Treatment choices in elderly patients with ST: elevation myocardial infarction—insights from the Vital Heart Response registry

Abstract

BackgroundManagement of elderly patients with ST elevation myocardial infarction (STEMI) is challenging and they are under-represented in trials. Accordingly, we analysed reperfusion strategies and their effectiveness in patients with STEMI ≥75 years compared to <75 years within a comprehensive inclusive registry.MethodsConsecutive patients with STEMI admitted to hospital and tracked within a regional registry (2006–2011) were analysed comparing reperfusion strategy (primary percutaneous coronary intervention (PPCI), fibrinolysis and no reperfusion) between patients ≥75 vs <75 years old as well as across the reperfusion strategies in those ≥75 years.ResultsThere were 3588 patients with STEMI with 646 (18%) ≥75 years old. Elderly patients were more likely female (46.9% vs 18.4%) and had more prior: angina (28.2% vs 17.2%), myocardial infarction (MI; 22.8% vs 13.9%), hypertension (67.6% vs 44.2%), heart failure (2.3% vs 0.3%) and atrial fibrillation (2.2% vs 0.5%) (all p<0.001). The reperfusion strategy for patients ≥75 vs <75: PPCI 45.3% vs 41.2%, fibrinolysis 24.8% vs 45.7%, and no reperfusion 29.9% vs 13.1% (p<0.001). Time from symptoms to first medical contact (median, 93 vs 78 min p=0.008) and PPCI (median, 166 vs 136 min (p<0.001) were longer for ≥75 years. In those ≥75 years outcomes by reperfusion (PPCI, fibrinolysis and none) were: in-hospital death 13.3%, 9.4% and 19.7% (p=0.018), and composite of death, recurrent-MI, cardiogenic shock and congestive heart failure 28%, 20% and 33.2% (p=0.022).ConclusionsElderly patients have more comorbidities, worst in-hospital clinical outcomes and are less likely to receive reperfusion. Acknowledging physician selection of the reperfusion strategy; outcomes appear favourable in the elderly receiving fibrinolysis.

Age‐Related Differences in Reperfusion Therapy and Outcomes for ST‐Segment Elevation Myocardial Infarction

“…Although the overall reperfusion rate was as high as 91.3%, older adults were less likely to receive any reperfusion therapy, a finding that was consistent with previous research. We identified 6 primary cohort studies (including the present one) 4,9,18,21 that reported use of any reperfusion therapy at baseline and short-term mortality for Median time to death for nonsurvivors was 4 days (interquartile range (IQR) 0-8 days) for those younger than 75, 1 day (IQR 0-5 days) for those aged 75-84, and 2 days (IQR 1-6 days) for those aged 85 and older (P 5 .04). b Intracranial hemorrhage (n 5 7), cardiac tamponade (n 5 11), decrease in hemoglobin concentration of >5 g/dL (n 5 26), and death related to hemorrhage (n 5 42).…”

Clinical characteristic and management of elderly patients with myocardial infarction

“…Stroke was defined as the development of new neurologic deficit not present on initial examination, neurologist diagnosis of stroke, or diagnosed by computed tomography imaging [16].…”

Coronary Reperfusion in Senile Patients With Acute St Elevation Myocardial Infarction

“…Как следствие всего выше изложенного, частота выполнения реперфузи-онных мероприятий у пациентов старческого возраста в реальной клинической практике значительно меньше, чем у более молодых пациентов [17,18].…”

“…Обна-ружено, что среди больных в возрасте 65-74 лет частота внутричерепных кровотечений составила 1,14%, а у больных ≥75 лет -1,9% [20]. Абсолютно такая же частота внутричерепных кровотечений после ТЛТ у больных ≥75 лет -1,9% -отмечена и в Канадском региональном регистре ОИМ в 2015г, т. е. на фоне уже современной противотромботической терапии [17]. Это значительно превышает частоту данного осложнения в рандомизированных исследованиях по ТЛТ.…”

“…Канадские исследователи по данным регио-нального регистра оценили коронарную реперфузию у 3588 больных ОИМпST ≥75 в 2006-2011гг. Госпиталь-ная летальность в группах ПЧКВ, ТЛТ и без реперфу-зии составила 13,3%, 9,4% и 19,7%, соответственно [17]. Таким образом, эти данные указывают на преимуще-ство догоспитального тромболизиса перед ПЧКВ у больных старческого возраста.…”