Elderly ST-elevation Myocardial Infarction Research Articles

Predictors and Impact of Cardiogenic Shock in Oldest-Old ST-Elevation Myocardial Infarction Patients

Background: Cardiogenic shock (CS) is the most frequent cause of in-hospital mortality after ST-elevation myocardial infarction (STEMI). Data about CS in very elderly (age ≥ 85 years) STEMI patients are scarce. We sought to assess the prognostic factors and the short- and mid-term impact of CS in this population. Methods: Consecutive very elderly STEMI patients undergoing invasive treatment were included in a retrospective multicenter registry. Results: Among 608 patients, 72 (11.8%) fulfilled experienced CS. Peripheral artery disease (PAD) (OR: 2.25, 95% CI: 1.29–3.92, p < 0.01) and cardiac arrest at presentation (OR: 4.36, 95% CI: 2.32–8.21, p < 0.01) were the major independent predictors of CS. Age (HR: 1.07, 95% CI: 1.03–1.11, p < 0.001), PAD (HR: 1.29, 95% CI: 1.01–1.66, p = 0.045), previous MI (HR: 2.16, 95% CI: 1.32–3.55, p = 0.002), and cardiac arrest at presentation (HR: 1.59, 95% CI: 1.29–1.96, p < 0.001) were the major independent predictors of death. CS was associated with a higher risk of mortality at 30 days (adjusted HR: 4.21, 95% CI: 2.19 to 7.78, p < 0.01) mostly driven by higher intraprocedural and in-hospital mortality. Among patients who survived the acute phase and hospitalization, CS at presentation was not associated with a higher mortality risk during the remaining follow-up period (log-rank p = 0.78). Conclusions: At short-term follow-up, very elderly STEMI patients presenting with CS had a higher risk of mortality when compared to non-CS patients. Interestingly, CS patients surviving the acute phase showed a similar survival rate to non-CS patients after discharge.

Frailty as an independent predictor for midterm adverse outcomes in the elderly undergoing primary percutaneous coronary intervention: A longitudinal cohort study.

Frailty is associated with poor health outcomes in elderly population. However, its effect on midterm outcomes in elderly patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains unknown. This study aimed to evaluate the association between frailty, as classified by the Clinical Frailty Scale (CFS), and midterm adverse outcomes in elderly STEMI patients after primary PCI. In this prospective, observational, multicenter cohort study, frailty status of 426 STEMI patients aged ≥60 years undergoing primary PCI was determined using the nine-point CFS 2 weeks before the occurrence of STEMI. Patients scoring at least four points on the CFS were considered frail. The primary outcome was a composite of cardiovascular death or readmission. Secondary outcomes included cardiovascular death, cardiovascular readmission, heart failure-related death or readmission, and myocardial reinfarction. Follow-up data were collected through medical record reviews and/or telephone interviews. Of 426 elderly patients, 116 were frail. The median follow-up period was 15 months (interquartile range 5-19 months). Primary outcome events occurred in 87 (75.0%) frail and 75 (24.2%) nonfrail patients. The adjusted hazard ratio was 3.278 after model selection using the Bayesian Model Averaging approach (95% confidence interval 2.372-4.531). Multivariate Cox proportional hazard survival analysis showed that frailty was significantly associated with a higher prevalence of all secondary outcome events after adjusting for TIMI, PAMI, and CADILLAC risk scores. Frailty, as defined by the CFS, was independently associated with midterm adverse outcomes in elderly patients undergoing primary PCI for STEMI.

Impact of Contrast-Associated Acute Kidney Injury on One-Year Outcomes in Very Elderly STEMI Patients: Insights From a Multicenter Registry in Northern Italy.

Data about contrast-associated acute kidney injury (CA-AKI) in oldest old (age ≥85years) ST-elevation myocardial infarction (STEMI) patients are scarce. We evaluated the incidence and the 1-year prognostic impact of CA-AKI in this population. Patients were included in a multicenter real-world registry, and CA-AKI was defined according to KDIGO (Kidney Disease Improving Global Outcomes) criteria. Major adverse cardiac and cerebrovascular events (MACCEs) were defined as the composite of all-cause death, stroke, unplanned coronary revascularization, and heart failure hospitalization. The primary outcome was the incidence and impact of CA-AKI on MACCEs at 1year follow-up. Out of 461 STEMI patients (mean age 88.6 ± 2.9years), 102 (22.1%) patients developed CA-AKI. Chronic kidney disease was the strongest predictor of CA-AKI (odds ratio [OR]: 4.52, 95% CI: 2.81-7.30, P < .01). The CA-AKI cohort showed a higher risk of MACCEs (adjusted HR: 1.75, 95% CI: 1.13-2.71, P = .01), driven mainly by all-cause death (adjusted hazard ratio [HR]: 2.39, 95% CI: 1.41-4.07, P = .01) and followed by heart failure hospitalization (adjusted HR: 2.01, 95% CI: 1.08-3.76, P = .01). Among oldest old STEMI, CA-AKI was frequent and associated with a higher incidence of MACCEs at 1-year follow-up.

P213 ROLE OF ANEMIA AND IRON IMPLEMENTATION ON PROGNOSIS AND MANAGEMENT OF ELDERLY STEMI PATIENTS

Abstract Introduction Elderly patients with S–T elevation myocardial infarction (STEMI) presented a very high risk for both in–hospital and long–term morbility and mortality. Comorbidities plays a key role in prognosis, in particular anemia (pre–existent or acquired) is a more and more emerging clinical element able to influence short– and long–term clinical outcome. Prognostic role of anemia in elderly STEMI patients in not completely clarified. Purpose of the present study is to evaluate the role of anemia and its therapy by iron implementation in a very–old population of STEMI patients followed for 1 year after index event. Methods we considered all STEMI patients admitted in our Coronary Care Unit from 2020 to 2021 and we selected only people aged &amp;gt; 80 years–old (n = 120). Haemoglobin (Hb, g/dl) values were considered at admission (T0), at hospital discharge (T1) and after 6 month (T2). In hospital and 1 year mortality, treatment by primary PCI, major bleedings (TIMI criteria), need of transfusion, double antiplatelet therapy (DAPT) discontinuation, were considered and compared between groups of patients without and with anemia (A, Hb &amp;lt; 13.5 for men and &amp;lt;12 for women at T1) and without (NA group). Type of iron implementation (sucrosomial or not) and its tolerability were considered only for A group. Data were expressed as means±SD or % values. Results 18 patients (15%) presented anemia at T0 (women 66%), 4 (22%) of them showed a TIMI major in–hospital bleeding (3, 20%, required blood transfusion) whereas 5 (5%) in non anemic, in–hospital mortality was similar between anemic and non–anemic (18% vs 17%). Sixteen (14%) presented mild anemia at T1 (14%, A group), mean age were similar to NA group (years, 86±4 vs 85±5, A vs NA, ns). In A 4 (25%) died during follow–up vs 11 (13%) in NA group during 1 year follow–up. Treatment with primary PTCA (31% vs 39%, A vs NA, ns) were similar. DAPT discontinuation In A group 16 patiens were discharged with indication to long–term iron implementation therapy, 6 of them with sucrosomial. Incidence of iron discontinuation was 16% (1 pt) for sucrosomial vs 50% (5 pts) for non–sucrosomial. Conclusions In elderly STEMI patients, 1) anemia at hospital admission influences in hospital major bleedings and need of blood trasfusions. 2) anemia at hospital discharge seems to affect DAPT discontinuation and long–term mortality. 3) use of sucrosomial iron reduces probability of discontinuation of implementation therapy.

Effects of RAAS blocker use on AKI in elderly hypertensive STEMI patients with propensity score weighed method

ABSTRACT Studies reported conflicting results on the effect of renin-angiotensin-aldosterone system (RAAS) blocker use on acute kidney injury (AKI) in patients undergoing elective coronary angiography but association in elderly patients with ST-elevation myocardial infarction (STEMI) is not known. Also, there are limited data on the effect of inflammatory markers on AKI. We aimed to investigate the effects of RAAS blocker pretreatment and inflammatory markers on AKI in this population. A total of 471 patients were compared according to presence of RAAS blocker pretreatment at admission. Conventional and inverse probability weighed conditional logistic regression were used to determine independent predictors of AKI. Mean age of the study group was 75.4 ± 7.1 years and 29.1% of the patients were female. AKI was observed in 17.2% of the study population. Weighted conditional multivariable logistic regression analysis revealed that AKI was associated with baseline creatinine levels and C-reactive protein/albumin ratio (CAR) (OR 2.08, 95% CI = 1.13–3.82, p = .02 and OR 1.19, 95% CI = 1.01–1.41, p = .04, respectively). No significant association was found between RAAS blocker pretreatment and AKI. CAR and elevated baseline creatinine levels were independent predictors of AKI in this patient group.

Outcomes of Very Elderly Patients with ST-Elevation or Non-ST-Elevation Acute Coronary Syndrome: Observational Study

Acute coronary syndromes (ACS) have been classified according to the finding of ST-segment elevation on the presenting electrocardiogram, with different treatment strategies and practice guidelines. However, a comparative description of the clinical characteristics and outcomes of acute coronary syndrome in elderly patients has not been published so far. To compare the baseline characteristics and outcomes of STEMI and NSTEMI patients. Retrospective, observational study of patients hospitalized for ACS between January 2018 and December 2019 in the cardiology department of the university hospital of Sfax. The main outcome measure was the incidence of major adverse cardiovascular events (MACE) including cardiovascular death, reinfarction, and stroke. Of 158 ACS patients aged ≥ 75 years (median age 79.72 years, interquartile range 75-97), 33% were classified as ST-elevation myocardial infarction (STEMI), and 67% had non-ST-elevation myocardial infarction (NSTEMI). As compared with those with NSTEMI, STEMI patients had more favorable baseline risk factors with a lower Charlson comorbidity index (3.48 ± 0.18 versus (vs.) 3,84 ± 0.96, P = 0.031), less kidney failure (19.2% vs. 44%, P = 0.005), less prior coronary events (15.7% vs. 44%, P = 0.006) but more severe coronary disease (double vessel disease and triple vessel disease were respectively (45.7% vs. 22%, P = 0.005) and (37% vs. 15.9%, P = 0.007). At a median follow-up of 12 months, MACE were more frequents in STEMI group (26% vs. 13.5%, P = 0.05). Despite more favorable baseline characteristics, elderly STEMI patients have a higher risk of major cardiovascular events compared with NSTEMI patients.

Abstract 12666: Role of a Comprehensive ST-Elevation Myocardial Infarction Protocol in Improving Outcomes among Elderly Patients With ST-Elevation Myocardial Infarction

Introduction: Increasing age is a harbinger of poor outcomes from ST-elevation myocardial infarction (STEMI). It is uncertain whether measures can be implemented to improve care delivery and outcomes in this high-risk cohort. We assessed the impact of a comprehensive STEMI protocol (CSP) in elderly patients presenting with STEMI. Methods: A 4-step CSP was implemented, including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; and (4) radial-first percutaneous coronary intervention (PCI). Baseline characteristics, complications, procedural features, and outcomes were compared between consecutive STEMI patients &gt;65 years of age who underwent PCI at the Cleveland Clinic pre- (01/01/2011-07/14/2014) and post-CSP (07/15/2014-07/15/2019) implementation. Results: Among 265 and 445 elderly patients in the pre- and post-CSP cohorts, respectively, overall the mean age was 74 years and 58% were males. More active smoking and obesity and less prior myocardial infarction and coronary artery bypass graft were observed in the post-CSP group. Relative to pre-CSP, post-CSP patients experienced significantly less cardiogenic shock (19% vs 9%, p&lt;0.001) and cardiac arrest (16% vs 9%, p=0.009). Significant improvements were observed post-CSP implementation in median door-to-balloon time [111 (84-146) vs 89 (67-109) minutes, p&lt;0.001] and trans-radial access (16% vs 72%, p&lt;0.001), translating to significant reductions in major adverse cardiovascular events (14% vs 8%, p=0.02), major bleeding (16% vs 11%, p=0.05), and in-hospital mortality (12% vs 5%, p=0.001). Conclusion: The implementation of a CSP was associated with marked reductions in complications and improvements in in-hospital outcomes including mortality among elderly patients presenting with STEMI. Our findings highlight the opportunity to improve outcomes in high-risk elderly STEMI patients through a CSP.

Outcomes of Elderly Patients with ST-Elevation or Non-ST-Elevation Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

IntroductionAcute coronary syndromes (ACS) have been classified according to the finding of ST-segment elevation on the presenting electrocardiogram, with different treatment strategies and practice guidelines. However, a comparative description of the clinical characteristics and outcomes of acute coronary syndrome elderly patients undergoing percutaneous coronary intervention during index admission has not been published so far. MethodsRetrospective cohort study of patients enrolled in the Elderly ACS-2 multicenter randomized trial. Main outcome measures were crude cumulative incidence and cause-specific hazard ratio (cHR) of cardiovascular death, noncardiovascular death, reinfarction, and stroke. ResultsOf 1443 ACS patients aged >75 years (median age 80 years, interquartile range 77-84), 41% were classified as ST-elevation myocardial infarction (STEMI), and 59% had non-ST-elevation ACS (NSTEACS) (48% NSTEMI and 11% unstable angina). As compared with those with NSTEACS, STEMI patients had more favorable baseline risk factors, fewer prior cardiovascular events, and less severe coronary disease, but lower ejection fraction (45% vs 50%, P < .001). At a median follow-up of 12 months, 51 (8.6%) STEMI patients had died, vs 39 (4.6%) NSTEACS patients. After adjusting for sex, age, and previous myocardial infarction, the hazard among the STEMI group was significantly higher for cardiovascular death (cHR 1.85; 95% confidence interval [CI], 1.02-3.36), noncardiovascular death (cHR 2.10; 95% CI, 1.01-4.38), and stroke (cHR 4.8; 95% CI, 1.7-13.7). ConclusionsDespite more favorable baseline characteristics, elderly STEMI patients have worse survival and a higher risk of stroke compared with NSTEACS patients after percutaneous coronary intervention.

Drug Treatment of STEMI in the Elderly: Focus on Fibrinolytic Therapy and Insights from the STREAM Trial.

Elderly patients constitute a large and growing proportion of ST-elevation myocardial infarction (STEMI) patients, yet they have been under-represented or even excluded from reperfusion trials. Despite evidence that fibrinolysis improves outcomes irrespective of age, many elderly STEMI patients still remain undertreated or subject to major delays to primary percutaneous coronary intervention (PCI). The fear of an excessive risk of intracranial hemorrhage (ICH) in these patients can lead to avoidance of potentially life-saving reperfusion treatment, despite the fact that current STEMI guidelines do not exclude the elderly from a pharmaco-invasive strategy. Age-specific dose reductions have been succesfully made to antithrombotic drugs such as clopidogrel and enoxaparin as an adjunct to fibrinolysis, but until recently no dose adjustments for elderly patients have been applied to the fibrinolytic agents. In the pharmaco-invasive STREAM trial, halving the bolus of tenecteplase for patients aged >75years because of an unacceptably high ICH rate in the elderly was associated with a more favorable safety/efficacy profile. Whether a pharmaco-invasive strategy including half-dose tenecteplase, age- and weight-adjusted enoxaparin, and a tailored P2Y12 inhibitor followed by routine angiography represents a safe and efficacious alternative reperfusion therapy for elderly patients remains to be prospectively assessed in a clinical trial in this age group.

0456: Reperfusion in elderly patients with acute ST-elevation myocardial infarction: results from the RENAU-RESURCOR STEMI network

Elderly patients with acute ST-elevation myocardial infarction (STEMI) remain undertreated. To evaluate the management of elderly STEMI patients treated in a formal regional network of care. This prospective analysis, based on data from the ongoing RESURCOR coronary emergency network, involved 6169 patients presenting with an acute STEMI between 2002 and 2011 in the north French Alps. Patients were divided into age groups: <65, 65-74, 75-84 and ≥85 years. Reperfusion rates, types, timing and adjunctive medications were compared. The RESURCOR network advocates primary percutaneous coronary intervention (PPCI) over fibrinolysis and bivalirudin over glycoprotein inhibitors (GPI) in the elderly. Lack of reperfusion therapy increased with age (Table). The rate of fibrinolysis was higher than that for PPCI in younger patients whereas the situation was reversed in elderly patients. In patients who had PPCI, use of bivalirudin increased and GPI decreased with age, system delays were similar. These regional French data indicate that elderly STEMI patients receive appropriate management with timely delivered PPCI and bivalirudin; however, a substantial proportion are still undertreated. Abstratct 0456 – Table: Reperfusion rates, types, timing and adjunctive medications among the age groups Age groups <65 years n=3476 65-74 years n=1238 75-84 years n=1147 ≥85 years n=308 P-value No reperfusion, n (%) 3.8 5.6 8.0 13.6 <0.001 Fibrinolysis, n (%) 1853 (53.3) 593 (47.9) 449 (39.2) 87 (28.3) <0.001 Primary PCI, n (%) 1492 (42.9) 576 (46.5) 606 (52.8) 179 (58.1) <0.001 Delay (first medical contact to PPCI), median (IQR), min 80 (58-123) 85 (60-125) 85 (64-130) 84 (60-124) 0.1 Bivalirudin * , n/N (%) 81/1197 (6.8) 30/429 (7.0) 48/373 (12.9) 28/121(23.1) <0.001 GPI * , n/N (%) 1375/2695 (51.0) 493/963 (51.2) 435/879 (49.5) 85/222 (38.3) 0.003 * Calculated among patients undergoing a coronarography. Bivalirudin has been used since 2008.

Reperfusion in elderly patients with acute ST-elevation myocardial infarction: Results from the RENAU-RESURCOR STEMI network

Background Elderly patients with acute ST-elevation myocardial infarction (STEMI) remain undertreated. Purpose To evaluate the management of elderly STEMI patients treated in a formal regional network of care. Methods This prospective analysis, based on data from the ongoing RESURCOR coronary emergency network, involved 6169 patients presenting with an acute STEMI between 2002 and 2011 in the north French Alps. Patients were divided into age groups: Results Lack of reperfusion therapy increased with age ( Table 1 ). The rate of fibrinolysis was higher than that for PPCI in younger patients whereas the situation was reversed in elderly patients. In patients who had PPCI, use of bivalirudin increased and GPI decreased with age, system delays were similar. Conclusion These regional French data indicate that elderly STEMI patients receive appropriate management with timely delivered PPCI and bivalirudin; however, a substantial proportion are still undertreated.

Atrial fibrillation: A kiss of death?

Atrial fibrillation: A kiss of death?

Trends in mortality rates in elderly ST elevation myocardial infarction patients submitted to primary percutaneous coronary intervention: A 7-year single-center experience

Limited data are available on the safety and outcome of percutaneous coronary intervention (PCI) in elderly patients with ST elevation myocardial infarction (STEMI), as elderly patients are under-represented in randomized trials. We therefore aimed at assessing the trends in mortality rates (both at short-term and at 1-year follow up) in an unselected cohort of 404 STEMI patients aged ≥ 75 years all submitted to primary PCI and consecutively admitted to our Intensive Cardiac Care Unit from 2004 to 2010. In the first period (2004-2006), 202 patients (202/661, 30.6%) were aged ≥ 75 years, whereas in the second period (2007-2010), 203 patients (203/607, 33.4%) were aged ≥ 75 years. In the second period, STEMI patients were older (P<0.001), more diabetic (P<0.001) and with a higher incidence of comorbidities (P<0.001). A significantly lower use of intra-aortic balloon pump was observed, together with a reduced rate of bleeding, whereas the incidence of worsening renal function significantly increased (P=0.011). No difference was observed in the length of stay and in mortality rate (both in-hospital and 1-year post-discharge) between the first and the second period. According to our data, patients aged ≥ 75 years are characterized by an increasing number of comorbidities (in particular, a higher incidence of diabetes). Over a 6-year period, despite a more advanced age, early mortality (and length of stay) remained unchanged (probably thanks to a significant reduction in bleeding events), and no difference was observed in 1-year post-discharge mortality in these patients.

The Impact of Age on Effects of Pre-hospital Initiation of High Bolus Dose of Tirofiban Before Primary Angioplasty for ST-Elevation Myocardial Infarction

Glycoprotein IIb/IIIa inhibitors are favourable in ST-elevation myocardial infarction (STEMI) patients, and the additional value of early pre-hospital high bolus dose tirofiban has recently been established. The aim of this study was to determine the impact of age on myocardial reperfusion and clinical outcomes of pre-hospital administration of high bolus dose tirofiban. This is a pre-specified sub-analysis of the multicentre, double-blind, placebo-controlled, randomised On-TIME 2 trial and it's open label phase. The primary endpoint was mean residual ST segment deviation 1h after primary PCI and was evaluated in three age groups. Of the 466 patients in the highest tertile (≥68years), median age was 74.4years (IQR 71.3-78.6years) and 231 (50%) were randomised to tirofiban. Mean residual ST segment deviation 1 h after PCI was significantly lower in elderly patients pre-treated with tirofiban compared to elderly patients without tirofiban pre-treatment (4.2 ± 5.2mm vs 6.4 ± 7.5mm, p = 0.001). Furthermore, elderly patients pre-treated with tirofiban had a non-significantly higher rate of 30-day major or minor bleeding compared to elderly patients without tirofiban pre-treatment (14.2% vs 9.0%, p = 0.088). 30-day net adverse clinical events in elderly patients with- or without tirofiban was not significantly different (11.9% vs 15.2%, p = 0.300). The effect of pre-hospital initiation of high bolus dose tirofiban on myocardial reperfusion, as determined by ST-segment resolution is highest in the elderly patients. However, this was associated with a trend towards more bleeding complications, resulting in a balanced clinical effect after 30-day follow-up. Future studies should evaluate whether the elderly STEMI patient may benefit from highly effective and safer antiplatelet therapy.

Predictors of the early outcome in elderly patients with ST elevation myocardial infarction treated with primary angioplasty: a single center experience

Elderly patients are under-represented in trials assessing strategies of early coronary revascularization in acute myocardial infarction, though they are the fastest growing segment of our population. The aims of the present investigation, performed in 357 elderly (≥75 years) patients with ST elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI) consecutively admitted to our Intensive Cardiac Care Unit (ICCU) from 1 January 2006 to 31 December 2009, were as follows: (a) to identify predictors for in-ICCU mortality among clinical, angiographic and metabolic factors and (b) to evaluate whether there are gender-related differences in management, outcome and in the metabolic and inflammatory responses to acute myocardial ischemia. At multivariable backward stepwise logistic regression analysis, the following variables were independent predictors for in-ICCU mortality in the overall population: age (OR 1.15; 95% CI 1.05-1.27; p < 0.003), admission glycemia (OR 2.24; 95% CI 1.41-3.56; p < 0.001), left ventricular ejection fraction (LVEF) (OR 0.92; 95% CI 0.88-0.97; p < 0.001), primary PCI failure (OR 4.70; 95% CI 1.70-12.98; p < 0.003). In elderly STEMI patients submitted to primary PCI, early mortality can be related to age, hemodynamic derangement (as indicated by LVEF), the rate of procedural success, and increased glucose values. No gender-related differences in management were detectable in our series. Our data strongly suggest that, in elderly patients in the acute phase of STEMI, since hyperglycemia is a modifying factor, glucose values deserve a more intensive treatment. Further studies, performed specifically in elderly STEMI patients, should be addressed to identify the glucose cut-off values able to influence the outcome.

Predictive Effect of Age in Elderly ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Interventions

Predictive Effect of Age in Elderly ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Interventions