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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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Peyracchia M, Errigo D, Raposeiras Rubin S, Conrotto F, DiNicolantonio JJ, Omedè P, Rettegno S, Iannaccone M, Moretti C, D'Amico M, Gaita F, D'Ascenzo F. Beta-blocker therapy reduces mortality in patients with coronary artery disease treated with percutaneous revascularization: a meta-analysis of adjusted results. J Cardiovasc Med (Hagerstown) 2019; 19:337-343. [PMID: 29877974 DOI: 10.2459/jcm.0000000000000662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AIMS The long-term impact of beta blockers on prognosis in patients treated with contemporary therapies for coronary artery disease remains to be defined. METHODS AND RESULTS All observational studies evaluating the impact of beta blockers in patients treated with coronary revascularization and contemporary therapies and adjusted with multivariate analysis were included. All-cause death was the primary endpoint, while Major Adverse Cardiac Events (MACE) (composite endpoint of all-cause death or myocardial infarction, MI) and MI were secondary endpoints. A total of 26 studies were included, with 863 335 patients. After 3 (1-4.3) years, long-term risk of all-cause death was lower in patients on beta blockers [odds ratio, OR 0.69 (0.66-0.72)], both for Acute Coronary Syndrome (ACS) [OR 0.60 (0.56-0.65)], and stable angina patients [OR 0.84 (0.78-0.91)], independently from ejection fraction [OR 0.64 (0.42-0.98) for reduced ejection fraction and OR 0.79 (0.69-0.91) for preserved ejection fraction]. The risk of long-term MACE was lower but NS for ACS patients treated with beta blockers [OR 0.83 (0.69-1.00)], as in stable angina. Similarly, risk of MI did not differ between patients treated with beta blockers or without beta blockers [OR 0.99 (0.89-1.09), all 95% confidence intervals]. Using meta-regression analysis, the benefit of beta blockers was increased for those with longer follow-up. The number needed to treat was 52 to avoid one event of all-cause death for ACS patients and 111 for stable patients. CONCLUSION Even in percutaneous coronary intervention era, beta blockers reduce mortality in patients with coronary artery disease, confirming their protective effect, which was consistent for both ACS and stable patients indifferently of preserved or reduced ejection fraction.
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Affiliation(s)
- Mattia Peyracchia
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Daniele Errigo
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Sergio Raposeiras Rubin
- Department of Cardiology and Coronary Care Unit, Hospital Clínico Universitario de Santiago de Compostela, A Coruña, Spain
| | - Federico Conrotto
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | | | - Pierluigi Omedè
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Sara Rettegno
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Mario Iannaccone
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Claudio Moretti
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Maurizio D'Amico
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, Turin, Italy
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Malanchini G, Stefanini GG, Malanchini M, Lombardi F. Higher in-hospital mortality during weekend admission for acute coronary syndrome: a large-scale cross-sectional Italian study. J Cardiovasc Med (Hagerstown) 2018; 20:74-80. [PMID: 30540646 DOI: 10.2459/jcm.0000000000000743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS An increased mortality risk during weekend hospital admission has been consistently observed. In the present study, we evaluated whether the current improvement in management of acute coronary syndromes (ACS) has reduced this phenomenon. METHODS AND RESULTS We extracted data from the Italian National Healthcare System Databank of 80 391 ACS admissions in the region of Lombardia between 2010 and 2014. ICD-9 codes were used to assess the diagnosis. We performed a multiple logistic regression analysis to compare the mortality rates between weekend and weekday admissions.Mean age of the study population was 67.6 years; 30.1% of patients were women. ST segment elevation myocardial infarction (STEMI) accounts for 42.2% of admissions. The total in-hospital mortality was 3.05% and was positively predicted by weekend admission [odds ratio (OR) 1.13, P = 0.006], age and female sex. The weekend effect on mortality was only significant for STEMI (OR 1.11, P = 0.04) in comparison to non-STEMI (NSTEMI) or unstable angina.The trend of the risk of death was found to be negatively correlated with age: the risk of death was significantly higher in all age clusters younger than 75 (OR 1.22, P < 0.01) and even greater in the very young subgroup under 45 years of age (OR 2.09, P = 0.03). CONCLUSION Our data indicate that increased mortality risk is still present during weekend admissions. This phenomenon is particularly evident in younger patients and in individuals admitted for STEMI.
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Affiliation(s)
- Giovanni Malanchini
- Cardiologia, Fondazione IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan
| | | | | | - Federico Lombardi
- Cardiologia, Fondazione IRCCS Ospedale Maggiore Policlinico, University of Milan, Milan
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Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification. Am J Cardiol 2017; 120:1421-1426. [PMID: 28844513 DOI: 10.1016/j.amjcard.2017.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Revised: 06/16/2017] [Accepted: 07/03/2017] [Indexed: 12/23/2022]
Abstract
There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.
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