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The use of percutaneous coronary intervention after ST-segment elevation myocardial infarction is increasing in older adults, and is associated with significantly lower in-hospital mortality, new research has found.
“Our study shows that the rates of utilization of PCI in older patients with STEMI and cardiogenic shock is rising. This rise has been paralleled by an equivalent decline in unadjusted mortality rates,” Abdulla A. Damluji, MD, and his coinvestigators wrote in an analysis published in the Journal of the American College of Cardiology.
They looked at outcomes of 317,728 cases of STEMI with cardiogenic shock during 1999-2013, of which 35% occurred in individuals aged 75 years or above.
Over the study period, the proportion of adults aged 75 years and over who underwent percutaneous coronary intervention after STEMI increased from 27% in 1999 to 56% in 2013. At the same time, in-hospital mortality rates in those patients declined from 64% in 1999 to 46% in 2013. Both differences were significant at P less than 0.001.
PCI more than halved the mortality associated with STEMI in older adults, even after adjustment for propensity score, and this was seen across all four U.S. Census Bureau regions in the analysis.
However, mortality rates were slightly higher in patients who underwent percutaneous coronary intervention and had a bleeding event, compared with those who did not have a bleeding event.
There were some significant differences in the prevalence of cardiovascular risk factors and noncardiovascular diagnoses between those who underwent percutaneous coronary intervention and those who did not. There was around a 20% higher prevalence of obesity, but a lower prevalence of valvular heart disease and heart failure, in individuals who were treated with percutaneous coronary intervention than among those who were not.
Older adults who received percutaneous coronary intervention also had a significantly lower disease burden compared with older adults who did not, and were more likely to be younger, male, and not an underrepresented minority.
“Despite the improvement in survival associated with early revascularization as reported by these studies, many older adults with multiple chronic conditions, worse disease burden, and possibly limited life expectancy as assessed by interventional cardiologists do not receive early revascularization with PCI,” wrote Dr. Damluji of Sinai Hospital of Baltimore and Johns Hopkins University, and his coauthors.
“This study was aimed to address this important selection bias by implementing different methods of propensity matching to understand the influence of early revascularization adjusting for demographic, clinical, and hospital characteristics between older adults with early revascularization versus those without revascularization.”
The study was partly supported by the Jane and Stanley F. Rodbell family. Three authors declared support from the National Institute on Aging. Two authors declared funding from private industry and one declared pharmaceutical stocks. No other conflicts of interest were declared.
SOURCE: Damluji A et al. J Am Coll Cardiol. 2019 Apr;73(15):1890-900.
Despite recent advances in early revascularization approaches, such as increasing availability and improved safety profile, which have seen a decrease in mortality rates after cardiogenic shock, many of the studies of these advances have excluded elderly patients. This limits the generalizability of the results.
This study is the largest analysis so far to explore the outcomes of cardiogenic shock and percutaneous coronary intervention in older adults. The authors have used a propensity score adjustment in an attempt to account for potentially confounding baseline characteristics, and shown significantly lower mortality after PCI.
However, the analysis is subject to the usual limitations of observational studies. In particular is the fact that patients with cardiogenic shock represent a spectrum of risk, comorbidities, degrees of disease, and coronary anatomy. These comorbid conditions could therefore have affected the selection decision for revascularization, and therefore outcomes. The challenge still remains also to identify older patients who are more likely to benefit from revascularization after STEMI.
Dr. Eliano P. Navarese is from Interventional Cardiology and Cardiovascular Medicine, Mater Dei Hospital and SIRIO MEDICINE Research Network, Italy. Dr. Sunil V. Rao is from the faculty of medicine at the University of Alberta, Edmonton. Dr. Mitchell W. Krucoff is from Duke University Medical Center/Duke Clinical Research Institute, Durham, N.C. These comments are adapted from their editorial (J Am Coll Cardiol. 2019 Apr;73(15):1901-4). No conflicts of interest were declared.
Despite recent advances in early revascularization approaches, such as increasing availability and improved safety profile, which have seen a decrease in mortality rates after cardiogenic shock, many of the studies of these advances have excluded elderly patients. This limits the generalizability of the results.
This study is the largest analysis so far to explore the outcomes of cardiogenic shock and percutaneous coronary intervention in older adults. The authors have used a propensity score adjustment in an attempt to account for potentially confounding baseline characteristics, and shown significantly lower mortality after PCI.
However, the analysis is subject to the usual limitations of observational studies. In particular is the fact that patients with cardiogenic shock represent a spectrum of risk, comorbidities, degrees of disease, and coronary anatomy. These comorbid conditions could therefore have affected the selection decision for revascularization, and therefore outcomes. The challenge still remains also to identify older patients who are more likely to benefit from revascularization after STEMI.
Dr. Eliano P. Navarese is from Interventional Cardiology and Cardiovascular Medicine, Mater Dei Hospital and SIRIO MEDICINE Research Network, Italy. Dr. Sunil V. Rao is from the faculty of medicine at the University of Alberta, Edmonton. Dr. Mitchell W. Krucoff is from Duke University Medical Center/Duke Clinical Research Institute, Durham, N.C. These comments are adapted from their editorial (J Am Coll Cardiol. 2019 Apr;73(15):1901-4). No conflicts of interest were declared.
Despite recent advances in early revascularization approaches, such as increasing availability and improved safety profile, which have seen a decrease in mortality rates after cardiogenic shock, many of the studies of these advances have excluded elderly patients. This limits the generalizability of the results.
This study is the largest analysis so far to explore the outcomes of cardiogenic shock and percutaneous coronary intervention in older adults. The authors have used a propensity score adjustment in an attempt to account for potentially confounding baseline characteristics, and shown significantly lower mortality after PCI.
However, the analysis is subject to the usual limitations of observational studies. In particular is the fact that patients with cardiogenic shock represent a spectrum of risk, comorbidities, degrees of disease, and coronary anatomy. These comorbid conditions could therefore have affected the selection decision for revascularization, and therefore outcomes. The challenge still remains also to identify older patients who are more likely to benefit from revascularization after STEMI.
Dr. Eliano P. Navarese is from Interventional Cardiology and Cardiovascular Medicine, Mater Dei Hospital and SIRIO MEDICINE Research Network, Italy. Dr. Sunil V. Rao is from the faculty of medicine at the University of Alberta, Edmonton. Dr. Mitchell W. Krucoff is from Duke University Medical Center/Duke Clinical Research Institute, Durham, N.C. These comments are adapted from their editorial (J Am Coll Cardiol. 2019 Apr;73(15):1901-4). No conflicts of interest were declared.
The use of percutaneous coronary intervention after ST-segment elevation myocardial infarction is increasing in older adults, and is associated with significantly lower in-hospital mortality, new research has found.
“Our study shows that the rates of utilization of PCI in older patients with STEMI and cardiogenic shock is rising. This rise has been paralleled by an equivalent decline in unadjusted mortality rates,” Abdulla A. Damluji, MD, and his coinvestigators wrote in an analysis published in the Journal of the American College of Cardiology.
They looked at outcomes of 317,728 cases of STEMI with cardiogenic shock during 1999-2013, of which 35% occurred in individuals aged 75 years or above.
Over the study period, the proportion of adults aged 75 years and over who underwent percutaneous coronary intervention after STEMI increased from 27% in 1999 to 56% in 2013. At the same time, in-hospital mortality rates in those patients declined from 64% in 1999 to 46% in 2013. Both differences were significant at P less than 0.001.
PCI more than halved the mortality associated with STEMI in older adults, even after adjustment for propensity score, and this was seen across all four U.S. Census Bureau regions in the analysis.
However, mortality rates were slightly higher in patients who underwent percutaneous coronary intervention and had a bleeding event, compared with those who did not have a bleeding event.
There were some significant differences in the prevalence of cardiovascular risk factors and noncardiovascular diagnoses between those who underwent percutaneous coronary intervention and those who did not. There was around a 20% higher prevalence of obesity, but a lower prevalence of valvular heart disease and heart failure, in individuals who were treated with percutaneous coronary intervention than among those who were not.
Older adults who received percutaneous coronary intervention also had a significantly lower disease burden compared with older adults who did not, and were more likely to be younger, male, and not an underrepresented minority.
“Despite the improvement in survival associated with early revascularization as reported by these studies, many older adults with multiple chronic conditions, worse disease burden, and possibly limited life expectancy as assessed by interventional cardiologists do not receive early revascularization with PCI,” wrote Dr. Damluji of Sinai Hospital of Baltimore and Johns Hopkins University, and his coauthors.
“This study was aimed to address this important selection bias by implementing different methods of propensity matching to understand the influence of early revascularization adjusting for demographic, clinical, and hospital characteristics between older adults with early revascularization versus those without revascularization.”
The study was partly supported by the Jane and Stanley F. Rodbell family. Three authors declared support from the National Institute on Aging. Two authors declared funding from private industry and one declared pharmaceutical stocks. No other conflicts of interest were declared.
SOURCE: Damluji A et al. J Am Coll Cardiol. 2019 Apr;73(15):1890-900.
The use of percutaneous coronary intervention after ST-segment elevation myocardial infarction is increasing in older adults, and is associated with significantly lower in-hospital mortality, new research has found.
“Our study shows that the rates of utilization of PCI in older patients with STEMI and cardiogenic shock is rising. This rise has been paralleled by an equivalent decline in unadjusted mortality rates,” Abdulla A. Damluji, MD, and his coinvestigators wrote in an analysis published in the Journal of the American College of Cardiology.
They looked at outcomes of 317,728 cases of STEMI with cardiogenic shock during 1999-2013, of which 35% occurred in individuals aged 75 years or above.
Over the study period, the proportion of adults aged 75 years and over who underwent percutaneous coronary intervention after STEMI increased from 27% in 1999 to 56% in 2013. At the same time, in-hospital mortality rates in those patients declined from 64% in 1999 to 46% in 2013. Both differences were significant at P less than 0.001.
PCI more than halved the mortality associated with STEMI in older adults, even after adjustment for propensity score, and this was seen across all four U.S. Census Bureau regions in the analysis.
However, mortality rates were slightly higher in patients who underwent percutaneous coronary intervention and had a bleeding event, compared with those who did not have a bleeding event.
There were some significant differences in the prevalence of cardiovascular risk factors and noncardiovascular diagnoses between those who underwent percutaneous coronary intervention and those who did not. There was around a 20% higher prevalence of obesity, but a lower prevalence of valvular heart disease and heart failure, in individuals who were treated with percutaneous coronary intervention than among those who were not.
Older adults who received percutaneous coronary intervention also had a significantly lower disease burden compared with older adults who did not, and were more likely to be younger, male, and not an underrepresented minority.
“Despite the improvement in survival associated with early revascularization as reported by these studies, many older adults with multiple chronic conditions, worse disease burden, and possibly limited life expectancy as assessed by interventional cardiologists do not receive early revascularization with PCI,” wrote Dr. Damluji of Sinai Hospital of Baltimore and Johns Hopkins University, and his coauthors.
“This study was aimed to address this important selection bias by implementing different methods of propensity matching to understand the influence of early revascularization adjusting for demographic, clinical, and hospital characteristics between older adults with early revascularization versus those without revascularization.”
The study was partly supported by the Jane and Stanley F. Rodbell family. Three authors declared support from the National Institute on Aging. Two authors declared funding from private industry and one declared pharmaceutical stocks. No other conflicts of interest were declared.
SOURCE: Damluji A et al. J Am Coll Cardiol. 2019 Apr;73(15):1890-900.
FROM JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY