Should primary percutaneous coronary intervention be the routine reperfusion strategy in octogenarians presenting with ST elevation myocardial infarction?

Showkathali, Refai; Boston-Griffiths, Edney; Parker, Michael; Davies, John R.; Clesham, Gerald J.; Sayer, Jeremy; Kelly, Paul A.; Aggarwal, Rajesh

doi:10.2459/jcm.0b013e3283649978

Cited by 4 publications

(8 citation statements)

References 11 publications

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“…The 30‐day and 1‐year mortality observed in our population is consistent with those reported in recent studies among octogenarian and nonagenarian STEMI patients . In populations similar to ours, Antonsen et al , Claessen et al , Showkathali et al , and Shah et al reported 30‐day mortality of 18%, 20%, 21%, and 25%, respectively. Newell et al reported a 1‐year mortality of 28.9% among patients age ≥80 years.…”

Section: Discussionsupporting

confidence: 91%

“…The lower utilization of DESs among our elderly patients reflects widespread perception of the higher risk of bleeding in elderly patients and the reluctance of operators to commit elderly patients to DAPT for a prolonged period without a detailed clinical history, which is often not available for patients presenting for pPCI. Although elderly patients are less likely to receive DESs, other authors reported a higher use of DESs than ours …”

Section: Discussioncontrasting

confidence: 50%

“…Although elderly patients are less likely to receive DESs, other authors reported a higher use of DESs than ours. 10,13…”

Section: Discussionmentioning

confidence: 99%

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Outcomes and Predictors of Mortality Among Octogenarians and Older With ST‐Segment Elevation Myocardial Infarction Treated With Primary Coronary Angioplasty

Caretta

Passamonti

Pedroni

et al. 2014

Clinical Cardiology

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Background: Elderly patients are at high risk of mortality when they present with ST-elevation myocardial infarction (STEMI). However, few data exist about prognostic factors in this sub-group when treated with primary percutaneous coronary intervention (pPCI). Hypothesis: To assess outcome and predictors of mortality among patients aged >80 years treated with pPCI. Methods: We evaluated 139 consecutive patients (age 85.1 ± 3.9 years, 43.2% males) who underwent pPCI for STEMI. Results: Male patients were younger and were more likely to have a history of coronary artery disease. Overall 30-day and 1-year mortality rates were 20.9% and 28.1%, respectively. Thrombolysis in Myocardial Infarction (TIMI) flow 3 was achieved in 82% of patients. There was a pPCI success rate in male patients. At univariable analysis, older age, diabetes mellitus, Killip class >III, left ventricular ejection fraction (LVEF) <40%, no use of stent, failure of pPCI, systolic blood pressure (SBP) <100 mm Hg, and infarct-related artery (left anterior descending vs others) were associated with higher 1-year mortality. Multivariate analysis identified LVEF <40% (hazard ratio: [HR] = 3.70; 95% confidence interval [CI]: 1.30-7.87; P = 0.0001), age (1-year step, HR: 1.13; 95% CI: 1.04-1.23; P = 0.007), failure of pPCI (HR: 2.93; 95% CI: 1.44-5.98; P = 0.0001), Killip class ≥III (HR: 2.29; 95% CI: 1.03-5.4; P = 0.04) and SBP <100 mm Hg (HR: 2.64; 95% CI: 1.22-5.19; P = 0.01) to be independently associated with increased 1-year mortality. Conclusions: Our data show that elderly patients with STEMI have a high risk of mortality, which is particularly high in the first 30 days. Older age, LVEF <40% at admission, hemodynamic instability (higher Killip class or low SBP), and postinterventional TIMI flow <3 were independent predictors of mortality in our population.

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Section: Discussionsupporting

confidence: 91%

Section: Discussioncontrasting

confidence: 50%

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Outcomes and Predictors of Mortality Among Octogenarians and Older With ST‐Segment Elevation Myocardial Infarction Treated With Primary Coronary Angioplasty

Caretta

Passamonti

Pedroni

et al. 2014

Clinical Cardiology

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“…Two observational studies (2.9%) specifically recruited older patients. 10 11 A systematic review of RCTs in ACS demonstrated that the percentage of randomised trials excluding older patients appears to be falling, from 31.9% in 1996–2001 to 22.7% in 2014. 5 Indeed, although enrolment of older patients (≥75 years) has increased in recent decades, only 10.3% of patients fell into this age category in RCTs published between 1996 and 2000.…”

Section: Discussionmentioning

confidence: 99%

Engaging older patients in cardiovascular research: observational analysis of the ICON-1 study

et al. 2016

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BackgroundAs a consequence of population ageing, the number of older patients presenting with acute coronary syndrome (ACS) is increasing. The historical underrepresentation of older patients in many pivotal ACS clinical trials undermines the practice of evidence-based medicine in this high-risk cohort. This study evaluates the feasibility of recruitment of older patients to a longitudinal, clinical study.MethodsThe study to Improve Cardiovascular Outcomes in high-risk patieNts with ACS (ICON-1) is an observational, prospective cohort study investigating predictors of poor outcome in older patients with ACS. All patients aged ≥75 years, referred to a tertiary cardiovascular centre in the North East of England for coronary angiography with a view to urgent percutaneous coronary intervention, were screened for inclusion. A screening log was prospectively maintained, and a detailed analysis was performed to identify the factors associated with recruitment and non-recruitment to ICON-1.ResultsOf the 629 patients screened over 34 months, 457 (72.7%) satisfied the a priori-defined study inclusion/exclusion criteria. Of those eligible to participate, 300 (68.5%) provided informed consent and were recruited to the study; 59 (13.5%) were unable to consent due to a lack of capacity or limitations in communication, and 79 patients (18.0%) declined to participate in the study. Those lacking adequate capacity to consent were older than those able to provide informed consent (83.0±4.7 vs 81.0±4.7 years, p=0.002). Women were more likely to decline than men (25.1% vs 10.0%, p<0.001).ConclusionsThe recruitment of patients was robust, comparing favourably to previous longitudinal studies within this age group. Although enrolling older people to research remains challenging, this cohort is enthusiastic to participate. The contribution of older patients must not be ignored, particularly in the setting of an ever-ageing population, in whom cardiovascular disease burden is high.Trial registration numberNCT01933581; Pre-results.

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“…The very elderly (those ≥ 85 years of age) are the most rapidly growing population in Western countries. The mortality rate of this group increases markedly following ST-segment elevation myocardial infarction (STEMI) [ 1 , 2 ]. However, limited data are available regarding the outcomes of primary percutaneous coronary intervention (PCI) in this age group, especially in nonagenarians, who are generally excluded from clinical trials [ 3 ].…”

Section: Introductionmentioning

confidence: 99%

Temporal trends and in-hospital outcomes of primary percutaneous coronary intervention in nonagenarians with ST-segment elevation myocardial infarction

Kim¹,

Jeong

Choi³

et al. 2015

Korean J Intern Med

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Background/Aims:Data regarding the outcomes of primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in nonagenarians are very limited. The aim of the present study was to evaluate the temporal trends and in-hospital outcomes of primary PCI in nonagenarian STEMI patients.Methods:We retrospectively reviewed data from the Korea Acute Myocardial Infarction Registry (KAMIR) from November 2005 to January 2008, and from the Korea Working Group on Myocardial Infarction (KorMI) from February 2008 to May 2010.Results:During this period, the proportion of nonagenarians among STEMI patients more than doubled (0.59% in KAMIR vs. 1.35% in KorMI), and the rate of use of primary PCI also increased (from 62.5% in KAMIR to 81.0% in KorMI). We identified 84 eligible study patients for which the overall in-hospital mortality rate was 21.4% (25.0% in KAMIR vs. 20.3% in KorMI, p = 0.919). Multivariate analysis identified two independent predictors of in-hospital mortality, namely a final Thrombolysis in Myocardial Infarction (TIMI) flow < 3 (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.2 to 59.0; p < 0.001) and cardiogenic shock during hospitalization (OR, 6.7; 95% CI, 1.5 to 30.3; p = 0.013).Conclusions:The number of nonagenarian STEMI patients who have undergone primary PCI has increased. Although a final TIMI flow < 3 and cardiogenic shock are independent predictors of in-hospital mortality, primary PCI can be performed with a high success rate and an acceptable in-hospital mortality rate.

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Should primary percutaneous coronary intervention be the routine reperfusion strategy in octogenarians presenting with ST elevation myocardial infarction?

Cited by 4 publications

References 11 publications

Outcomes and Predictors of Mortality Among Octogenarians and Older With ST‐Segment Elevation Myocardial Infarction Treated With Primary Coronary Angioplasty

Outcomes and Predictors of Mortality Among Octogenarians and Older With ST‐Segment Elevation Myocardial Infarction Treated With Primary Coronary Angioplasty

Engaging older patients in cardiovascular research: observational analysis of the ICON-1 study

Temporal trends and in-hospital outcomes of primary percutaneous coronary intervention in nonagenarians with ST-segment elevation myocardial infarction

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