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Primary angioplasty for acute myocardial infarction in octogenarians

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Primary angioplasty for acute myocardial infarction in octogenarians
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   The American Journal of Cardiology Copyright © 2001 by Excerpta Medica, Inc. All rights reserved. Volume 88(6) 15 September 2001 pp 680-683 Primary Angioplasty for Acute Myocardial Infarction in Octogenarians [Brief Reports] Matetzky, Shlomi MD; Sharir, Tali MD; Noc, Marko MD; Domingo, Michelle BSc; Chyu, Kuang-Yuh MD; Kar, Saibal MD; Eigler, Neal MD; Kaul, Sanjay MD; Shah, Prediman K. MD; Cercek, Bojan MD From the Division of Cardiology, Cedars-Sinai Medical Center/UCLA School of Medicine, Los Angeles, California. Drs. Matetzky and Sharir were supported by the Save A Heart Foundation, Los Angeles, California; and Dr. Noc was supported by the Slovenian Science Foundation and University Medical Center, Ljubljana, Slovenia. Dr. Cercek's address is: Division of Cardiology, Cedars-Sinai Medical Center, Room 5314, 8700 Beverly Boulevard, Los Angeles, California 90048-1865. E-mail: cercek@cshs.org. Manuscript received March 20, 2001; revised manuscript received and accepted May 1, 2001. Graphics • Table 1  • Table 2  • Table 3  • Table 4 In patients with acute myocardial infarction (AMI), mortality increases sharply in the elderly and reaches >30% in octogenarian patients.1-3 Elderly patients are less likely to receive thrombolytic therapy 4-8 and the risk of hemorrhagic complications is higher.9-15 Although  primary percutaneous coronary interventions (PCI) with angioplasty and stenting may offer an attractive alternative for these patients, only few and conflicting data exist regarding the effect of advanced age on success rate, complications, and clinical outcome of primary PCI. In the  present study, we report angiographic and clinical outcomes and complications of primary PCI in 48 consecutive octogenarians, and compare these results with those of younger patients in the same series of patients. The study comprised 181 consecutive patients with AMI who underwent primary PCI for AMI with ST-segment elevation at Cedars-Sinai Medical Center from January 1997 to January 1999. During this period, primary PCI was the standard therapy for patients  presenting within 12 hours of symptoms of an ST elevation AMI. Stent deployment and adjunctive therapy with IIb/IIIa inhibitors and intraaortic balloon pump were used at the discretion of the attending physician. All patients received aspirin and clopidogrel or ticlopidin for 4 weeks after stent deployment.  Coronary angiograms were interpreted by 2 investigators who were blinded to Thrombolysis In Myocardial Infarction (TIMI) trial flow grade in the infarct-related artery and a number of coronary arteries with significant (>=70%) stenosis. Successful PCI was defined as TIMI 3 flow and a residual stenosis of <30%. During hospital stay, patients were followed for the occurrence of congestive heart failure (CHF), shock, and/or death. Major bleeding was defined as intracranial bleeding, bleeding with hemodynamic compromise, or bleeding requiring transfusion. Acute worsening of renal function was defined as any elevation in creatinine of >1.5 mg/dl, or with preexisting renal insufficiency, an increase in creatinine level of >=0.5 mg/dl. Before discharge, left ventricular ejection fraction was determined by 2-dimensional echocardiography. After discharge, patients were followed for an average of 18 months (follow-up was completed by July 1999). Follow-up data were analyzed for total and cardiac mortality, cardiac events (cardiac mortality and nonfatal reinfarction), and target vessel revascularization. Comparison between groups was performed using the t test for continuous variables and the chi-square or Fisher's exact test for categorical variables. Stepwise multivariate logistic regression analysis was applied to identify independent predictors of the prespecified end  point of death, CHF, and shock during hospital stay. Stepwise multivariate hazard Cox regression was used to identify the independent predictors of the occurrence of a cardiac event during the follow-up period. Of 181 consecutive patients included in the present study, 48 (27%) were aged >=80 years (mean 84 ± 5, range 80 to 94) and 133 patients (73%) were aged <80 years (mean 60 ± 11, range 28 to 77). Admission demographic and clinical characteristics are listed in Table 1. TABLE 1 Baseline Characteristics [Help with image viewing]  Initial angiographic characteristics were similar in patients aged >=80 and <80 years (Table 2). After diagnostic angiography, 1 patient aged >=80 years and 2 aged <80 years were referred for urgent bypass surgery because of extensive coronary artery disease. All other  patients underwent primary PCI. PCI was successful in 87% of both groups of patients. Failure was due to inability to cross the culprit lesion in 8.5% and 4% of patients, and TIMI flow <=2, despite adequate dilatation of the culprit lesion, was achieved in 4.5% and 9% of  patients aged >=80 and <80 years, respectively (p = 0.25). There were no significant differences in the use of temporary pacemaker (17% vs 10%, p = 0.21), intraaortic balloon  pump (13% vs 8%, p = 0.4), or IIb/IIIa inhibitors (71% vs 83%, p = 0.11) in patients >=80 and <80 years of age, respectively.    [Help with image viewing]  TABLE 2 Angiographic Characteristics and Primary PCI Results Compared with younger patients, octogenarians had a significantly higher incidence of CHF and a trend toward a higher incidence of cardiogenic shock and mortality (Table 3). Patients with versus those without CHF had a higher incidence of PCI failure (32% vs 9%, p = 0.004). The combined end point of CHF, cardiogenic shock, and/or mortality was significantly more  prevalent in octogenarians than in younger patients (35% vs 17% p = 0.006). In multivariate analysis, after adjustment for initial demographic and clinical characteristics, use of intraaortic  balloon pump (odds ratio [OR] 23, 95% confidence interval [CI] 4.8 to 117), Killip class (OR 6.2, 95% CI 3 to 13), and success of primary PCI (OR 0.12, 95% CI 0.035 to 0.46) were the only independent predictors of the combined end point. When any age and age >=80 years were forced into this model they had no significant incremental value. [Help with image viewing]  TABLE 3 In-Hospital Clinical Course Intracranial hemorrhage or ischemic stroke did not occur in either group. Octogenarians had a higher incidence of major bleeding (6.3% vs 1.5%, p = 0.12), minor bleeding (8.7% vs 5.3%,  p = 0.18), and thrombocytopenia (4% vs 0.75%, p = 0.17), although none was fatal. Patients aged >=80 years had an increased risk of worsening of renal function (21% vs 2.3%, p <0.001). Impaired renal function was present before PCI in 8 of the 10 patients who developed worsening of renal function. No patient required hemodialysis and renal function improved at least partially in all. A comparable proportion of octogenarians and younger patients had a Q-wave AMI pattern on the discharge electrocardiogram (51% vs 54%, p = 0.79), and there was no significant difference in the predischarge left ventricular ejection fraction (45 ± 12% vs 49 ± 11%, p = 0.11). Complete data were obtained for 42 of the octogenarian survivors (95%) and for 117 of the survivors <80 years of age (91%) (Table 4). Postdischarge octogenarians were followed for 18.2 ± 8.8 compared with 18.4 ± 8.0 months in younger patients (p = 0.9). As expected, octogenarians had a higher postdischarge total mortality (17% vs 3.4%, p = 0.0065). Cardiac mortality was relatively low in both groups of patients, although insignificantly higher in octogenarians than in younger patients (7.1% and 1.7%, respectively; p = 0.12). Of the 5 cardiac deaths 2, were due to reinfarction, 1 occurred during bypass surgery, and 2 deaths  were sudden. One patient each died of mesenteric ischemia, stroke, and pulmonary embolism.  Noncardiovascular deaths were due to cancer in 2 and sepsis in 1 patient. There were no significant differences in the incidence of reinfarction, cardiac events, incidences of readmissions for angina or CHF, or need for bypass surgery during the 18-month follow-up  period between the 2 groups. In univariate (Cox regression) analysis, failed primary PCI (p = 0.014) and CHF during hospitalization (p = 0.047) were the only significant predictors of future cardiac events, and in multivariate analysis, both remained independent predictors of outcome. [Help with image viewing]  TABLE 4 Long-Term Outcome (during postdischarge period) In this study we demonstrated that primary PCI for ST elevation AMI in octogenarians has a success rate that is similar to younger patients. The strategy applied in this study of primary PCI, provisional stenting, and the use of IIb/IIIa inhibitors was safe and not associated with an increase in the risk of stroke or intracranial bleed. Octogenarians had only a small increase in the risk of bleeding complications and thrombocytopenia, and had a significantly higher risk of reversible worsening of renal function than younger patients. The higher risk for combined CHF, shock, or mortality in octogenarians was not due to age, but to worse hemodynamic characteristics at admission, which are often seen in the elderly. Although thrombolytic therapy results in a reperfusion rate in the very elderly that is similar to that in younger patients,7,16 mortality remains unfavorably high: >=30% in patients aged >80 years.5,6,10,17 A recent large observational study even suggests that thrombolytic therapy might be deleterious in patients aged >75 years.18 In the present study we demonstrated a high success rate of primary PCI that was associated with relatively low in-hospital mortality of 8% in ST elevation AMI patients aged >=80 years. The low incidence of significant bleeding and stroke strengthened the apparent benefit of early reperfusion in elderly patients when compared with previous studies of thrombolytic therapy.12-14 In the Global Use of Strategies To open Occluded coronary arteries II (GUSTO IIB) study, the 30-day mortality among the 45 patients >=80 years of age treated with primary PCI was comparable to that of patients treated with tissue plasminogen activator (26.7% and 27%, respectively).10 This was substantially higher than the 17% seen in our experience. The less favorable outcome in the GUSTO study might be in part due to the lesser use of stents (5%) than used in >50% of our patients and the use of potent antiplatelet therapy instead of anticoagulation in our study. The shift from anticoagulation to aggressive antiplatelet therapy appears to be especially beneficial in elderly patients because of lower bleeding complications, stroke, and reinfarction.19 The early use of aggressive antiplatelet therapy may also explain a relatively high incidence of TIMI flow >2 on the initial angiogram. Also, our study represents experience of a single center with a high volume of PCIs.  In contrast to a previous report,20 in our study the rate of recurrent angina and the target vessel revascularization rate did not differ significantly between octogenarians and younger  patients. We conclude that in octogenarians with ST elevation AMI, primary angioplasty is safe and as effective in achieving reperfusion as in younger patients. 1. Weaver WD, Litwin PE, Martin JS, Kudenchuk PJ, Maynard C, Eisenberg MS, Ho MT, Cobb LA, Kennedy JW, Wirkus MS. Effect of age on use of thrombolytic therapy and mortality in acute myocardial infarction. J Am Coll Cardiol 1991;18:657-662. [Medline Link] [Context Link] 2. Udvarhelyi IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the Medicare population: process of care and clinical outcomes. JAMA 1992;268:2530-2536. [Medline Link] [BIOSIS Previews Link] [Context Link]  3. Goldberg RJ, McCormick D, Gurwitz JH, Yarzebski J, Lessard D, Gore JM. Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year   population-based perspective (1975-1995). Am J Cardiol 1998;82:1311-1317. [Fulltext Link] [Medline Link] [BIOSIS Previews Link] [Context Link]  4. Smith SC, Gilpin E, Ahnve S, Dittrich H, Nicod P, Henning H, Ross J. Outlook after acute myocardial infarction in the very elderly compared with that in patients aged 65 to 75 years. J Am Coll Cardiol 1990;16:784-792. [Medline Link] [Context Link]  5. Maggioni AP, Maseri A, Fresco C, Franziosi MG, Mauri F, Santoro E, Tognoni G. Age-related increase in mortality among patients with first myocardial infarctions treated with thrombolysis. N Engl J Med 1993;329:1442-1448. [Medline Link] [BIOSIS Previews Link]  [Context Link] 6. Barakat K, Wilkinson P, Deaner A, Fluck D, Ranjadayalan K, Timmis A. How should age affect management of acute myocardial infarction? A prospective cohort study. Lancet 1999;353:955-959. [Medline Link] [CINAHL Link] [BIOSIS Previews Link] [Context Link]  7. Himbert D, Steg PG, Juliard JM, Neukirch F, Aumont MC, Gourgon R. Eligibility for  reperfusion therapy and outcome in elderly patients with acute myocardial infarction. Eur  Heart J 1994;15:483-488. [Medline Link] [BIOSIS Previews Link] [Context Link]  8. Bueno H, Lopez-Palop R, Perez-David E, Garcia-Garcia J, Lopez-Sendon JL, Delcan JL. Combined effect of age and right ventricular involvement on acute inferior myocardial infarction prognosis. Circulation 1998;98:1714-1720. [Fulltext Link] [Medline Link] [BIOSIS  Previews Link] [Context Link]  9. White HD, Barbash GI, Califf RM, Simes RJ, Granger CB, Weaver WD, Kleiman NS, Aylward PE, Gore JM, Vahanian A, Lee KL, Ross AM, Topol EJ. Age and outcome with contemporary thrombolytic therapy: results from the GUSTO-I trial. Circulation 1996;94:1826-1833. [Medline Link] [BIOSIS Previews Link] [Context Link] 
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