1
|
Sarma D, Padkins M, Smith R, Bennett CE, Murphy JG, Bell MR, Damluji AA, Anavekar NS, Barsness GW, Jentzer JC. Patients Aged 90 Years and Above With Acute Coronary Syndrome in the Cardiac Intensive Care Unit: Management and Outcomes. Am J Cardiol 2024; 215:19-27. [PMID: 38266797 PMCID: PMC11025344 DOI: 10.1016/j.amjcard.2023.12.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/03/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024]
Abstract
Limited data exist regarding outcomes after coronary angiography (CAG) and percutaneous coronary intervention (PCI) in patients aged ≥90 years admitted to the cardiac intensive care unit (CICU) with acute coronary syndrome (ACS). We studied sequential CICU patients ≥90 years admitted with ACS from 2007 to 2018. Three therapeutic approaches were defined: (1) No CAG; (2) CAG without PCI (CAG/No PCI); and (3) CAG with PCI (CAG/PCI). In-hospital mortality was evaluated using multivariable logistic regression. All-cause 1-year mortality was evaluated using Kaplan-Meier and multivariable Cox proportional hazards analysis. The study included 239 patients with a median age of 92 (range 90 to 100) years (57% females; 45% ST-elevation myocardial infarction; 8% cardiac arrest; 16% shock). The No CAG group had higher Day 1 Sequential Organ Failure Assessment scores, more co-morbidities, worse kidney function, and fewer ST-elevation myocardial infarctions. In-hospital mortality was 20.8% overall and did not differ between the No CAG (n = 103; 21.4%), CAG/No PCI (n = 47; 21.3%), and CAG/PCI (n = 90; 20.0%) groups, before or after adjustment. Overall 1-year mortality was 52.5% and did not differ between groups before or after adjustment. Median survival was 6.9 months overall and 41.2% of hospital survivors died within 1 year of CICU admission. CICU patients aged ≥90 years with ACS have a substantial burden of illness with high in-hospital and 1-year mortality that was not lower in those who underwent CAG or PCI. These results suggest that careful patient selection for invasive coronary procedures is essential in this vulnerable population.
Collapse
Affiliation(s)
- Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mitchell Padkins
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ryan Smith
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney E Bennett
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph G Murphy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory W Barsness
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
2
|
Park DY, Hu JR, Jamil Y, Kelsey MD, Jones WS, Frampton J, Kochar A, Aronow WS, Damluji AA, Nanna MG. Shorter Dual Antiplatelet Therapy for Older Adults After Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2024; 7:e244000. [PMID: 38546647 PMCID: PMC10979312 DOI: 10.1001/jamanetworkopen.2024.4000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/31/2024] [Indexed: 04/01/2024] Open
Abstract
Importance The optimal duration of dual antiplatelet therapy (DAPT) for older adults after percutaneous coronary intervention (PCI) is uncertain because they are simultaneously at higher risk for both ischemic and bleeding events. Objective To investigate the association of abbreviated DAPT with adverse clinical events among older adults after PCI. Data Sources The Cochrane Library, Google Scholar, Embase, MEDLINE, PubMed, Scopus, and Web of Science were searched from inception to August 9, 2023. Study Selection Randomized clinical trials comparing any 2 of 1, 3, 6, and 12 months of DAPT were included if they reported results for adults aged 65 years or older or 75 years or older. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline was used to abstract data and assess data quality. Risk ratios for each duration of DAPT were calculated with alternation of the reference group. Main Outcomes and Measures The primary outcome of interest was net adverse clinical events (NACE). Secondary outcomes were major adverse cardiovascular events (MACE) and bleeding. Results In 14 randomized clinical trials comprising 19 102 older adults, no differences were observed in the risks of NACE or MACE for 1, 3, 6, and 12 months of DAPT. However, 3 months of DAPT was associated with a lower risk of bleeding compared with 6 months of DAPT (relative risk [RR], 0.50 [95% CI, 0.29-0.84]) and 12 months of DAPT (RR, 0.57 [95% CI, 0.45-0.71]) among older adults. One month of DAPT was also associated with a lower risk of bleeding compared with 6 months of DAPT (RR, 0.68 [95% CI, 0.54-0.86]). Conclusions and Relevance In this systematic review and meta-analysis of different durations of DAPT for older adults after PCI, an abbreviated DAPT duration was associated with a lower risk of bleeding without any concomitant increase in the risk of MACE or NACE despite the concern for higher-risk coronary anatomy and comorbidities among older adults. This study, which represents the first network meta-analysis of this shortened treatment for older adults, suggests that clinicians may consider abbreviating DAPT for older adults.
Collapse
Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yasser Jamil
- Department of Medicine, Yale-Waterbury Hospital, Waterbury, Connecticut
| | - Michelle D. Kelsey
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - W. Schuyler Jones
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ajar Kochar
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Wilbert S. Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, New York
| | - Abdulla A. Damluji
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
3
|
Charman SJ, Blain AP, Trenell MI, Jakovljevic DG, Kunadian V. Physical activity, inactivity and sleep in older patients with coronary artery disease following percutaneous coronary intervention: a longitudinal, observational study. Coron Artery Dis 2023; 34:441-447. [PMID: 37335243 DOI: 10.1097/mca.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Physical activity presents an important cornerstone in the management and care of coronary artery disease (CAD) patients following percutaneous coronary intervention (PCI) and research in older patients continues to be overlooked. This study evaluated differences in physical activity, inactivity and sleep of CAD patients following PCI for acute coronary syndrome consisting of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) and elective admission of stable angina patients over 12 months. METHODS This was an observational, longitudinal study. Fifty-eight patients were recruited (STEMI, n = 20, NSTEMI, n = 18 and stable angina, n = 20) and completed 7-day monitoring (physical activity, inactivity and sleep) using wrist-worn tri-axial accelerometers (GENEActiv, ActivInsights Ltd, Kimbolton, Cambridgeshire, UK) upon discharge from a tertiary centre and repeated measurements at 3 months ( n = 43), 6 months ( n = 40) and 12 months ( n = 33). RESULTS Following PCI, CAD patients showed a general trend of increasing light and moderate-vigorous physical activity over the 12-month follow-up. Time in inactivity remained high but decreased over time. Sleep duration and sleep efficiency remained consistent. NSTEMI patients spent less time asleep, more time inactive and less time in light and moderate-vigorous physical activity in comparison to STEMI and stable angina patients. Differences between the groups over time were minimal. CONCLUSION These findings suggest that older patients with CAD spend long periods in inactivity but the increasing trend of both light and moderate-vigorous physical activity over time presents a positive change in behaviour in the year following PCI.
Collapse
Affiliation(s)
- Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
- Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - Alasdair P Blain
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
| | - Michael I Trenell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne
| | - Djordje G Jakovljevic
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
- Newcastle upon Tyne Hospitals NHS Foundation Trust
- Research Centre for Health and Life Sciences, Institute for Health and Wellbeing, Faculty of Health and Life Sciences, Coventry University, Coventry
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
4
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
|
5
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | | | | | | | | |
Collapse
|
6
|
Huang BT, Cheng YH, Yang BS, Zhang YK, Huang FY, Peng Y, Pu XB, Chen M. The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older. World J Emerg Med 2023; 14:112-121. [PMID: 36911061 PMCID: PMC9999128 DOI: 10.5847/wjem.j.1920-8642.2023.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/21/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older. METHODS This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome. RESULTS Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups. CONCLUSIONS In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.
Collapse
Affiliation(s)
- Bao-Tao Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Heng Cheng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo-Sen Yang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Ke Zhang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Fang-Yang Huang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yong Peng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiao-Bo Pu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu 610041, China
| |
Collapse
|
7
|
Saada M, Kobo O, Polad J, Halabi M, IJsselmuiden AJJ, Puentes Á, Monségu J, Austin D, Baisebenov RK, Spanó F, Roguin A. Prognosis of PCI in AMI setting in the elderly population: Outcomes from the multicenter prospective e-ULTIMASTER registry. Clin Cardiol 2022; 45:1211-1219. [PMID: 36072999 DOI: 10.1002/clc.23902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 07/03/2022] [Accepted: 07/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Elderly patients with ST-elevation myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI) are usually excluded from major trials. HYOPTHESIS This study sought to assess 1-year clinical outcomes following PCI with a drug-eluting stent in patients older than 80 years old with STEMI. METHODS The large all-comer, multicontinental e-ULTIMASTER registry included 7507 patients with STEMI who underwent PCI using the Ultimaster stent. The primary clinical endpoint was 1-year target lesion failure, a composite of cardiac death (CD), target vessel-related myocardial infarction (TV-MI), or clinically driven target lesion revascularization (CD-TLR). RESULTS There were 457 (6.1%) patients in the elderly group (≥80 years old) that were compared to 7050 (93.9%) patients <80 years. The elderly patients included more female patients and had significantly more comorbidities and had more complex coronary anatomy. The primary endpoint occurred in 7.2% of the elderly, compared to 3.1% of the younger group (p < .001). All-cause mortality was significantly higher among the elderly group compared to the younger group (10.1% vs. 2.3%, p < .0001), as well as CD (6.1% vs. 1.6%, p < .0001), but not TV-MI (1.1% vs. 0.7%, p = .34) or CD-TLR (1.1% vs. 1.4%, p = .63). CONCLUSION Elderly patients with STEMI presentation had a higher incidence of the composite endpoint than younger patients. All-cause and CD were higher for elderly patients compared to patients younger than 80 years old. However, there was no difference in the incidence of TV-MI or target lesion revascularizations. These findings suggest that PCI for STEMI in elderly patients is relatively safe.
Collapse
Affiliation(s)
- Majdi Saada
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
| | - Ofer Kobo
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, The Netherlands
| | - Majdi Halabi
- Department of Cardiology, Ziv Hospital, Safed, Israel
| | | | - Ángel Puentes
- Department of Cardiology, San Juan de Dios Hospital, Santiago, Chile
| | - Jacques Monségu
- Department of Cardiology, Groupe Hospitalier Mutualiste, Institut Cardiovasculaire, Grenoble, France
| | - David Austin
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, UK
| | | | - Fabrizio Spanó
- Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands
| | - Ariel Roguin
- Department of Cardiology, Hillel Yaffe Medical Center, Technion-Faculty of Medicine, Hadera, Israel
| | | |
Collapse
|
8
|
Park DY, Hanna JM, Kadian S, Kadian M, Jones WS, Damluji AA, Kochar A, Curtis JP, Nanna MG. In-hospital outcomes and readmission in older adults treated with percutaneous coronary intervention for stable ischemic heart disease. J Geriatr Cardiol 2022; 19:631-642. [PMID: 36284680 PMCID: PMC9548058 DOI: 10.11909/j.issn.1671-5411.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in older adults requires a meticulous assessment of procedural risks and benefits, but contemporary data on outcomes in this population is lacking. Therefore, we examined the risk of near-term readmission, bleeding, and mortality in high-risk cohort of older adults undergoing inpatient PCI for SIHD. METHODS We analyzed the National Readmissions Database from 2017 to 2018 to identify index hospitalizations in which PCI was performed for SIHD. Patients were stratified into those ≥ 75 years old (older adults) and those < 75 years old. The primary outcome was 90-day readmission. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and total hospital charge. RESULTS A total of 74,516 patients underwent inpatient PCI for SIHD, of whom 24,075 were older adults. Older adult patients had higher odds of in-hospital mortality (OR = 2.00, 95% CI: 1.68-2.38), intracranial hemorrhage (OR = 2.03, 95% CI: 1.24-3.34), and gastrointestinal hemorrhage (OR = 1.72, 95% CI: 1.43-2.07) during index hospitalization, with longer LOS and in-hospital charge. Older adults also experienced a higher hazard of 90-day readmission for any cause (HR = 1.61, 95% CI: 1.57-1.66) and cardiovascular causes (HR = 1.84, 95% CI: 1.77-1.91). CONCLUSION Older adults undergoing inpatient PCI for SIHD were at increased risk for in-hospital mortality, periprocedural morbidities, higher cost, and readmissions compared with younger adults. Understanding these differences may improve shared decision-making for patients with SIHD being considered for PCI.
Collapse
Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Jonathan M. Hanna
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | - W. Schuyler Jones
- Section of Interventional Cardiology, Duke University Health System, Durham, NC, USA
| | - Abdulla Al Damluji
- Section of Interventional Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Ajar Kochar
- Section of Interventional Cardiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
9
|
One-year outcome after percutaneous coronary intervention in nonagenarians: Insights from the J-PCI OUTCOME registry. Am Heart J 2022; 246:105-116. [PMID: 35016854 DOI: 10.1016/j.ahj.2022.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/24/2021] [Accepted: 01/06/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Nonagenarian patients who undergo percutaneous coronary intervention (PCI) are increasing, and a few previous studies have reported their long-term outcomes. However, differences in their long-term outcomes between generations remain unclear. This study aimed to investigate 1-year all-cause and cardiovascular (CV) mortality, and major adverse cardiovascular events (MACE; cardiovascular death, myocardial infarction, and stroke) of nonagenarian patients who underwent PCI compared with the other elder patients, using a nationwide registration system. METHODS The patient-level data registered between January 2017 and December 2017 was extracted from the J-PCI OUTCOME Registry endorsed by the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT). The one-year all-cause and cardiovascular (CV) mortality, MACE, and major bleeding events were identified. RESULTS Out of 40,722 patients over 60 years of age, 880 (2.1%) were nonagenarians. For nonagenarians, the 1-year mortality rate was substantial (13.5%). The MACE and CV death rates were also high (8.1%, and 6.8%, respectively) for nonagenarians, and these event rates were approximately 1.5 times higher in nonagenarians than octogenarians. Multivariate regression analysis showed that presentation with cardiogenic shock [hazard ratio (HR) 2.32; 95 confidence intervals (CI): 1.22-4.41], or cardiac arrest (HR 2.91; 90% CI: 1.28-6.62), and use of oral anticoagulants (HR 2.10; 90% CI: 1.07-4.12) were the predictors of 1-year MACE. CONCLUSIONS Even in the contemporary era, nonagenarians who have undergone PCI still face a considerably increased risk for adverse cardiovascular events that reduces long-term survival. In addition to having poorer lesion characteristics, adverse events, including death, MACEs, and major bleeding, occurred 1.5 times more frequently in nonagenarians than in octogenarians.
Collapse
|
10
|
Pajjuru VS, Thandra A, Guddeti RR, Kothapalli SR, Walters RW, Jhand A, Aboeata A, Andukuri VG, Goldsweig AM. ST-elevation myocardial infarction in nonagenarians: A nationwide analysis of trends and outcomes in the United States. Catheter Cardiovasc Interv 2020; 98:638-646. [PMID: 33010099 DOI: 10.1002/ccd.29313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/03/2020] [Accepted: 09/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess ST elevation myocardial infarction (STEMI) trends and outcomes in nonagenarians undergoing primary percutaneous coronary intervention (pPCI) compared to medical management. BACKGROUND Although nonagenarians (age greater than 90 years) represent the fast-growing age decade of the US population, limited evidence is available regarding trends and outcomes of treatment strategies for STEMI in this population cohort. METHODS We performed a retrospective analysis using the National Inpatient Sample (NIS) database to identify nonagenarians presenting with STEMI and treated with either pPCI or medical management. In-hospital mortality, in-hospital complications, length of stay and in-hospital costs were analyzed. RESULTS Between 2010-2017, 41,042 STEMI hospitalizations were identified in nonagenarians, of which 11, 155 (27.2%) included pPCI whereas 29, 887 (72.8%) included medical management. STEMI hospitalizations among nonagenarians decreased over the study period. Overall unadjusted in-hospital mortality was 21.6%, and the hospitalizations that included pPCI had significantly lower mortality compared to the medical management (13.6% vs. 24.5%, p < .001). After adjusting for baseline characteristics, hospitalizations that included pPCI had 42.1% lower odds of in-hospital mortality (adjusted OR: 0.58, 95% CI: 0.50 to 0.67, p < .001). Altogether, in-hospital cardiac, bleeding and vascular complications, length of stay and in-hospital costs were higher in pPCI hospitalizations. CONCLUSION In nonagenarians, STEMI mortality is high, but pPCI is associated with superior outcomes compared to medical management alone. Therefore, pPCI can be considered an acceptable treatment strategy in this population.
Collapse
Affiliation(s)
- Venkata S Pajjuru
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Abhishek Thandra
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Raviteja R Guddeti
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | | | - Ryan W Walters
- Department of Medicine, Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, Nebraska
| | - Aravdeep Jhand
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Ahmed Aboeata
- Department of Medicine, Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska
| | - Venkata G Andukuri
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Andrew M Goldsweig
- Department of Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| |
Collapse
|
11
|
Temporal trends and predictors of time to coronary angiography following non-ST-elevation acute coronary syndrome in the USA. Coron Artery Dis 2020; 30:159-170. [PMID: 30676387 DOI: 10.1097/mca.0000000000000693] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE This study aims to investigate the temporal trends in utilization of invasive coronary angiography (CA) at different time points and changing profiles of patients undergoing CA following non-ST-elevation acute coronary syndrome (NSTEACS). We also describe the association between time to CA and in-hospital clinical outcomes. PATIENTS AND METHODS We queried the National Inpatient Sample to identify all admissions with a primary diagnosis of NSTEACS from 2004 to 2014. Patients were stratified into early (day 0, 1), intermediate (day 2) and late strategy (day≥3) according to time to CA. Multivariable logistic regression was used to investigate the association between time to CA and in-hospital mortality, major bleeding, stroke and Major Adverse Cardiac and Cerebrovascular Events. RESULTS A total of 4 380 827 records were identified with a diagnosis of NSTEACS, out of which 57.5% received CA. The proportion of patients undergoing early CA increased from 65.6 to 72.6%, whereas late CA commensurately declined from 19.6 to 13.5%. Patients receiving early CA were younger (age: 64 vs. 70 years), more likely to be male (63.7 vs. 55.3%) and of Caucasian ethnic background (68.7 vs. 64.7%) compared with late CA group. Similarly, Women, weekend admissions and African Americans remain less likely to receive early CA. In-hospital mortality was lowest in the intermediate group (odds ratio=0.30, 95% confidence interval: 0.28-0.33). CONCLUSION Use of early CA has increased in the management of NSTEACS; however, there remain significant disparities in utilization of an early invasive approach in women, African Americans, admission day and older patients in the USA.
Collapse
|
12
|
Numasawa Y, Inohara T, Ishii H, Yamaji K, Kohsaka S, Sawano M, Kodaira M, Uemura S, Kadota K, Amano T, Nakamura M. Comparison of Outcomes After Percutaneous Coronary Intervention in Elderly Patients, Including 10 628 Nonagenarians: Insights From a Japanese Nationwide Registry (J-PCI Registry). J Am Heart Assoc 2020; 8:e011183. [PMID: 30791799 PMCID: PMC6474917 DOI: 10.1161/jaha.118.011017] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Scarce data exist about the outcomes after percutaneous coronary intervention ( PCI ) in old patients. This study sought to provide an overview of PCI in elderly patients, especially nonagenarians, in a Japanese large prospective nationwide registry. Methods and Results We analyzed 562 640 patients undergoing PCI (≥60 years of age) from 1018 Japanese hospitals between 2014 and 2016 in the J-PCI (Japanese percutaneous coronary intervention) registry. Among them, 10 628 patients (1.9%), including 6780 (1.2%) with acute coronary syndrome ( ACS ) and 3848 (0.7%) with stable coronary artery disease, were ≥90 years of age. We investigated differences in characteristics and in-hospital outcomes among sexagenarians, septuagenarians, octogenarians, and nonagenarians. Older patients were more frequently women and had a greater frequency of heart failure and chronic kidney disease than younger patients. In addition, older patients had a higher rate of in-hospital mortality, cardiac tamponade, cardiogenic shock after PCI , and bleeding complications requiring blood transfusion. Nonagenarians had the highest risk of in-hospital mortality (odds ratio, 3.60; 95% CI , 3.10-4.18 in ACS ; odds ratio , 6.24; 95% CI, 3.82-10.20 in non- ACS ) and bleeding complications ( odds ratio, 1.79; 95% CI, 1.35-2.36 in ACS ; odds ratio , 2.70; 95% CI, 1.68-4.35 in non- ACS ) when referenced to sexagenarians. More important, transradial intervention was an inverse independent predictor of both in-hospital mortality and bleeding complications. Conclusions Older patients, especially nonagenarians, carried a greater risk of in-hospital death and bleeding compared with younger patients after PCI . Transradial intervention might contribute to risk reduction for periprocedural complications in elderly patients undergoing PCI .
Collapse
Affiliation(s)
- Yohei Numasawa
- 1 Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - Taku Inohara
- 2 Duke Clinical Research Institute Duke University Medical Center Durham NC.,3 Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Hideki Ishii
- 4 Department of Cardiology Nagoya University Graduate School of Medicine Nagoya Japan
| | - Kyohei Yamaji
- 5 Department of Cardiology Kokura Memorial Hospital Kitakyushu Japan
| | - Shun Kohsaka
- 3 Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Mitsuaki Sawano
- 3 Department of Cardiology Keio University School of Medicine Tokyo Japan
| | - Masaki Kodaira
- 1 Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - Shiro Uemura
- 6 Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Kazushige Kadota
- 7 Department of Cardiology Kurashiki Central Hospital Kurashiki Japan
| | - Tetsuya Amano
- 8 Department of Cardiology Aichi Medical University Nagakute Japan
| | - Masato Nakamura
- 9 Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | | |
Collapse
|
13
|
Sanoussi H, Bitton N, Kourireche N, Bernasconi F, Tounsi A, Bellemain-Appaix A, Jacq L. [Interests and limitations of percutaneous coronary intervention strategy in nonagenarian patients: A single center experience]. Ann Cardiol Angeiol (Paris) 2020; 69:1-6. [PMID: 32145882 DOI: 10.1016/j.ancard.2020.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 01/05/2020] [Indexed: 10/24/2022]
Abstract
AIM To expose our center results in the angioplasty in nonagenarians and to evaluate its effectiveness but also the MACEs and the mortality in the short and long term. METHODS A retrospective study of 98 patients admitted to the Antibes hospital center from November 2013 to September 2018. RESULTS The median age was 91.8 [90.8-93.4]. 52.6% was male. 9.7% of the patients had a polyvascular site. 50.6% of patients had moderate renal failure. The radial approach was used in 88.4% of cases. 21.6% of patients had tri-truncal lesions, while 46.4% were monotruncular, LAD artery was the culprit artery in 67% of cases. One stent per lesion was used in the majority of cases. Our successful rate was 90%. After angioplasty, 96% of the patients underwent double antiaggregation platelet therapy, 74.4% under clopidogrel. The presence of arrhythmias before angioplasty, the femoral approach, the coronary dissection and cardiogenic shock after angioplasty were predictors of short- and long-term mortality. Diabetes, history of myocardial infarction, impaired left ventricular ejection fraction, calcified coronary lesions, occurrence of arrhythmias or signs of heart failure on post-procedure were predictors of MACE occurrence. CONCLUSIONS This study demonstrates that angioplasty in selected population of nonagenarians is perfectly feasible with a good risk/benefit ratio and specifies the different predictors of MACE, both short- and long-term mortality.
Collapse
Affiliation(s)
- H Sanoussi
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France.
| | - N Bitton
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| | - N Kourireche
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| | - F Bernasconi
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| | - A Tounsi
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| | - A Bellemain-Appaix
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| | - L Jacq
- Service de cardiologie, centre hospitalier Antibes Juan-Les-Pins, groupe hospitalier Sophia-Antipolis-Vallée-du-Var, 107, avenue de Nice, 06606 Antibes cedex, France
| |
Collapse
|
14
|
Chandrasekhar J, Baber U, Sartori S, Aquino M, Moalem K, Kini AS, Rao SV, Weintraub W, Henry TD, Vogel B, Ge Z, Muhlestein JB, Weiss S, Strauss C, Toma C, DeFranco A, Claessen BE, Keller S, Baker BA, Effron MB, Pocock S, Dangas G, Kapadia S, Mehran R. Prasugrel use and clinical outcomes by age among patients undergoing PCI for acute coronary syndrome: from the PROMETHEUS study. Clin Res Cardiol 2020; 109:725-734. [DOI: 10.1007/s00392-019-01561-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
|
15
|
Goel K, Gupta T, Gulati R, Bell MR, Kolte D, Khera S, Bhatt DL, Rihal CS, Holmes DR. Temporal Trends and Outcomes of Percutaneous Coronary Interventions in Nonagenarians: A National Perspective. JACC Cardiovasc Interv 2019; 11:1872-1882. [PMID: 30236360 DOI: 10.1016/j.jcin.2018.06.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 05/15/2018] [Accepted: 06/13/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study sought to assess temporal trends and outcomes of percutaneous coronary intervention (PCI) in nonagenarians. BACKGROUND With increasing life expectancy, nonagenarians requiring PCI are increasing even though outcomes data are limited. METHODS The National Inpatient Sample was used to identify all hospitalizations for PCI in patients aged ≥90 years from January 1, 2003, to December 31, 2014. The primary outcome was in-hospital mortality. RESULTS Nonagenarians (n = 69,271) constituted 0.9% of all PCI hospitalizations, increasing from 0.6% in 2003 to 2004 to 1.4% in 2013 to 2014 (ptrend < 0.001). From 2003-2004 to 2013-2014, the proportion of PCIs performed for ST-segment elevation myocardial infarction (STEMI) (23.1% to 30.9%) and non-ST-segment elevation acute coronary syndromes (49.6% to 52.6%) increased, whereas those for stable ischemic heart disease (SIHD) decreased (27.3% to 16.5%), respectively (ptrend < 0.001 for all). Overall in-hospital mortality after PCI for STEMI, non-ST-segment elevation acute coronary syndromes, and SIHD were 16.4%, 4.2%, and 1.8%, respectively. After multivariable risk adjustment for demographics, comorbidities, and hospital-level characteristics, in-hospital mortality remained unchanged in STEMI (odds ratio: 1.04; 95% confidence interval: 0.98 to 1.11; ptrend = 0.20) and non-ST-segment elevation acute coronary syndromes (odds ratio: 0.99; 95% confidence interval: 0.91 to 1.08; ptrend = 0.82), but increased in SIHD (odds ratio: 1.21; 95% confidence interval: 1.01 to 1.44; ptrend = 0.04) from 2003 to 2004 to 2013 to 2014. The rates of bleeding and vascular complications decreased or remained stable in all 3 subgroups, whereas risk-adjusted incidence of stroke increased in patients with STEMI or SIHD. CONCLUSIONS The rate of in-hospital mortality, major bleeding, vascular complications, and stroke after PCI in nonagenarians changed significantly from 2003 to 2014. This study provides a benchmark for discussion of PCI-related risks among physicians, patients, and families.
Collapse
Affiliation(s)
| | | | | | | | | | - Sahil Khera
- Massachusetts General Hospital, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | | | | |
Collapse
|
16
|
Schulman-Marcus J, Peterson K, Banerjee R, Samy S, Yager N. Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:5. [PMID: 30739215 DOI: 10.1007/s11936-019-0706-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). These patients are older, have complex coronary disease, and a substantial comorbidity burden including frailty. The procedural risks and outcomes of CABG and PCI in these patients are more difficult to assess based on the available literature, which has generally studied a younger population with a lower comorbidity burden. RECENT FINDINGS There have been initiatives to recalibrate and expand risk models derived from procedural registries to inform the care of complex higher-risk patients, including patients "turned down" for CABG. There is greater recognition of the need for improved assessment of risk, quality, and benefits of coronary revascularization in higher-risk SIHD patients with a substantial comorbidity burden. Clinicians and patients should be aware that there are significant evidence gaps regarding revascularization in complex high-risk patients. The limitations of procedural-derived risk scores should be understood when presenting treatment options. Future randomized controlled trials and expanded registries are greatly desired and should be achievable. Meanwhile, a multidisciplinary heart team approach should be employed for proper decision-making.
Collapse
Affiliation(s)
- Joshua Schulman-Marcus
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA.
| | | | - Riju Banerjee
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| | - Sanjay Samy
- Division of Cardiothoracic Surgery, Albany Medical Center, Albany, USA
| | - Neil Yager
- Division of Cardiology, Albany Medical Center, 47 New Scotland Ave, Albany, NY, 12208, USA
| |
Collapse
|
17
|
Kheiri B, Osman M, Abdalla A, Haykal T, Chahine A, Gwinn M, Ahmed S, Hassan M, Bachuwa G, Bhatt DL. Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:744-751. [PMID: 30446398 DOI: 10.1016/j.carrev.2018.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 10/22/2018] [Accepted: 11/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS). METHODS Electronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted. RESULTS We included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62-0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89-1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05-2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60-0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84-1.22; P = 0.89, respectively). CONCLUSIONS In older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients. SUMMARY This meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.
Collapse
Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV 26506, USA
| | - Ahmed Abdalla
- Division of Hematology & Oncology, St. John Hospital, Grosse Pointe Woods, MI 48236, USA
| | - Tarek Haykal
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Meghan Gwinn
- Michigan State University, College of Human Medicine, Flint, MI 48502, USA
| | | | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA 02115, USA.
| |
Collapse
|
18
|
Potts J, Sirker A, Martinez SC, Gulati M, Alasnag M, Rashid M, Kwok CS, Ensor J, Burke DL, Riley RD, Holmvang L, Mamas MA. Persistent sex disparities in clinical outcomes with percutaneous coronary intervention: Insights from 6.6 million PCI procedures in the United States. PLoS One 2018; 13:e0203325. [PMID: 30180201 PMCID: PMC6122817 DOI: 10.1371/journal.pone.0203325] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 08/17/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Prior studies have reported inconsistencies in the baseline risk profile, comorbidity burden and their association with clinical outcomes in women compared to men. More importantly, there is limited data around the sex differences and how these have changed over time in contemporary percutaneous coronary intervention (PCI) practice. METHODS AND RESULTS We used the Nationwide Inpatient Sample to identify all PCI procedures based on ICD-9 procedure codes in the United States between 2004-2014 in adult patients. Descriptive statistics were used to describe sex-based differences in baseline characteristics and comorbidity burden of patients. Multivariable logistic regressions were used to investigate the association between these differences and in-hospital mortality, complications, length of stay and total hospital charges. Among 6,601,526 patients, 66% were men and 33% were women. Women were more likely to be admitted with diagnosis of NSTEMI (non-ST elevation acute myocardial infarction), were on average 5 years older (median age 68 compared to 63) and had higher burden of comorbidity defined by Charlson score ≥3. Women also had higher in-hospital crude mortality (2.0% vs 1.4%) and any complications compared to men (11.1% vs 7.0%). These trends persisted in our adjusted analyses where women had a significant increase in the odds of in-hospital mortality men (OR 1.20 (95% CI 1.16,1.23) and major bleeding (OR 1.81 (95% CI 1.77,1.86). CONCLUSION In this national unselected contemporary PCI cohort, there are significant sex-based differences in presentation, baseline characteristics and comorbidity burden. These differences do not fully account for the higher in-hospital mortality and procedural complications observed in women.
Collapse
Affiliation(s)
- Jessica Potts
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Alex Sirker
- University College London Hospitals and St Bartholomew's Hospital, London, United Kingdom
| | - Sara C. Martinez
- Division of Cardiology, Providence St. Peter Hospital, Olympia, Washington, United States of America
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix, AZ, United States of America
| | | | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
- Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
- Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
| | - Joie Ensor
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Danielle L. Burke
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Richard D. Riley
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom
- Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
- * E-mail:
| |
Collapse
|
19
|
Clinical outcomes in nonagenarians undergoing a percutaneous coronary intervention: data from the ORPKI Polish National Registry 2014-2016. Coron Artery Dis 2018; 29:573-578. [PMID: 29912784 DOI: 10.1097/mca.0000000000000649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Despite an increase in the proportion of nonagenarians in demographic structure, there is still a paucity of data on the utilization and outcome of percutaneous coronary interventions (PCIs) in this population. Also, very old patients are under-represented in randomized clinical trials and their treatment is still an emerging challenge. Thus, we sought to compare patient profiles and periprocedural outcomes of PCI in nonagenarians and patients younger than 90 years. PATIENTS AND METHODS Data were based on the Polish National Registry of PCI (ORPKI). A total of 651 080 consecutive patients with stable angina (SA) (n=260 920) or acute coronary syndrome (ACS) (n=390 160) undergoing PCI with at least one stent implanted were included. Patients were stratified according to age (<90 and ≥90 years). RESULTS Of all included patients, 4413 (0.7%) were older than or equal to 90 years. A similar rate of periprocedural complications was observed in both groups. However, cardiac arrest during both angiography and PCI occurred more often in nonagenarians (0.21 vs. 0.83%; 0.42 vs. 1.07%, respectively, for both P=0.001). Similarly, periprocedural mortality was higher in patients older than or equal to 90 years (0.27 vs. 1.88%; P=0.001). There were no differences in periprocedural outcomes between groups in the SA setting. However, a higher rate of periprocedural cardiac arrest [1971 (0.51%) vs. 43 (1.15%); P=0.001] and mortality [1622 (0.42%) vs. 83 (2.2%); P=0.001] were observed in nonagenarians compared with younger counterparts admitted with ACS. CONCLUSION Nonagenarians undergoing PCI because of SA may have similar outcomes as patients younger than 90 years. In ACS presentation, they may have worse outcomes than younger counterparts.
Collapse
|
20
|
Four Score and 10 Years. JACC Cardiovasc Interv 2017; 10:1304-1306. [PMID: 28683936 DOI: 10.1016/j.jcin.2017.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/28/2017] [Indexed: 11/24/2022]
|