Particularities in coronary revascularization in elderly patients presenting with ST segment elevation acute myocardial infarction (STEMI)

Abstract

Nowadays, ST elevation acute myocardial infarction (STEMI) is seen with greater incidence in older patients. Current guidelines recommend an immediate invasive evaluation and eventually primary percutaneous coronary intervention (PCI) in all STEMI patients regardless of age. Nevertheless, data in literature show a significant underuse of interventional treatment in older patients with STEMI.Our objective is to assess the in-hospital outcome of the elderly STEMI patients compared to the younger ones in the setting of systematic interventional management. We also discussed some particular aspects which we considered as significant concerning the management of elderly patients with STEMI.We evaluated 975 consecutive STEMI patients admitted to a single centre between January 2012 to July 2013. There were 203 (20.8%) patients ≥75 years old.Compared to the younger group, in the older group there were more women (47. 2% vs 22.7%; p<0.001), an increased prevalence of hypertension (78.8% vs 65.0%; p<0.001) but a decreased prevalence of smoking (13.7% vs 48.8%; p<0.001) and dyslipidemia (54.7% vs 41.3%; p=0.03). The ≥75 years group had more cardiovascular comorbidities: stroke (11.8% vs 4.1%; p<0.001), atrial fibrillation (23.6% vs 53.9%; p<0.001) and severe valvulopathies (6.8% vs 1.2%; p<0.001). Elderly patients presented more frequently with signs of heart failure (Killip class>1: 21.1% vs 7.2%; p<0.001). Both groups had similar ischaemia time with 54.1% vs 55.1% presenting within 6h.There were fewer PCIs performed in the elderly group (74.3% vs 85.7%; p=0.02). The extension of coronary lesions was not significantly different between the two groups, except for left main disease in favour of the elderly (12.2% vs 5.1%; p<0.001). There were no significant differences between the two groups regarding the in-hospital treatment (dual antiplatelet, anticoagulation, beta-blockers, ACEI/ARB and statin). The in-hospital mortality for our entire study group was 4.41%, with a rate of 11.3% in the older group and 2.59% in the <75 years group (p<0.001).In-hospital outcome in older patients with STEMI is worse, with an increased mortality rate, especially when associated with heart failure on admission. Fewer PCI were performed in the older patients, although there was no difference in the pharmacological treatment. A strategy based on urgent coronary angiography and, if necessary, primary PCI, should be applied in all eligible patients irrespective of age.