and death, and for both antithrombotic therapy and catheter-based complications. This prespecified analysis investigates the effect and treatment-related complications of ticagrelor versus clopidogrel in elderly patients (≥75 years of age) with acute coronary syndrome compared with those <75 years of age.

Methods and Results—

The association between age and the primary composite outcome, as well as major bleeding were evaluated in the PLATelet inhibition and patient Outcomes (PLATO) trial using Cox proportional hazards. Similar models were used to evaluate the interaction of age with treatment effects. Hazard ratios were adjusted for baseline characteristics. The clinical benefit of ticagrelor over clopidogrel was not significantly different between patients aged ≥75 years of age (n=2878) and those <75 years of age (n=15 744) with respect to the composite of cardiovascular death, myocardial infarction, or stroke (interaction P =0.56), myocardial infarction ( P =0.33), cardiovascular death ( P =0.47), definite stent thrombosis ( P =0.81), or all-cause mortality ( P =0.76). No increase in PLATO-defined overall major bleeding with ticagrelor versus clopidogrel was observed in patients aged ≥75 years (hazard ratio, 1.02; 95% confidence interval, 0.82–1.27) or patients aged <75 years (hazard ratio, 1.04; 95% confidence interval, 0.94–1.15). Dyspnea and ventricular pauses were more common during ticagrelor than clopidogrel treatment, with no evidence of an age-by-treatment interaction.

Conclusions—

The significant clinical benefit and overall safety of ticagrelor compared with clopidogrel in acute coronary syndrome patients in the PLATO cohort were not found to depend on age.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00391872.

Myocardial infarction in patients over 90 years of age

BACKGROUND

The aim of this study was to examine the trend in increasing life expectancy in relation to heart attack and cardiac catheterization.

METHODS

A retrospective study of very elderly patients over 90 years of age (study group) and between 70 and 79 years of age (control group) with myocardial infarction and acute coronary syndrome who underwent coronary angiography was conducted.

RESULTS

A total of 1100 cardiac catheterizations were performed in the cardiac catheterization laboratory of Vinzentius-Hospital in Landau, Germany from 2007 to 2011. The number of coronary angiographies performed in patients aged over 90 years and those aged 70-79 years was 36 and 354, respectively, during this same time period. No increase in the number of evidence-based therapy for coronary heart disease by cardiac catheterization was observed in the very elderly patients over this time period.

CONCLUSION

An increase in the number of patients aged over 90 years and a rise in heart attacks, as evaluated by coronary angiography, could not be found in this study.

Trends in acute myocardial infarction treatment between 1998 and 2007 in a Belgian area (Charleroi)

BACKGROUND/OBJECTIVES

To describe the evolution of the therapeutic practices over 10 years of follow-up of acute myocardial infarction (AMI) in Charleroi and to analyse the factors influencing the choice of treatments and the mortality of these patients.

METHODS

The Charleroi register of ischaemic cardiopathies is the oldest register of infarctions in the French-speaking community of Belgium and is one of the very rare registers that allows identifying tendencies over 25 years. Analyses presented hereafter relate only patients in the 25-69-year age range over time from 1998 to 2007. The data were analysed in five periods of 2 years. Treatment evolutions over time were analysed using chi-squared tests for trend and logistic regression analyses identify factors influencing the type of treatment.

RESULTS

The present study shows a marked increase in the utilization of percutaneous transluminal coronary angioplasty (PTCA) between 1998-1999 and 2006-2007. The use of thrombolytic agents on approximately one-third of the patients treated remained fairly stable between 1998 and 2007. A lower proportion of patients with a history of AMI received thrombolytic agents. Thrombolysis seems beneficial for men and without effect for women. The use of β-blockers continued to increase until the 2000-2001 period and remained fairly stable for the two following periods. 42% of patients were administered three medications (angiotensin-converting enzyme inhibitors, antiplatelet drugs, and β-blockers). Association of PTCA with antiplatelet drugs, β-blockers, and thrombolysis was observed for 58.7, 50.6, and 25.7%, respectively. These associations were still observed after adjustment for gender, age, and comorbidity. The factors associated with fatality were specifically old-aged patients, antecedents of diabetes, hypercholesterolaemia and oral antiplatelet drugs, and β-blockers therapies and PTCA.

CONCLUSIONS

The evolution of the therapeutic data on AMI in this register confirms the use and the efficacy of thrombolytic therapy. PTCA becomes the main coronary reperfusion treatment with less risk of bleeding. Angiotensin-converting enzyme inhibitors were without effect on mortality.

Factor Xa inhibitors for acute coronary syndromes

BACKGROUND

The activation of coagulation mechanisms plays a central role in the pathogenesis of acute coronary syndromes (ACS). Administration of unfractionated heparin (UFH) and low molecular weight heparins (LMWH), agents preventing the progression of thrombus formation, is a crucial therapeutic strategy. However, some limitations related to their use have recently stimulated the development of new synthetic agents.

OBJECTIVES

To evaluate the clinical efficacy and safety of factor Xa inhibitors for treatment of ACS compared to UFH or LMWH.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library (Issue 1, 2008), PubMed, EMBASE and LILACS as well as the publications from International Congresses and the reference lists of the selected studies in December 2008.

SELECTION CRITERIA

We used randomized controlled trials (RCTs) comparing factor Xa inhibitors to UFH or LMWH during the course of ACS. Outcome measures included all-cause mortality, myocardial infarction, re-infarction, ischemia recurrence, and adverse events.

DATA COLLECTION AND ANALYSIS

The selection, quality assessment and data extraction of the included trials were done independently by two authors and disagreements were resolved by consensus. Data were analysed by the use of risk ratio (RR) with 95% confidence interval (CI), and the numbers needed to treat (NNT) were reported as needed.

MAIN RESULTS

A total of four RCTs involving 27,976 subjects were included. Fondaparinux was the only factor Xa inhibitor identified in our included RCTs. Fondaparinux appeared to be related to a lower risk in all-cause mortality at 90 to 180 days (RR 0.89; 95% CI 0.81 to 0.97), especially in the group where enoxaparin (a LMWH) was the control drug. Fondaparinux was also associated with a lower risk in major and minor bleeding at 30 days compared to enoxaparin (RR 0.63, 95% CI 0.55 to 0.73; RR 0.34, 95% CI 0.28 to 0.43, respectively), but not when compared to UFHs (RR 1.41; 95% CI 0.49 to 4.10; RR 0.70, 95% CI 0.14 to 3.39 respectively).

AUTHORS' CONCLUSIONS

The therapeutic efficacy of factor Xa inhibitors in ACS seemed to be related to a reduced risk in all-cause mortality at 90 to 180 days, with a better safety profile than enoxaparin in terms of reduce incidence of major and minor bleeding.

[Are very old patients good candidates for percutaneous coronary intervention? A monocentric retrospective study]

AIM

To determine the feasibility of percutaneous coronary intervention (PCI) in very old patients.

BACKGROUND

The elderly are a growing population with a high prevalence of ischemic heart disease and then subsequent possibility to benefit from coronary interventions.

METHOD

We have conducted a retrospective study using our PCI database since January 2000. Population characteristics, clinical presentation, type of lesions, technical procedure, immediate results and in hospital outcome are compare between patients older than 85 and the other.

RESULTS

Between January 2008 and March 2009, 3130 patients benefit from coronary angioplasty. Among them, 85 patients were older than 85. There were more female in this group (24.7 vs. 14.3%, P=0.007), but no difference in cardiovascular risk profile. The older was more symptomatic (acute coronary syndrome: 59.52 vs. 44%, P=0.004; silent ischemia: 3.6 vs. 25.7%, P=0.000003). The ejection fraction was worse (EF<55%: 29.4 vs. 14.5%, P=0.0001). The lesion was more complex (B2 and C: 67.2 vs. 57.1% P=0.027) and concern more often the left descending artery (85.9 vs. 57.1%, P=0.000001). The technical success was similar in the two groups (93.28 vs. 94.32%, P=0.34) with similar rate of per procedure complications (2.35 vs. 1.5%, P=0.37). Nevertheless, the in-hospital rate mortality was higher in the older patients (7 vs 1.38%, P=0.0014).

CONCLUSION

PCI is safe and safety in very old patients despite significant but acceptable increasing in-hospital mortality due to more severe disease and co morbidities. Further evaluations are necessary in order to edict specific recommendations.