Comparison of impact of emergency percutaneous revascularization on outcome of patients ≥75 to those

Abstract

Age is a strong predictor of cardiogenic shock (CS) and death in patients with acute myocardial infarction (AMI). Few data exist on the impact of an early percutaneous coronary intervention (PCI) in older patients in CS complicating AMI. This report assesses the impact of an emergency PCI on 6-month outcomes in patients 75 years of age with AMI complicated by CS due to predominant ventricular failure.  This investigation included consecutive patients with AMI complicated by CS who underwent primary PCI between January 1995 and September 2001. CS due to predominant ventricular failure was defi ned as systolic blood pressure 90 mm Hg (without inotropic or intra-aortic balloon support) that was believed to be secondary to ventricular dysfunction and associated with signs of end-organ hypoperfusion (e.g., cold or diaphoretic extremities, altered mental status, or anuria). The diagnosis of CS was confi rmed during cardiac catheterization by the measurement of a systolic blood pressure 90 mm Hg and left ventricular fi lling pressure 20 mm Hg. Patients in CS with severe mitral regurgitation not due to valve rupture were included. Enrolment criteria for PCI included: (1) chest pain persisting 30 minutes associated with ST-segment elevation of 0.1 mV in 2 contiguous electrocardiographic leads, and (2) admission within 24 hours of symptom onset. Patients were included without any restriction based on age or clinical status on presentation. The only exclusion criterion from the analysis was the previous administration of fi brinolytics. A policy of routine infarct artery stenting was adopted in 1998. Abciximab therapy was strongly encouraged from 1999, and the decision whether to administer abciximab was made after the operator’s assessment of major bleeding risk. Abciximab was administered immediately before the procedure (0.25 mg/kg of body weight followed by a 12-hour infusion at 10 g/min). Patients were routinely treated with aspirin (325 mg/day indefi nitely) and ticlopidine (500 mg/day for 1 month). Creatine kinase measurements were systematically performed during admission, every 3 hours for the subsequent 24 hours, and then every 12 hours for 2 days. The peak value of creatine kinase and the time-to-peak creatine kinase were estimated for each patient. The clinical events considered were death from any cause, reinfarction, and repeat target vessel revascularization within 6 months of the initial revascularization. Patients with 1 event were assigned the highest ranked event according to the previously mentioned list. Coronary fl ow in the infarct-related artery was graded using the Thrombolysis In Myocardial Infarction (TIMI) Study Group classifi cation.1 Collateral fl ow was graded using the classifi cation developed by Rentrop et al.2 No-refl ow phenomenon was defi ned as