Outcome in Elderly Patients Undergoing Primary Coronary Intervention for Acute Myocardial Infarction

Abstract

Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction (AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty. Methods and Results-In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty, angioplasty plus abciximab, stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age (1.6% for patients Ͻ55 years, 2.1% for 55 to 65 years, 7.1% for 65 to 75 years, 11.1% for patients Ͼ75 years; PϽ0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (Ն65 years), 1-year rates of ischemic target revascularization (7.0% versus 17.6%; PϽ0.0001) and subacute or late thrombosis (0% versus 2.2%; Pϭ0.005) were reduced with stenting compared with balloon angioplasty. Routine abciximab administration, although safe, was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality. Conclusions-Despite contemporary mechanical reperfusion strategies, mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein IIb/IIIa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

“…764 However, increased risks of complications such as major bleeding and stroke mandate careful consideration of the benefits and risks of PCI in elderly patients. 373 …”

Trends in the Association Between Age and In-Hospital Mortality After Percutaneous Coronary Intervention

“…4,5,7,8,19,20 In this study, the mortality rate in octogenarians was 5 times higher compared with the younger population and represents almost 30% of all deaths after PCI. Age in other studies was an independent predictor of outcomes after percutaneous coronary revascularization overall, and also in the setting of primary PCI.…”

“…7,8 Age is an important covariate that determines death and other major adverse cardiovascular events in all risk adjustment revascularization models. 9 -13 Much of the data on the effect of age as an independent determinant of outcome are relatively old and are derived from late 1990s and early 2000, and therefore, do not include patients receiving current therapies, including drug-eluting stents.…”

Duration of Symptoms Is the Key Modulator of the Choice of Reperfusion for ST-Elevation Myocardial Infarction

“…66,68 Perhaps it is the elderly who provide the best example of Hobson's choice or the risk-treatment paradox and constitute a major element of the undertreated and understudied STEMI population. 69 As developed in Figure 2, a variety of situational and personal factors appear especially influential in modulating the delay between symptom onset and the summoning of medical assistance.…”