Myocardial Infarction In Elderly Patients Research Articles

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

The 59th Annual Meeting of the American Academy of Neurology, Boston, Massachusetts April 28-May 5, 2007

Kidney Function and Use of Recommended Medications after Myocardial Infarction in Elderly Patients

Several studies have found reduced use of recommended medications after myocardial infarction (MI) in patients with impaired kidney function. However, the reasons for such undertreatment are not well understood. A total of 1380 Medicare patients who survived at least 90 d after MI and had prescription drug coverage through Pennsylvania's medication assistance program for the elderly were studied. Filled prescriptions were used to assess use of angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), beta blockers, and statins within 90 d of MI. Patients' demographics, comorbidities, and health care utilization before MI also were ascertained. We used logistic regression to test the association between kidney function and postdischarge use of each medication. Overall, 619 (45%) patients filled a prescription for a beta blocker, 675 (49%) received an ACEI or ARB, and 406 (29%) received a statin after discharge but within 90 d after their admission for MI. Reduced kidney function was associated with both lower beta blocker and statin use (P = 0.01 and P = 0.002, respectively), but after multivariate adjustment, these associations disappeared (P = 0.23 and P = 0.62, respectively). Use of ACEI or ARB was nearly half in patients with estimated GFR <30 ml/min compared with patients with better kidney function in univariate and multivariate analyses (P < 0.001). Analyses using serum creatinine measurements rather than estimations of GFR yielded similar results. Differences in other characteristics such as age, rather than kidney function, may be responsible for much or all the reported reduction in use of preventive medications after MI seen in patients with chronic kidney disease.

Quality of Care for Acute Myocardial Infarction in Elderly Patients with Alcohol‐Related Diagnoses

Elderly adults with alcohol-related diagnoses represent a vulnerable population that may receive lower quality of treatment during hospitalization for acute myocardial infarction. We sought to determine whether elderly patients with alcohol-related diagnoses are less likely to receive standard indicators of quality care for acute myocardial infarction. We conducted a retrospective cohort analysis using administrative and medical record data from the Cooperative Cardiovascular Project. Subjects were Medicare beneficiaries with a confirmed principal discharge diagnosis of acute myocardial infarction from all acute care hospitals in the United States over an 8-month period. Our primary outcome was the receipt of 7 guideline-recommended care measures among all eligible patients and patients who were ideal candidates for a given measure. In all, 1,284 (1%) of the 155,026 eligible patients met criteria for an alcohol-related diagnosis. Among the alcohol-related diagnoses, 1,077/1,284 (84%) were for the diagnoses of alcohol dependence or alcohol abuse. Patients with alcohol-related diagnoses were less likely than those without alcohol-related diagnoses to receive beta-blockers at the time of discharge (55% vs. 60%, p = 0.02). We found no other significant differences in performance of the quality indicators after stratifying by indication and adjustment for baseline characteristics. Alcohol-related diagnoses are not a barrier to receiving most quality of care measures in elderly patients hospitalized for acute myocardial infarction.

Herz und Gefäße

Aging is one of the most important cardiovascular risk factors. Age-related morphologic changes in large resistance vessels include an intima-media-thickening and increased deposition of matrix substance, ultimately leading to a reduced compliance and an increased stiffness of the vessels. Aging of the heart is mainly characterized by an increase of the left ventricular mass in relation to the chamber volume and a decrease of diastolic function. There is some controversy in regard to the question if these changes in the vessel wall are the consequence of aging or if a decrease in physical activity is a major contributor of this process. With age the cardiovascular profile is changing. Whereas smoking is less prominent, arterial hypertension and diabetes mellitus are more often encountered. Primary and secondary prevention through cardiovascular risk factor management is also very important in the aging population due to the increased risk of acute vascular complications with age. Preventive measures have to include life style factor interventions as well as optimized drug therapy. There is no scientific evidence that vascular aging can be prevented by administration of supplements such as antioxidant vitamins. Aspirin is effective for cardiovascular prevention up to a higher age. Betablockers and ACE-inhibitors are generally underused in older patients after myocardial infarctions. Statins are effective in reducing cardiovascular complications up to an age of 80 years. Myocardial infarction in elderly patients is often characterized by atypical symptoms and may be even silent. Interventional therapy in elderly patients is as successful as in younger patients but has an increased complication rate. Ambulatory cardiac rehabilitation in elderly patients leads to significant improvements of physical capacity, well-being and quality of life and may help to prevent social isolation.

Type of Treatment and Short-Term Outcome in Elderly Patients With Acute Myocardial Infarction Admitted to Hospitals With a Primary Coronary Angioplasty Facility. The TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) Registry

The nature and outcome of treatment for acute myocardial infarction in elderly patients admitted to Spanish hospitals with primary angioplasty facilities are not well documented. Prospective analysis of registry data on patients > or =75 years old with ST-segment-elevation acute myocardial infarction admitted between April and July 2002 to Spanish hospitals with an active primary angioplasty program. We followed up 410 consecutive patients for 1 month. Their mean age was 80 (4.3) years and 46% were female. The median delay between symptom onset and arrival at hospital was 190 minutes. Around 42% of patients received no reperfusion therapy, 35% were treated by thrombolysis, and 22% by primary angioplasty. Patients who underwent reperfusion therapy were younger, were more frequently male, had a shorter delay from symptom onset to hospital arrival, and had a better initial hemodynamic status (Killip Class). However, they were more likely to have extensive anterior infarctions. Overall, 30-day mortality was 24.9%. Independent predictors of death were age, systolic blood pressure, and Killip class >1, but not use of thrombolysis or primary angioplasty. Over 42% of elderly patients with myocardial infarction admitted to Spanish hospitals with angioplasty facilities did not receive reperfusion therapy. Thrombolysis was the most frequently used reperfusion therapy. However, neither thrombolysis nor primary angioplasty improved 30-day mortality.

Impact of ST-segment resolution after primary angioplasty on outcomes after myocardial infarction in elderly patients: an analysis from the CADILLAC trial

Background Age is a strong independent predictor of outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Whether lower rates of reperfusion success contribute to the poor prognosis in elderly patients is unknown. Methods A formal ST-segment analysis substudy was performed in 695 patients undergoing primary PCI for AMI in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Reperfusion success (determined by the magnitude of ST-segment elevation resolution [STR] after PCI) was evaluated in 4 age groups: <50 years (n = 163), ≥50 to <60 years (n = 187), ≥60 to <70 years (n = 194), and ≥70 years (n = 151). Results There were no differences in the age groups for angiographic procedural success >91% in all, P = .6), postprocedural Thrombolysis in Myocardial Infarction grade 3 flow >94%, P = .8), and the proportions of patients with complete, partial, or absent STR ( P >.8). However, rates of 30-day mortality (0.6%, 1.1%, 3.6%, 6.0%, respectively) and major adverse cardiac events (MACE; 2.5%, 4.8%, 6.2% 9.3%, respectively) increased with age. Rates of mortality and MACE were also inversely related to the magnitude of STR. Absent STR (hazard ratio, 3.00; 95% CI, 1.37–6.58; P = .006) and age (hazard ratio, 1.34; 95% CI, 1.01–1.77; P = .04) were independent predictors of 30-day MACE by using multivariable modeling. Conclusions Lack of effective myocardial reperfusion is not a contributory mechanism responsible for the high morbidity and mortality rates observed in elderly patients. Nevertheless, advanced age and absent STR are both independent predictors of adverse outcomes after primary PCI, emphasizing the importance of successful reperfusion in the elderly population.

Association between functional status and use and effectiveness of beta-blocker prophylaxis in elderly survivors of acute myocardial infarction.

To examine whether physical and cognitive impairments explain low use of beta-blockers in elderly patients and whether functionally impaired older adults have improved survival if a beta-blocker is prescribed at hospital discharge. Cross-sectional and retrospective cohort study. Acute care hospitals in the United States. National cohort of 45,370 elderly acute myocardial infarction survivors, with no chart-documented contraindications to beta-blocker treatment. The main outcome measures were beta-blocker prescription at hospital discharge and 1-year survival. Fifty percent (n=22,683) of eligible patients were prescribed a beta-blocker at discharge. Older age and functional impairments (incontinence, mobility impairment, and cognitive impairment) were independently associated with decreased use of beta-blockers. The odds ratios for prescribing a beta-blocker at hospital discharge were 0.82 (95% confidence interval (CI)=0.77-0.86), 0.63 (95% CI=0.56-0.71), and 0.40 (95% CI=0.32-0.51) for persons with one, two, and three impairments, respectively, compared with those with no impairments. In survival analysis, patients prescribed a beta-blocker were 21% less likely than nonrecipients to die within 1 year of follow-up (relative risk=0.79, P=.0001). Similar survival benefit was observed in patients with and without functional impairments. This study shows a strong association between functional impairment and the use of beta-blockers after acute myocardial infarction in elderly patients. The results suggest that increasing use of beta-blockers in this group provides an opportunity to improve outcomes.

Review Article: Treatment of Unstable Angina Pectoris/Non-ST-Segment Elevation Myocardial Infarction in Elderly Patients

Elderly patients with unstable angina pectoris/non-ST-segment elevation myocardial infarction should be hospitalized. Precipitating factors should be identified and corrected. Electrocardiogram monitoring is important. Aspirin should be given as soon as possible and continued indefinitely. Clopidogrel should given for up to 9 months in patients in whom an early noninterventional approach is planned or in whom a percutaneous coronary intervention (PCI) is planned. Clopidogrel should be withheld for 5-7 days in patients in whom elective coronary artery bypass graft surgery (CABGS) is planned. A platelet glycoprotein IIb/IIIa inhibitor should also be given in addition to aspirin, clopidogrel, and heparin in patients in whom cardiac catheterization and PCI are planned. Patients whose symptoms are not fully relieved with three 0.4-mg sublingual nitroglycerin tablets or spray taken 5 minutes apart and the initiation of an intravenous beta blocker should be treated with continuous intravenous nitroglycerin. Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be given and continued indefinitely. The benefit of long-acting nondihydropyridine calcium channel blockers is limited to symptom control. Intra-aortic balloon pump counterpulsation should be used for severe ischemia that is continuing or occurs frequently despite intensive medical therapy or for hemodynamic instability. Statins should be used if the serum low-density lipoprotein (LDL) cholesterol is >or=100 mg/dl and continued indefinitely. Enoxaparin is preferable to intravenous unfractionated heparin in the absence of renal failure and unless CABGS is planned within 24 hours. Thrombolysis is not beneficial. High-risk patients should have an early invasive strategy with CABGS or PCI performed depending on the coronary artery anatomy, left ventricular function, presence or absence of diabetes, and findings on noninvasive testing. Following hospital discharge, patients should have intensive risk factor modification with cessation of smoking, maintenance of blood pressure below 135/85 mmHg, indefinite use of statins if needed to maintain the serum LDL cholesterol <100 mg/dl, intensive control of diabetes, maintenance of optimal weight, and daily exercise. Patients should be treated indefinitely with aspirin, beta blockers, and ACE inhibitors and with clopidogrel for up to 9 months. Nitrates should be given for ischemic symptoms. Hormonal therapy should not be given to postmenopausal women.

Beta-blockers after acute myocardial infarction in elderly patients with diabetes mellitus: time to reassess.

Beta-blockers effectively reduce mortality and recurrent cardiovascular events in patients surviving myocardial infarction. However, these agents are underused in clinical practice, especially in older patients with diabetes mellitus. The current literature shows that beta-blockers are at least as effective in older diabetic patients as in other patients, without major safety concerns for their possible adverse effects. The use of these agents in clinical practice should therefore be encouraged, in order to reduce the burden of cardiovascular mortality and morbidity in older diabetic patients post-infarction.

Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients.

Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown. To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction. Cohort study. All nongovernment hospitals in the United States. 130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995. Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 micromol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records. Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction. Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

Death following spontaneous recovery from cardiopulmonary arrest in a hospital mortuary: ‘Lazarus phenomenon’ in a case of alleged medical negligence

We report a possibly first forensic autopsy case of death following a spontaneous recovery from cardiopulmonary arrest (CPA) after clinical declaration of death: ‘Lazarus phenomenon’. A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. During pre-hospital and clinical resuscitation including defibrillation and medications for about 35min, CPA persisted under electrocardiographic (ECG) monitoring and therefore, his death was pronounced. However, about 20min later, a police officer who had been called for the postmortem investigation found the patient moving in the mortuary. The patient subsequently showed typical ECG signs and laboratory findings of early inferior wall myocardial infarction and died 4 days later. The forensic autopsy, due to alleged medical negligence, revealed myocardial infarction with thrombotic occlusion of the right coronary artery and secondary hypoxic brain damage. The present case and the related clinical literature suggest that, especially in cases of acute myocardial infarction in elderly patients, a careful observation to confirm death after discontinuation of resuscitation is recommended to provide appropriate medical care, irrespective of the quality or duration of advanced life supporting efforts.

Cardiogenic shock complicating acute myocardial infarction in elderly patients: Does admission to a tertiary center improve survival?

Background The role of early revascularization among patients with acute myocardial infarction complicated by cardiogenic shock remains controversial. Angioplasty registries, while suggesting a benefit, are subject to selection bias, and clinical trials have been underpowered to detect early benefits. If an invasive strategy is beneficial in this population, patients admitted to hospitals with onsite coronary revascularization might be expected to have a better prognosis. We sought to determine whether access to cardiovascular resources at the admitting hospital influenced the prognosis of patients with acute myocardial infarction complicated by cardiogenic shock. Methods By use of the Cooperative Cardiovascular Project database (a retrospective medical record review of Medicare patients discharged with acute myocardial infarction), we identified patients aged ≥65 years whose myocardial infarction was complicated by cardiogenic shock. Results Of the 601 patients with cardiogenic shock, 287 (47.8%) were admitted to hospitals without revascularization services and 314 (52.2%) were admitted to hospitals with coronary angioplasty and coronary artery bypass surgery facilities. Clinical characteristics were similar across the subgroups. Patients admitted to hospitals with revascularization services were more likely to undergo coronary revascularization during the index hospitalization and during the first month after acute myocardial infarction. After adjustment for demographic, clinical, hospital, and treatment strategies, the presence of onsite revascularization services was not associated with a significantly lower 30-day (odds ratio 0.83, 95% CI 0.47, 1.45) or 1-year mortality (odds ratio 0.91, 95% CI 0.49, 1.72). Conclusions In a community-based cohort, patients with acute myocardial infarction complicated by cardiogenic shock did not have significantly different adjusted 30-day and 1-year mortality, irrespective of the revascularization capabilities of the admitting hospital. (Am Heart J 2002;143:768-76.)

Office blood pressure variability as a predictor of acute myocardial infarction in elderly patients receiving antihypertensive therapy

Larger variability of office blood pressure (BP) was reportedly associated with a higher risk of stroke or mortality from all causes. In the present study, we focused on the relationship of variability of office BP and occurrence of acute myocardial infarction (MI). We registered 139 patients receiving antihypertensive therapy for more than 1 year who experienced first-ever episode of MI at the age of 60 years or over. At least two sex- and age-matched (+/- 5 years) control patients were registered for every MI patient. Average systolic and diastolic BP during the 12-month period prior to the occurrence of MI, or the time of registration in the case of control patients, was similar in both patient groups. The office BP variability was evaluated by calculating the variation coefficient (VC) of BP. VC of diastolic BP was significantly higher in the MI patients (10.0 +/- 4.0%) compared with the control patients (8.8 +/- 3.4%). VC of systolic BP was not different between the MI and the control patients. Multiple logistic analysis revealed the relationship of the VC for office diastolic BP to the occurrence of MI was significant after adjustment for BP level, age, gender, body mass index, serum total cholesterol concentrations, diabetes mellitus, and current smoking. In conclusion, larger long-term variability of office diastolic BP during antihypertensive therapy is a predictor of MI.

Association between obesity and coronary atherosclerosis and vascular remodeling

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Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma

OBJECTIVESWe evaluated the use and effectiveness of beta-blocker therapy after acute myocardial infarction (AMI) for elderly patients with chronic obstructive pulmonary disease (COPD) or asthma.BACKGROUNDBecause patients with COPD and asthma have largely been excluded from clinical trials of beta-blocker therapy for AMI, the extent to which these patients would benefit from beta-blocker therapy after AMI is not well defined.METHODSUsing data from the Cooperative Cardiovascular Project, we examined the relationship between discharge use of beta-blockers and one-year mortality in patients with COPD or asthma who were not using beta-agonists, patients with COPD or asthma who were concurrently using beta-agonists and patients with evidence of severe disease (use of prednisone or previous hospitalization for COPD or asthma) compared with patients without COPD or asthma.RESULTSOf 54,962 patients without contraindications to beta-blockers, patients with COPD or asthma (20%) were significantly less likely to be prescribed beta-blockers at discharge after AMI. After adjusting for demographic and clinical factors, we found that beta-blockers were associated with lower one-year mortality in patients with COPD or asthma who were not on beta-agonist therapy (relative risk [RR] = 0.85, 95% confidence interval [CI] 0.73 to 1.00), similar to patients without COPD or asthma (RR = 0.86, 95% CI 0.81 to 0.92). A survival benefit for beta-blockers was not found among patients concurrently using beta-agonists or with severe COPD or asthma.CONCLUSIONSBeta-blocker therapy after AMI may be beneficial for COPD or asthma patients with mild disease. A survival benefit was not found for elderly AMI patients with more severe pulmonary disease.

Acute myocardial infarction complicated by heart block in the elderly: Prevalence and outcomes

Background Although second- and third-degree heart block (HB) are common conduction disorders associated with acute myocardial infarction (MI), patient characteristics and HBs association with outcomes, particularly among the elderly, remain poorly defined. Methods We evaluated 106,780 Medicare beneficiaries aged 65 years and older treated for acute MI between January 1994 and February 1996 for development of HB. HB and non-HB patients were compared by univariate analysis, and the influence of HB on outcomes was evaluated by unadjusted and multiple logistic regression. Results HB was documented in 5048 (4.7%) patients; 1646 presented with HB and 3402 developed HB during hospitalization. HB was more common among patients with inferior infarctions than anterior infarctions (7.3% vs 3.0%, P =.001), particularly the cohort of patients with inferior MI treated with reperfusion therapy (8.3%). HB patients had higher rates of in-hospital mortality (29.6% vs 17.5% vs non-HB patients, P =.001). After adjustment for demographic and clinical factors, HB remained an independent predictor of in-hospital mortality (relative risk [RR] 1.41, 95% confidence interval [CI] 1.34-1.48), but HB had no prognostic significance at 1 year among hospital survivors (RR 0.94, 95% CI 0.88-1.01). Mortality risks varied on the basis of MI location. Both anterior MI (RR 1.46, 95% CI 1.30-1.63) and inferior MI (RR 1.52, 95% CI 1.39-1.66) patients with HB had increased risks of in-hospital mortality. There was a trend toward increased mortality among patients with anterior MI (RR 1.15, 95% CI 0.99-1.32) at 1 year, whereas those with inferior MI were at lower risk (RR 0.83, 95% CI 0.75-0.98). Conclusions HB is a common complication of acute MI in elderly patients, particularly among patients with inferior MIs who received reperfusion therapy. HB is independently associated with short-term but not long-term mortality. (Am Heart J 2001;141:47-54.)

Does angina the week before protect against first myocardial infarction in elderly patients?

Mortality rates for coronary artery disease are greater in elderly patients. Although prodromal angina occurring shortly before an acute myocardial infarction (MI) has protective effects against ischemia, this effect has not been well documented in older patients. This study investigated whether angina 1 week before a first MI provides protection in this group of patients. A total of 290 consecutive elderly (>64 years old, n = 143) and adult patients (<65 years old, n = 147) with a first MI were examined to assess the effect of preceding angina on the short- and long-term prognosis. Elderly patients with a history of prodromal angina were less likely than those without angina to experience in-hospital death, heart failure, or the combined end point of in-hospital death and heart failure (6% vs 20.4%, p = 0.02; 10% vs 23.7%, p = 0.07; 14% vs 32.3%, p = 0.01, respectively). Left ventricular function was more frequently depressed (ejection fraction <40%) in elderly patients without (44.8%) than with (26%, p = 0.04) preinfarction angina, and the incidence of arrhythmias (complete heart block and ventricular fibrillation) was greater in the former group (16.1% vs 4%, p = 0.03). Multivariate analysis confirmed that the presence of preinfarction angina was an independent predictor of in-hospital death and heart failure in older patients (odds ratio 0.28, p = 0.009). The occurrence of angina 1 week before a first MI may confer protection against in-hospital adverse outcomes, and may preserve left ventricular function in older patients.

The Association Between Hospital Volume and Survival After Acute Myocardial Infarction in Elderly Patients

Background Patients with chest pain thought to be due to acute coronary ischemia are typically taken by ambulance to the nearest hospital. The potential benefit of field triage directly to a hospital that treats a large number of patients with myocardial infarction is unknown. Methods We conducted a retrospective cohort study of the relation between the number of Medicare patients with myocardial infarction that each hospital in the study treated (hospital volume) and long-term survival among 98,898 Medicare patients 65 years of age or older. We used proportional-hazards methods to adjust for clinical, demographic, and health-system–related variables, including the availability of invasive procedures, the specialty of the attending physician, and the area of residence of the patient (rural, urban, or metropolitan). Results The patients in the quartile admitted to hospitals with the lowest volume were 17 percent more likely to die within 30 days after admission than patients in the quartile admitted to hos...

Primary Coronary Angioplasty vs Thrombolysis for the Management of Acute Myocardial Infarction in Elderly Patients

ContextDespite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known.ObjectiveTo determine survival after primary PTCA vs thrombolysis in elderly patients.DesignThe Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files.SettingAcute care hospitals in the United States.PatientsA total of 20,683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy.Main Outcome MeasuresThirty-day and 1-year survival.ResultsA total of 80,356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08).ConclusionIn elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.

Acute myocardial infarction complicated by atrial fibrillation in the elderly: prevalence and outcomes.

Although atrial fibrillation (AF) is a common complication of acute myocardial infarction (MI), patient characteristics and association with outcomes remain poorly defined in the elderly. We evaluated 106 780 Medicare beneficiaries > or =65 years of age from the Cooperative Cardiovascular Project treated for acute MI between January 1994 and February 1996 to determine the prevalence and prognostic significance of AF complicating acute MI in elderly patients. Patients were categorized on the basis of the presence of AF, and those with AF were further subdivided by time of AF (present on arrival versus developing during hospitalization). AF and non-AF patients were compared by univariate analysis, and logistic regression modeling was used to identify clinical predictors of AF. The influence of AF on outcomes was evaluated by unadjusted Kaplan-Meier survival curves and logistic regression models. AF was documented in 23 565 patients (22. 1%): 11 510 presented with AF and 12,055 developed AF during hospitalization. AF patients were older, had more advanced heart failure, and were more likely to have had a prior MI and undergone coronary revascularization. AF patients had poorer outcomes, including higher in-hospital (25.3% versus 16.0%), 30-day (29.3% versus 19.1%), and 1-year (48.3% versus 32.7%) mortality. AF remained an independent predictor of in-hospital (odds ratio [OR], 1. 21), 30-day (OR, 1.20), and 1-year (OR, 1.34) mortality after multivariate adjustment. Patients developing AF during hospitalization had a worse prognosis than patients who presented with AF. AF is a common complication of acute MI in elderly patients and independently influences mortality, particularly when it develops during hospitalization.