Invasive strategy and frailty in very elderly patients with acute coronary syndromes

AIMS

Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients.

METHODS AND RESULTS

The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-hazard ratio [sHR] 2.32, 95% confidence interval [CI]: 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI: 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI: 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032).

CONCLUSIONS

An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

Clinical picture, management and risk stratification in patients with cardiogenic shock: does gender matter?

Background

Early recognition and risk stratification are crucial in cardiogenic shock (CS). A lower adherence to recommendations has been described in women with cardiovascular diseases. Little information exists about disparities in clinical picture, management and performance of risk stratification tools according to gender in patients with CS.

Methods

Data from the multicenter Red-Shock registry were used. All consecutive patients with CS were included. Both CardShock and IABP-SHOCK II risk scores were calculated. The primary end-point was in-hospital mortality. The discriminative ability of both scores according to gender was assessed by binary logistic regression, calculating Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC).

Results

A total of 793 patients were included, of whom 222 (28%) were female. Women were significantly older and had a lower proportion of chronic obstructive pulmonary disease and prior myocardial infarction. CS was less often related to acute coronary syndromes (ACS) in women. The use of vasoactive drugs, renal replacement therapy, invasive ventilation, therapeutic hypothermia and mechanical circulatory support was similar between both groups. In-hospital mortality was 346/793 (43.6%). Mortality was not significantly different according to gender (p = 0.194).

Cardshock risk score showed a good ability for predicting in-hospital mortality both in man (AUC 0.69) and women (AUC 0.735). Likewise, the IABP-II successfully predicted in-hospital mortality in both groups (man: AUC 0.693; women: AUC 0.722).

Conclusions

No significant differences were observed regarding management and in-hospital mortality according to gender. Both the CardShock and IABP-II risk scores depicted a good ability for predicting mortality also in women with CS.

Comorbidity and low use of new antiplatelets in acute coronary syndrome

INTRODUCTION

Despite the use of the new generation P2Y12 inhibitors (Ticagrelor and Prasugrel) with aspirin is the recommended therapy in acute NSTE-ACS patients, their current use in clinical practice remains quite low and might be related, among several variables, with increased comorbidity burden. We aimed to assess the prevalence of these treatments and whether their use could be associated with comorbidity.

METHOD

A multicentric prospective registry was conducted at 8 Cardiac Intensive Care Units (October 2017-April 2018) in patients admitted with non ST elevation myocardial infarction. Antithrombotic treatment was recorded and the comorbidity risk was assessed using the Charlson Comorbidity Index. We created a multivariate model to identify the independent predictors of the use of new inhibitors of P2Y12.

RESULTS

A total of 629 patients were included, median age 67 years, 23.2% women, 359 patients (57.1%) treated with clopidogrel and 40.6% with new P2Y12 inhibitors: ticagrelor (228 patients, 36.2%) and prasugrel (30 patients, 4.8%). Among the patients with very high comorbidity (Charlson Score > 6) clopidogrel was the drug of choice (82.6%), meanwhile in patients with low comorbility (Charlson Score 0-1) was the ticagrelor or prasugrel (63.6%). Independent predictors of the use of ticagrelor or prasugrel were a low Charlson Comorbidity Index, a low CRUSADE score and the absence of prior bleeding.

CONCLUSION

Antiplatelet treatment with Ticagrelor or Pasugrel was low in patients admitted with NSTE-ACS. Comorbidity calculated with Charlson Comorbidity Index was a powerful predictor of the use of new generation P2Y12 inhibitors in this population.

Statin Treatment and Prognosis of Elderly Patients Discharged after Non-ST Segment Elevation Acute Coronary Syndrome

Background: Statins are recommended for secondary prevention. Our aims were to describe the proportion of very elderly patients receiving statins after non-ST segment elevation acute coronary syndrome (NST-ACS) and to determine the prognostic implications of statins use. Methods: This prospective registry was performed in 44 hospitals that included patients ≥80 years discharged after a NST-ACS from April 2016 to September 2016. Results: We included 523 patients, the mean age was 84.2 ± 4.0 years and 200 patients (38.2%) were women. Previous statin treatment was recorded in 282 patients (53.4%), and 135 (32.5%) had LDL cholesterol levels >2.6 mmol/L. Mean LDL cholesterol levels during admission were 2.3 ± 0.9 mmol/L. Statins were prescribed at discharge to 474 patients (90.6%). Compared with patients discharged on statins, those that did not receive statins were more often frail (22 [47.8%] vs. 114 [24.4%], p < 0.01) and underwent an invasive approach less frequently (30 [61.2%] vs. 374 [78.9%], p = 0.01). During a 6-month follow-up, 50 patients died (9.5%). There was a nonsignificant trend to higher mortality in patients not treated with statins (6 [15%] vs. 44 [9.6%], p = 0.30), but statins were not independently associated with lower mortality (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.30–2.11, p = 0.65), nor with a reduction in the combined endpoint mortality/hospitalizations (HR 0.89; 95% CI 0.52–1.55, p = 0.69). Conclusions: Although most octogenarians presenting a NST-ACS are already on statins before the episode, their LDL cholesterol is frequently >2.6 mmol/L. Octogenarians who do not receive statins have a high-risk profile, with significant frailty and comorbidity.

Mitral Regurgitation and Prognosis After Non-ST-Segment Elevation Myocardial Infarction in Very Old Patients

BACKGROUND/OBJETCTIVES

Mitral regurgitation (MR)after an acute coronary syndrome is associated with a poor prognosis. However,the prognostic impact of MR in elderly patients with non-ST-segment elevation myocardialinfarction (NSTEMI) has not been well addressed.

DESIGN

Prospective registry.

SETTING AND PARTICIPANTS

The multicenter LONGEVO-SCA prospective registry included 532 unselected NSTEMI patients aged ≥80 years.

MEASUREMENTS

MR was quantified using echocardiography during admission in 497 patients. They were classified in two groups: significant (moderate or severe) or not significant MR (absent or mild). We evaluated the impact of MR status on mortality or readmission at 6 months.

RESULTS

Mean age was 84.3±4.1 years, and 308 (61.9%) were males. A total of 108 patients (21.7%) had significant MR. Compared with those without significant MR, they were older and showed worse baseline clinical status, with higher frailty, disability, and risk of malnutrition. They also had lower systolic blood pressure, higher heart rate, worse Killip class, lower left ventricular ejection fraction, and higher pulmonary pressure on admission, as well as more often new onset atrial fibrillation (all p values = 0.001). Patients with significant MR also had higher in-hospital mortality (4.6% vs. 1.3%, p = 0.04), longer hospital stay (median 8 [5-12] vs. 6 [4-10] days, p = 0.002), and higher mortality/readmission at 6 months (hazard ratio 1.54, 95% confidence interval 1.09-2.18, p = 0.015). However, after adjusting for potential confounders, this last association was not significant.

CONCLUSIONS

Significant MR is seen in one fifth of octogenarians with NSTEMI. Patients with significant MR have a poor prognosis, mainly determined by their baseline clinical characteristics. J Am Geriatr Soc 67:1641-1648, 2019.

Geriatric Assessment and In-Hospital Economic Cost of Elderly Patients With Acute Coronary Syndromes

BACKGROUND

Elderly patients with acute coronary syndromes (ACS) are at higher risk for complications and health care resources expenditure. No previous study has assessed the specific contribution of frailty and other geriatric syndromes to the in-hospital economic cost in this setting.

METHOD

Unselected patients with ACS aged ≥75 years were prospectively included. A comprehensive geriatric assessment was performed during hospitalisation. Hospitalisation-related cost per patient was calculated with an analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in Euros (2019). The contribution of geriatric syndromes and clinical factors to the economic cost was assessed with a linear regression method.

RESULTS

A total of 194 patients (mean age 82.6 years) were included. Mean length of hospital stay was 11.3 days. The admission-related economic cost was €6,892.15 per patient. Most of this cost was attributable to hospital length of stay (77%). The performance of an invasive strategy during the admission was associated with economic cost (p=0.008). Of all the ageing-related variables, comorbidity showed the most significant association with economic cost (p=0.009). Comorbidity, disability, nutritional risk, and frailty were associated with the hospital length of stay-related component of the economic cost. The final predictive model of economic cost included age, previous heart failure, systolic blood pressure, Killip class at admission, left main disease, and Charlson index.

CONCLUSIONS

Management of ACS in elderly patients is associated with a significant economic cost, mostly due to hospital length of stay. Comorbidity mostly contributes to in-hospital resources expenditure, as well as the severity of the coronary event.

Clinical profile, management and outcomes of patients with cardiogenic shock undergoing transfer between centers in Spain

INTRODUCTION AND OBJECTIVES

The aim of this study was to analyze the clinical profile, management, and prognosis of ST segment elevation myocardial infarction-related cardiogenic shock (STEMI-CS) requiring interhospital transfer, as well as the prognostic impact of structural variables of the treating centers in this setting.

METHODS

This study included patients with STEMI-CS treated at revascularization-capable centers from 2016 to 2020. The patients were divided into the following groups: group A: patients attended throughout their admission at hospitals with interventional cardiology without cardiac surgery; group B: patients treated at hospitals with interventional cardiology and cardiac surgery; and group C: patients transferred to centers with interventional cardiology and cardiac surgery. We analyzed the association between the volume of STEMI-CS cases treated, the availability of cardiac intensive care units (CICU), and heart transplant with hospital mortality.

RESULTS

A total of 4189 episodes were included: 1389 (33.2%) from group A, 2627 from group B (62.7%), and 173 from group C (4.1%). Transferred patients were younger, had a higher cardiovascular risk, and more commonly underwent revascularization, mechanical circulatory support, and heart transplant during hospitalization (P<.001). The crude mortality rate was lower in transferred patients (46.2% vs 60.3% in group A and 54.4% in group B, (P<.001)). Lower mortality was associated with a higher volume of care and CICU availability (OR, 0.75, P=.009; and 0.80, P=.047).

CONCLUSIONS

The proportion of transfers in patients with STEMI-CS in our setting is low. Transferred patients were younger and underwent more invasive procedures. Mortality was lower among patients transferred to centers with a higher volume of STEMI-CS cases and CICU.

Impact of annual volume of cases and Intensive Cardiac Care Unit availability on mortality of patients with acute myocardial infarction- related cardiogenic shock treated at revascularization capable centers

BACKGROUND

Cardiogenic shock (CS) is associated with high mortality. The purpose of this study was to assess the impact of Hospital structure-related variables on mortality in patients with CS treated at percutaneous and surgical revascularization capable centers (psRCC) from a large nationwide registry.

METHODS

Retrospective observational study including consecutive patients with main or secondary diagnosis of CS and ST elevation myocardial infarction (STEMI). Patients discharged from Spanish National Healthcare System psRCC were included (2016-2020). The association between the volume of CS cases attended by each center, availability of Intensive Cardiac Care Unit (ICCU) and heart transplantation (HT) programs and in-hospital mortality was assessed by multilevel logistic regression models.

RESULTS

The study population consisted of 3,074 CS-STEMI episodes, of whom 1,759 (57.2%) occurred in 26 centers with ICCU. A total of 17/44 hospitals (38.6%) were high-volume centers and 19/44 (43%) centers had HT programs availability. Treatment at HT centers was not associated with a lower mortality (p = 0.121). Both high volume of cases and ICCU showed a trend to an association with lower mortality in the adjusted model (OR: 0.87 and 0.88, respectively). The interaction between both variables was significantly protective (OR 0.72; p = 0.024). After propensity score matching, mortality was lower in high volume hospitals with ICCU [OR = 0.79; p = 0.007].

CONCLUSIONS

Most CS-STEMI patients were attended at psRCC with high volume of cases and ICCU available. The combination of high-volume and ICCU availability showed the lowest mortality. These data should be taken into account when designing regional networks for CS management.

Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units

OBJECTIVE

Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU).

DESIGN

A prospective cohort study was carried out.

SETTING

The ICCUs of 8 hospitals in Catalonia (Spain).

PATIENTS

Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria.

INTERVENTIONS

EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients.

OUTCOME VARIABLES

Mortality or readmission at 6 months.

RESULTS

A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035).

CONCLUSIONS

The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.

Influence of sex on the timing of coronary angiography and the prescription of antiplatelet therapy in patients with nonST-segment elevation myocardial infarction

OBJECTIVES

To assess differences in the clinical management of nonST-segment elevation myocardial infarction (NSTEMI), including in-hospital events, according to biological sex.

MATERIAL AND METHODS

Prospective observational multicenter study of patients diagnosed with NSTEMI and atherosclerosis who underwent coronary angiography.

RESULTS

We enrolled 1020 patients in April and May 2022; 240 (23.5%) were women. Women were older than men on average (72.6 vs 66.5 years, P .001), and more women were frail (17.1% vs 5.6%, P .001). No difference was observed in pretreatment with any P2Y12 inhibitor (prescribed in 68.8% of women vs 70.2% of men, P = .67); however, more women than men were prescribed clopidogrel (56% vs 44%, P = .009). Women prescribed clopidogrel were more often under the age of 75 years and not frail. Coronary angiography was performed within 24 hours less corooften in women (29.8% vs 36.9%, P = .03) even when high risk was recognized. Frailty was independently associated with deferring coronary angiography in the adjusted analysis; biological sex by itself was not related. The frequency and type of revascularization were the same in both sexes, and there were no differences in in-hospital cardiovascular events.

CONCLUSION

Women were more often prescribed less potent antithrombotic therapy than men. Frailty, but not sex, correlated independently with deferral of coronary angiography. However, we detected no differences in the frequency of coronary revascularization or in-hospital events according to sex.