Outcomes of Nonagenarians With Acute Coronary Syndrome

OBJECTIVES

Nonagenarians are a fast-growing age group among cardiovascular patients, but data about their management and prognosis after an acute coronary syndrome (ACS) is scarce. This study aimed to analyze characteristics of nonagenarian patients with ACS and to compare in-hospital and 1-year clinical outcomes between those treated with medical treatment (MT) alone and those receiving percutaneous coronary intervention (PCI).

DESIGN

Multicenter observational study.

SETTING AND PARTICIPANTS

We included consecutive nonagenarian patients with ACS admitted at 4 academic centers between 2005 and 2018. Only patients with type 1 myocardial infarction were included.

METHODS

Standardized definitions of all patient-related variables, clinical diagnoses, and hospital complications and outcomes were used. The primary endpoint was 1-year all-cause mortality. Long-term survival was compared between patients undergoing PCI and those managed with MT alone. Given differences in baseline characteristics could substantially interfere in outcomes, 3 sensitivity analyses were performed to adjust for confounders.

RESULTS

A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non-ST-segment elevation ACS (NSTE-ACS) and 307 (45%) with ST-segment elevation myocardial infarction (STEMI). A coronary angiogram was performed in 115 (31%) of NSTE-ACS and in 182 (60%) of STEMI patients with subsequent PCI in 81 (22%) and 156 (51%), respectively. Overall mortality rates were 17% in-hospital and 39% at 1-year follow-up. PCI was independently associated with a decreased risk of 1-year all-cause death [hazard ratio (HR) 0.57, 95% confidence interval (CI) 0.35, 0.95; P < .05], mainly observed in those patients without disability (HR 0.59, 95% CI 0.37, 0.94; P < .01) and lower Killip class (HR 0.50, 95% CI 0.28, 0.89; P < .001).

CONCLUSIONS AND IMPLICATIONS

The prognosis of nonagenarians after an ACS was associated with comorbidities and the therapeutic approach. Although PCI appeared to be a safe and effective strategy, it is still necessary to refine the decision-making process in this high-risk population group.

Sex-gender disparities in nonagenarians with acute coronary syndrome

Background

Acute coronary syndrome (ACS) remains one of the leading causes of mortality for women, increasing with age. There is an unmet need regarding this condition in a fast‐growing and predominantly female population, such as nonagenarians.

Hypothesis

Our aim is to compare sex‐based differences in ACS management and long‐term clinical outcomes between women and men in a cohort of nonagenarians.

Methods

We included consecutive nonagenarian patients with ACS admitted at four academic centers between 2005 and 2018. The study was approved by the Ethics Committee of each center.

Results

A total of 680 nonagenarians were included (59% females). Of them, 373 (55%) patients presented with non‐ST‐segment elevation ACS and 307 (45%) with ST‐segment elevation myocardial infarction (STEMI). Men presented a higher disease burden compared to women. Conversely, women were frailer with higher disability and severe cognitive impairment. In the STEMI group, women were less likely than men to undergo percutaneous coronary intervention (PCI) (60% vs. 45%; p = .01). Overall mortality rates were similar in both groups but PCI survival benefit at 1‐year was greater in women compared to their male counterparts (82% vs. 68%; p = .008), persisting after sensitivity analyses using propensity‐score matching (80% vs. 64%; p = .03).

Conclusion

Sex‐gender disparities have been observed in nonagenarians. Despite receiving less often invasive approaches, women showed better clinical outcomes. Our finding may help increase awareness and reduce the current gender gap in ACS management at any age.

Outcomes of nonagenarians with acute coronary syndrome

Background

Myocardial infarction (MI) in nonagenarians is associated with high morbidity and mortality. Nonetheless, this population has typically been underrepresented in cardiovascular clinical trials.

Objective

The aim of this study was to evaluate outcomes of nonagenarian patients presenting with MI who underwent either conservative or invasive management.

Methods

We retrospectively included all consecutive patients equal to or older than 90yo admitted with non-ST segment elevation (NSTEMI) or ST segment elevation MI (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristic and procedural data. In-hospital and at 1-year follow-up all-cause mortality and major adverse cardiovascular events were assessed.

Results

523 patients (mean age 92.6±2 years; 60% females) were analyzed. Overall, 184 patients (35.2%) underwent percutaneous coronary intervention (PCI), increasing over the years, mostly in STEMI group (from 16% of patients in 2005 to 75% in 2018). PCI was preferred in those subjects with less prevalence of disability for activities of daily living (p&lt;0.01). The use of a radial access (76.6%) and bare metal stents (52.7%) was predominant. No significant differences were found in the incidence of major bleeding events or MI-related mechanical complications between both strategies. During index hospitalization, 99 (18.9%) patients died. Whereas no differences were found in the NSTEMI group (p=0.61), a significant lower in-hospital mortality was observed in STEMI group treated with PCI (p&lt;0.01). At one-year follow up, 203 (38.8%) patients died, most of them due to a cardiovascular cause (60.6%). PCI was related to a lower all-cause mortality in either NSTEMI (p&lt;0.01) or STEMI groups (p&lt;0.01) however, lower cardiovascular mortality was only found in STEMI group (p=0.03).

Conclusion

An invasive approach was performed in over a third of nonagenarian patients, carrying prognostic implications and with a few numbers of complications. PCI seems to be the preferred strategy for STEMI in this high-risk population in spite of age.

Figure 1

Funding Acknowledgement

Type of funding source: None

Acute coronary syndromes in nonagenarians: do we have reliable risk scores?

Introduction

GRACE score is strongly validated to determine the probability of death in acute coronary syndrome (ACS), nevertheless its usefulness in nonagenarians, a population with frequently associated comorbidities, is less stablished. BARTHEL and CHARLSON scores might be useful tools to predict outcomes in this population.

Objective

The aim of this study was to evaluate the potential applicability of GRACE score and two comorbidity scores (CHARLSON and BARTHEL) to estimate prognosis in nonagenarians with ACS.

Material and methods

We retrospectively included all consecutive patients equal to or older than 90 years old admitted with non-ST (NSTEMI) or ST segment elevation myocardial infarction (STEMI) in four tertiary care centers between 2005 and 2018. Patients with type 2 myocardial infarction were excluded. We collected patients' baseline characteristics and procedural data. In-hospital and at 1-year follow-up all-cause and cardiovascular mortality were assessed. Risk score accuracy was evaluated by area under the curve ROC (AUC).

Results

A total of 444 patients (mean age 92.6±2.4 years, 60% females) were analyzed.

Approximately half of them (n=241, 54%) with STEMI and the remainder (n=203, 46%) with NSTEMI. Global GRACE-AUC for in-hospital and 1-year all-cause mortality were moderate (0.64; 95% CI: 0.59–0.69 and 0.62; 95% CI: 0.57–0.67, respectively). Only in the NSTEMI group, the GRACE-AUC was better to predict in-hospital mortality, 0.70 (95% CI: 0.63–0.77). Neither CHARLSON nor BARTHEL showed better predictive results than GRACE score (AUC ≤0.60).

Conclusion

GRACE score has moderate accuracy to estimate mortality in nonagenarian patients with ACS. BARTHEL and CHARLSON scores do not improve the predictive value of GRACE score. An individualized approach is required to make therapeutic decisions in this special population.

Figure 1. ROC-GRACE curves

Funding Acknowledgement

Type of funding source: None

Outcomes of Nonagenarians With ST Elevation Myocardial Infarction

Although older adults are the fastest-growing age group among cardiovascular patients, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are under-represented in clinical trials. The aims of this study are to analyze the clinical presentation and outcomes of nonagenarian patients presenting with STEMI and to compare in-hospital and 1-year clinical outcomes between those treated with optimal medical treatment alone and those receiving primary percutaneous coronary intervention (pPCI). We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2006 and 2018. There were no exclusion criteria. All-cause mortality was assessed in-hospital and at 1-year follow-up. In total, 167 patients (mean age 91.9 ± 0.17 years; 60% females) were included. Emergent catheterization was performed in 60% of our patients, and pPCI was performed in 50% (n = 83). Overall mortality was 22% in-hospital and 41% at 1-year follow-up. The pPCI group had lower mortality than the medical treatment group: 12% versus 32% in-hospital (p <0.01) and 26% versus 45% at 1-year follow-up (p <0.01), respectively. Multivariable analysis identified 4 independent predictors of all-cause mortality at 1 year: mechanical complications (adjusted odds ratio [OR] 9.25, p <0.01), Killip class III/IV (adjusted OR 4.22, p <0.01), serum creatinine at admission (mg/dl; adjusted OR 1.8, p <0.01), and pPCI (adjusted OR 0.52; p <0.05). In conclusion, STEMI in nonagenarians is becoming increasingly common. pPCI may be the preferred strategy in this high-risk cohort when a high grade of disability is not present. Hemodynamic compromise, the presence of complications related to myocardial infarction, renal impairment, and early revascularization may be related to prognosis in these patients.

P1562Outcomes of nonagenarians with ST elevation myocardial infarction

Background

Developed countries are facing a sustained increase in life expectancy. Elderly people represent the fastest growing portion of cardiovascular patients. However, nonagenarians with ST-segment elevation myocardial infarction (STEMI) are often underrepresented in clinical trials as prolonged follow-up may be compromised by limited life expectancy. The aim of this retrospective study is to analyse the clinical presentation, risk factors, co-morbidities, outcomes of nonagenarian patients presenting with STEMI.

Methods

We included all consecutive nonagenarians presenting with STEMI admitted in 2 academic centers between 2007 and 2017. There were no exclusion criteria. We collected demographic, clinical, and procedural data. All-cause mortality was assessed in-hospital, at 6 months and at 1-year follow-up.

Results

A total of 140 patients (mean age 91.6 years [91.3–92]; 59% females) were included. The number of patients increased over the years (from 6.5 cases per year before 2012 to 14.4 cases per year after 2012). One out of 5 patients presented disability or dependence for activities of daily living (ADL). Emergent catheterization was performed in 70% of our patients, and primary percutaneous coronary intervention (pPCI) in 57% (n=80). The use of bare metal stent was preponderant (72%) in this cohort. Successful revascularization of the culprit vessel was achieved in 90% of patients. Dual antiplatelet therapy with aspirin and clopidogrel was used in 97% of patients. Overall, in-hospital mortality was 22%, increased up to 27% at 6 months and up to 34% at 1-year follow-up. In-hospital mortality was lower in pPCI group than in conservative group (13.7% versus 31.6%, adjusted OR: 0.17, 95% CI: 0.04–0.67, P<0.01). One-year mortality was also lower in pPCI group than in conservative group (26% versus 45%, P<0.01). Multivariable analysis identified mechanical complications (adjusted OR: 28.1, 95% CI: 3.18–247.7, P<0.01), Killip class (III/IV) (adjusted OR: 4.19, 95% CI: 3.37–22.3, P<0.01) and pPCI (adjusted OR: 0.40, 95% CI: 0. 16- 0. 95, P<0.05) as independent predictors of all-cause mortality at 1 year.

Conclusions

STEMI in nonagenarians is becoming more and more common. pPCI may be also the preferred strategy in this high-risk cohort. The hemodynamic compromise (Killip class III/IV), the presence of complications related to myocardial infarction and early revascularization may be related to prognosis of these patients.