How should age affect management of acute myocardial infarction? A prospective cohort study

Predicting the Prognosis of Patients in the Coronary Care Unit: A Novel Multi-Category Machine Learning Model Using XGBoost

Background

Early prediction and classification of prognosis is essential for patients in the coronary care unit (CCU). We applied a machine learning (ML) model using the eXtreme Gradient Boosting (XGBoost) algorithm to prognosticate CCU patients and compared XGBoost with traditional classification models.

Methods

CCU patients' data were extracted from the MIMIC-III v1.4 clinical database, and divided into four groups based on the time to death: <30 days, 30 days−1 year, 1–5 years, and ≥5 years. Four classification models, including XGBoost, naïve Bayes (NB), logistic regression (LR), and support vector machine (SVM) were constructed using the Python software. These four models were tested and compared for accuracy, F1 score, Matthews correlation coefficient (MCC), and area under the curve (AUC) of the receiver operating characteristic curves. Subsequently, Local Interpretable Model-Agnostic Explanations method was performed to improve XGBoost model interpretability. We also constructed sub-models of each model based on the different categories of death time and compared the differences by decision curve analysis. The optimal model was further analyzed using a clinical impact curve. At last, feature ablation curves of the XGBoost model were conducted to obtain the simplified model.

Results

Overall, 5360 CCU patients were included. Compared to NB, LR, and SVM, the XGBoost model showed better accuracy (0.663, 0.605, 0.632, and 0.622), micro-AUCs (0.873, 0.811, 0.841, and 0.818), and MCC (0.337, 0.317, 0.250, and 0.182). In subgroup analysis, the XGBoost model had a better predictive performance in acute myocardial infarction subgroup. The decision curve and clinical impact curve analyses verified the clinical utility of the XGBoost model for different categories of patients. Finally, we obtained a simplified model with thirty features.

Conclusions

For CCU physicians, the ML technique by XGBoost is a potential predictive tool in patients with different conditions, and it may contribute to improvements in prognosis.

Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior

BACKGROUND

This study set out to describe age differences in patient's chief complaint related to a first myocardial infarction and how the "typicality" of patient's acute symptoms relates to extent of prehospital delay.

METHODS

The medical records of 2586 residents of central Massachusetts hospitalized at 11 greater Worcester medical centers with a first myocardial infarction on a biennial basis between 2001 and 2011 were reviewed.

RESULTS

The average age of the study population was 66.4 years, 39.6% were women, 40.2% were diagnosed with a ST-elevation myocardial infarction (STEMI), and 72.0 % presented with typical symptoms of myocardial infarction, namely acute chest pain or pressure. Patients were categorized into 5 age strata: >55 years (23%), 55-64 years (20%), 65-74 years (19%), 75-84 years (22%), and ≥85 years (16%). The lowest proportion (11%) of atypical symptoms of myocardial infarction was observed in patients <55 years, increasing to 17%, 28%, 40%, and 51% across the respective age groups. The most prevalent chief complaint reported at the time of hospitalization was chest pain, but the proportion of patients reporting this symptom decreased from the youngest (83%) to the oldest patient groups (45%). There was a slightly increased risk of prehospital delay across the different age groups (higher in the oldest old) in those who presented with atypical, rather than typical, symptoms of myocardial infarction.

CONCLUSIONS

The present results provide insights to the presenting chief complaint of patients hospitalized with a first myocardial infarction according to age and the relation of symptom presentation to patient's care-seeking behavior.

Evaluation of risk factors for adverse outcome in extracorporeal membrane oxygenation-supported elderly postcardiotomy patients

BACKGROUND

Recently extracorporeal membrane oxygenation is becoming the commonly used mechanical assist device for the treatment of severe cardiogenic shock in postcardiotomy patients. Evaluation of risk factors of negative outcome would be beneficial in decision-making in the elderly patient population.

METHODS

This was a retrospective single-centre analysis of elderly patients who underwent extracorporeal membrane oxygenation treatment for refractory cardiogenic shock in a tertiary care centre. Demographic data, comorbidities and perioperative parameters were collected to evaluate their impact on the outcome of extracorporeal membrane oxygenation treatment in this patient group. Logistic regression analysis of the variables was performed to identify factors predicting an adverse outcome.

RESULTS

Forty consecutive elderly patients underwent extracorporeal membrane oxygenation treatment during the study period. The mean age was 76.7 ± 3.8 years, 27 (68%) were male. The mean Survival after Veno-Arterial extracorporeal membrane oxygenation score before initiating extracorporeal membrane oxygenation support was - 11 ± 6. Intra-aortic counterpulsation was used as the first-line mechanical support in 31 (77%) patients. The mean duration of extracorporeal membrane oxygenation support was 172 ± 128 hours. Twenty-four patients (56%) were successfully weaned from extracorporeal membrane oxygenation, and 8 (20%) survived to hospital discharge. Lactate level before extracorporeal membrane oxygenation initiation was the only predictor of unfavourable outcome in multivariate analysis (p < 0.05).

CONCLUSION

High lactate level before initiation of extracorporeal membrane oxygenation was the most important prognostic values of an unfavourable outcome.

Quality of life of patients with first-time AMI: a descriptive study

Background

Outcomes following acute myocardial infarction (AMI) may result in death, increased morbidity, and change in quality of life (QOL). This study explores health-related QOL of first-time patients following AMI.

Methods

This cross-sectional study used a sample of patients with first-time AMI experienced between April 2011 and March 2015 at a tertiary health institution. Recruited patients belonged to different post-AMI periods: 2–10 weeks, 5–22 months, and > 22 months to 4 years post AMI. Inclusion criteria were not confused and communicating freely. Exclusion criteria were non-contactable, refusing to participate, and deceased. One-on-one interviews were conducted using the validated and pre-tested Quality of Life after Myocardial Infarction (QLMI) questionnaire. QOL of patients after AMI was evaluated at each period. Descriptive, Mann–Whitney U, Kruskal–Wallis, and regression analyses were conducted using SPSS version 24.

Results

A total of 534 participant interviews (overall response rate 65.4%) were conducted. Interviewees were predominantly male (67%), aged 51–65 years (45%), Indo-Trinidadian (81.2%), NSTEMI (64.4%), and hypertensive (72.4%). Overall QOL improved over time and in all domains: Emotional, Physical, and Social. Lower QOL was found among women, patients with NSTEMI, and diabetics in all domains; in patients with hypertension and renal disease in the Physical and Social domains only; and in patients with ischaemic heart disease (IHD) in the Physical domain only. Self-reported stress and lack of exercise were associated with lower QOL while drinking alcohol and eating out were related to better QOL. Hypercholesterolemia, smoking, and ethnicity showed no association with QOL. Declining QOL in the Physical domain with age was also found. The leading components of QOL were self-confidence and social exclusion (early post AMI), lack of self-confidence (intermediate post AMI), and tearfulness (late post AMI).

Conclusions

QOL in AMI survivors improves over time. Female gender, NSTEMI, diabetes, hypertension, renal disease, stress, and lack of exercise were associated with lower QOL while hypercholesterolemia, smoking, and ethnicity showed no association with QOL. Cardiac rehabilitation and psychological support may enhance earlier increased QOL among survivors, particularly among vulnerable groups.

The Prognostic Values of the Admission Electrocardiography, Myocardial Injury Markers and Physical Examination in Patients with Acute Myocardial Infarction

Introduction

Acute coronary syndromes (ACS) are leading life threatening causes of chest pain, which is one of the most common complaints in the emergency department (ED). The aim of the study was to demonstrate the usefulness of physical examination, ECG and cardiac markers to predict short term outcome of ACS patients.

Methods

A total of 1728 patients with chest pain were evaluated between 1st January 2003 and 31st December 2003 in the ED and 236 of the patients matched our study criteria.

Results

In the study group 184 patients were (78%) male and the mean age was 59.8±12.2 (range=4-92) years old. Age, Killip score, cardiac marker values, the time interval between the beginning of the chest pain and ED entry and the ECG changes were the studied variables. With the logistic regression analysis, Killip score and any rhythm other than normal sinus rhythm on the first ECG were found to be the only independent variables to predict early mortality (p=0.036 and p=0.033).

Conclusion

Simple measures in the ED such as ECG and serum markers of myocardial injury along with the thorough physical evaluation of the physician may predict early negative outcome.

Prognostic Impact of Age and Hemoglobin in Acute ST-Segment Elevation Myocardial Infarction Treated With Reperfusion Therapy

Advanced age and low hemoglobin levels have been associated with a poor prognosis in ST-segment elevation myocardial infarction (STEMI). We studied 1,111 patients with STEMI who received reperfusion treatment (1,032 [92.9%] primary angioplasty and 79 [7.1%] fibrinolysis without rescue percutaneous coronary intervention). Mean age was 64.1 ± 14.0 years, and 23.2% were women. Patients in the last age quartile (>76 years) were more frequently women, presented more risk factors (except smoking), received thrombolysis less frequently, had less complete revascularization, and presented more complications and higher mortality. Hemoglobin level at admission was associated with age and ranged from 14.8 ± 1.5 g/dl in the first quartile to 13.2 ± 1.8 g/dl in the last, p <0.001. Multivariate analysis identified age as a predictor of in-hospital and long-term mortality (odds ratio 1.04, 95% confidence interval [CI] 1.00 to 1.07, hazard ratio 1.06, 95% CI 1.04 to 1.08). Hemoglobin levels were associated with better survival (odds ratio 0.8, 95% CI 0.6 to 0.9, hazard ratio 0.85, 95% CI 0.78 to 0.92). The other predictors of inhospital mortality were Killip class, chronic kidney disease, left ventricular ejection fraction, significant pericardial effusion, and ventricular arrhythmias. The association of hemoglobin with hospital mortality was seen in men and in women ≥65 years. In men ≥65 years, this association was also present in those with hemoglobin levels in the normal range. In conclusion, in patients with STEMI, hemoglobin is an independent predictor of inhospital and long-term mortality, especially in those aged ≥65 years. This association is also present in men ≥65 years with normal hemoglobin levels.

Decade Long Trends (2001-2011) in Duration of Pre-Hospital Delay Among Elderly Patients Hospitalized for an Acute Myocardial Infarction

BACKGROUND

Early intervention with medical and/or coronary revascularization treatment approaches remains the cornerstone of the management of patients hospitalized with acute myocardial infarction (AMI). However, several patient groups, especially the elderly, are known to delay seeking prompt medical care after onset of AMI-associated symptoms. Current trends, and factors associated with prolonged prehospital delay among elderly patients hospitalized with AMI, are incompletely understood.

METHODS AND RESULTS

Data from a population-based study of patients hospitalized at all 11 medical centers in central Massachusetts with a confirmed AMI on a biennial basis between 2001 and 2011 were analyzed. Information about duration of prehospital delay after onset of acute coronary symptoms was abstracted from hospital medical records. In patients 65 years and older, the overall median duration of prehospital delay was 2.0 hours, with corresponding median delays of 2.0, 2.1, and 2.0 hours in those aged 65 to 74 years, 75 to 84 years, and in patients 85 years and older, respectively. There were no significant changes over time in median delay times in each of the age strata examined in both crude and multivariable adjusted analyses. A limited number of patient characteristics were associated with prolonged delay in this patient population.

CONCLUSIONS

The results of this community-wide study demonstrate that delay in seeking prompt medical care continues to be a significant problem among elderly patients hospitalized with AMI. The lack of improvement in the timeliness of patients' care-seeking behavior during the years under study remains of considerable clinical and public health concern.

Administration of low molecular weight and unfractionated heparin during percutaneous coronary intervention

This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p<0.001), which was associated with similar target vessel revascularization (p=0.6), similar incidence of stroke (p=0.7), and significantly lower incidence of re-myocardial infarction (p<0.001), major bleeding (p=0.02) and mortality (p<0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

Cost-effectiveness of renal denervation therapy for the treatment of resistant hypertension in The Netherlands

OBJECTIVES

Safety and efficacy data for catheter-based renal denervation (RDN) in the treatment of resistant hypertension have been used to estimate the cost-effectiveness of this approach. However, there are no Dutch-specific analyses. This study examined the cost-effectiveness of RDN from the perspective of the healthcare payer in The Netherlands.

METHODS

A previously constructed Markov state-transition model was adapted and updated with costs and utilities relevant to the Dutch setting. The cost-effectiveness of RDN was compared with standard of care (SoC) for patients with resistant hypertension. The efficacy of RDN treatment was modeled as a reduction in the risk of cardiovascular events associated with a lower systolic blood pressure (SBP).

RESULTS

Treatment with RDN compared to SoC gave an incremental quality-adjusted life year (QALY) gain of 0.89 at an additional cost of €1315 over a patient's lifetime, resulting in a base case incremental cost-effectiveness ratio (ICER) of €1474. Deterministic and probabilistic sensitivity analyses (PSA) showed that treatment with RDN therapy was cost-effective at conventional willingness-to-pay thresholds (€10,000-80,000/QALY).

CONCLUSION

RDN is a cost-effective intervention for patients with resistant hypertension in The Netherlands.

Cost effectiveness of renal denervation therapy for the treatment of resistant hypertension in the UK

BACKGROUND

Patients with resistant hypertension are at a high risk for developing serious cardiovascular events and renal complications. Catheter-based renal denervation (RDN) is a procedure with the potential to normalize systolic blood pressure (SBP).

OBJECTIVE

The overall objective of the study was to estimate the cost effectiveness of RDN in the UK for patients with diagnosed resistant hypertension, expressed as a standard cost per quality-adjusted life-year (QALY) ratio.

METHODS

A patient lifetime, economic, Markov heath-state model was developed, linking expected changes in SBP to reductions in risks for cardiovascular events and renal complications, using the Framingham, PROCAM, and other published risk equations. The model was developed from the perspective of the healthcare payer in the UK using relevant cost data from 2012. Clinical effectiveness for RDN (a mean reduction of 32 mmHg in SBP) was taken from the phase III Symplicity HTN-2 trial, in patients with a mean baseline SBP of 178 mmHg. HTN-2 was the largest, multicenter randomized controlled trial on the effectiveness of RDN therapy at the time of the model development. A systematic review identified UK-specific sources for utility, mortality, and cost parameter values, and included recently published UK guidelines for the clinical management of hypertension.

RESULTS

RDN therapy resulted in an increase in health benefit over a patient's lifetime compared with anti-hypertensive pharmacological treatment alone (12.77 vs. 12.16 QALYs; discounted). Additional lifetime costs per patient were modeled at £2,961; equivalent to an incremental cost per additional QALY of £4,805. This result was robust to full probabilistic sensitivity and scenario analyses.

CONCLUSION

RDN is an effective clinical procedure that offers patients a meaningful and cost-effective alternative for achieving SBP control, where traditional combination, anti-hypertensive pharmacologic strategies have been proven to be ineffective.

Interventional treatment and outcome in elderly patients with stable coronary artery disease. Results from the German ALKK registry

BACKGROUND

The number of elderly and very elderly patients undergoing percutaneous coronary interventions (PCI) is increasing. We therefore analyzed data from the German ALKK registry (Arbeitsgemeinschaft Leitende Krankenhausärzte; Working Group of Hospital Cardiologists) to determine differences in procedural features, antithrombotic treatment, and in-hospital outcome in patients with coronary artery disease (CAD) according to age in a large series of patients.

METHODS AND RESULTS

The present analysis was based on the data of 35,534 consecutive patients undergoing elective PCI who were enrolled in the ALKK registry. Of these 27,145 (76.4 %) were younger than 75 years, 7,645 (21.5 %) were aged between 75 and 84 years, and 744 (2.1 %) patients were older than 85 years. Mean age was 68.5 years (60.9-74.5 years), and 25,784 patients (72.6 %) were male. Overall intraprocedural events were very low (1.1 %) and there was no significant difference between the three age groups [< 75 years (1.1 %); 75-< 85 years (1.2 %); ≥ 85 years (0.5 %) (p = not significant)]. Rates of in-hospital death, stroke and transient ischemic attack (TIA), as well as the combined endpoint in-hospital major adverse cardiac and cerebrovascular events (MACCE) were also very low (0.6 % vs. 0.9 % vs. 0.9 %; p < 0.001) but significantly higher in elderly patients with no further increase in the very elderly patient group.

CONCLUSION

We found no differences in this registry in intraprocedural complications during elective PCI between younger and elderly patients. Although in-hospital MACCE were somewhat higher in the elderly, the overall event rate was low and thus elderly patients should not be deprived from this therapy because of age alone.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

Adiposity has differing associations with incident coronary heart disease and mortality in the Scottish population: cross-sectional surveys with follow-up

OBJECTIVE

Investigation of the association of excess adiposity with three different outcomes: all-cause mortality, coronary heart disease (CHD) mortality and incident CHD.

DESIGN

Cross-sectional surveys linked to hospital admissions and death records.

SUBJECTS

19 329 adults (aged 18-86 years) from a representative sample of the Scottish population.

MEASUREMENTS

Gender-stratified Cox proportional hazards models were used to estimate hazard ratios (HRs) for all-cause mortality, CHD mortality and incident CHD. Separate models incorporating the anthropometric measurements body mass index (BMI), waist circumference (WC) or waist-hip ratio (WHR) were created adjusted for age, year of survey, smoking status and alcohol consumption.

RESULTS

For both genders, BMI-defined obesity (30 kg m(-2)) was not associated with either an increased risk of all-cause mortality or CHD mortality. However, there was an increased risk of incident CHD among the obese men (hazard ratio (HR)=1.78; 95% confidence interval=1.37-2.31) and obese women (HR=1.93; 95% confidence interval=1.44-2.59). There was a similar pattern for WC with regard to the three outcomes; for incident CHD, the HR=1.70 (1.35-2.14) for men and 1.71 (1.28-2.29) for women in the highest WC category (men 102 cm, women 88 cm), synonymous with abdominal obesity. For men, the highest category of WHR (1.0) was associated with an increased risk of all-cause mortality (1.29; 1.04-1.60) and incident CHD (1.55; 1.19-2.01). Among women with a high WHR (0.85) there was an increased risk of all outcomes: all-cause mortality (1.56; 1.26-1.94), CHD mortality (2.49; 1.36-4.56) and incident CHD (1.76; 1.31-2.38).

CONCLUSIONS

In this study excess adiposity was associated with an increased risk of incident CHD but not necessarily death. One possibility is that modern medical intervention has contributed to improved survival of first CHD events. The future health burden of increased obesity levels may manifest as an increase in the prevalence of individuals living with CHD and its consequences.

Development and validation of a clinical risk score predicting the no-reflow phenomenon in patients treated with primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVE

The 'no-reflow' phenomenon after a primary percutaneous coronary intervention (pPCI) in patients with acute ST-segment elevation myocardial infarction (STEMI) is a strong predictor of both short- and long-term mortality. We therefore developed and prospectively validated a risk score system in order to identify STEMI patients at high risk in terms of no-reflow after primary PCI.

METHODS

The first part of our study used data from 1,615 STEMI patients who underwent primary PCI within 12 h from symptom onset. Using logistic regression, we derived a risk score to predict angiographic no-reflow using baseline clinical variables. From this score, we developed a simplified fast-track screen that can be used before reperfusion. In the second part of our study, we prospectively validated the score system using receiver-operating characteristic (ROC) curves with data from 692 STEMI patients.

RESULTS

The model included six clinical items: age, neutrophil count, admission plasma glucose, β-blocker treatment, time-to-hospital admission and Killip classes. The risk score system demonstrated a good risk prediction with a c-statistic of 0.757 (95% CI 0.732-0.781) based on ROC analysis.

CONCLUSION

A simple risk score system based on clinical variables is useful to predict the risk of developing no-reflow after pPCI in patients with STEMI.

A Study of Prognosis, Outcome, and Changing Tendency of Hospitalized AMI Patients in Beijing Third-Grade A-Level Traditional Chinese Medicine Hospitals from 1999 to 2008

Objectives. To survey and analyse the prognosis, outcome, and changing tendency of the Acute Myocardial Infarction (AMI) patients in Beijing third-grade A-level Traditional Chinese Medicine (TCM) hospitals. Methods. We collected the clinical datum of hospitalized AMI patients in Beijing 6 TCM hospitals from January 1999 to December 2008 and then analysed the clinical datum. Results. (1) The mean age of patients had showed a slowly rising tendency during this ten years. The patients who had previous history of cerebrovascular diseasea and multiple comorbidities had increased year by year. (2) The rate of reperfusion therapy, revascularization and standardized using of drug, and usage of TCM of AMI patients presented a significant increasing tendency in these hospitals. (3) The proportion of AMI patients combined with cardiac arrhythmia and heart failure had decreased significantly. (4) The AMI mortality presented a decreasing tendency in 10 years. Conclusions. The AMI patients in Beijing TCM hospitals had their own unique clinical features, and it can improve their prognosis by combined therapy of Western Medicine and Traditional Chinese Medicine.

Comparison of bleeding complications and one-year survival of low molecular weight heparin versus unfractioned heparin for acute myocardial infarction in elderly patients. The FAST-MI registry

BACKGROUND

There are limited data on the safety and efficacy of low molecular weight heparin (LMWH) in elderly patients with acute myocardial infarction (AMI).

METHODS

We aimed to compare LMWH with unfractioned heparin (UFH) in the management of AMI in elderly patients. FAST-MI is a nationwide registry carried out over a 1-month period in 2005, including consecutive patients with AMI admitted to intensive care unit <48 h from symptom onset in 223 participating centers. We assessed the impact of LMWH on bleeding, the need for blood transfusion and one-year survival in elderly patients (≥ 75 years).

RESULTS

963 patients treated with heparin were included (mean age 82 ± 5 years; 51% women; 42.5% ST-elevation myocardial infarction). Major bleeding (2.4% vs. 6.1%, P=0.004) and blood transfusions (4.6% vs. 9.7%, P=0.002) were significantly less frequent with LMWH compared with the UFH, a difference that persisted after multivariate adjustment (OR=0.41, 95% CI: 0.20-0.83 and OR=0.49, 95% CI: 0.28-0.85, respectively). One-year survival and stroke and reinfarction-free survival were also significantly higher with LMWH compared with UFH (OR=0.66, 95% CI: 0.50-0.85 and OR=0.71, 95% CI: 0.56-0.91, respectively). In two cohorts of patients matched on a propensity score for getting LMWH and with similar baseline characteristics (328 patients per group), major bleeding and transfusion were significantly lower while one-year survival was significantly higher in patients receiving LMWH.

CONCLUSIONS

The present data show that in elderly patients admitted for AMI, use of LMWH is associated with less bleeding, less need for transfusion, and higher survival, compared with the use of UFH.

Procedural and long-term outcome of primary percutaneous coronary intervention in octogenarians

Background/objectives. To investigate the procedural and long-term outcome of primary percutaneous coronary intervention (PCI) in octogenarians with an acute myocardial infarction.Methods. We performed a retrospective analysis of all consecutive octogenarian patients (n=98) with an acute myocardial infarction treated with primary PCI in the Catharina Hospital in the year 2006. We compared procedural results and outcome with a matched control group composed of non-octogenarians undergoing primary PCI. Follow-up period was one year.Results. The initial success rate of PCI was similar in the two groups but short-term mortality was higher among the elderly patients: 30-day mortality 26.3 vs. 9.6%. Age-adjusted mortality between 30 days and one year was comparable in the two groups and similar to natural survival in the Netherlands. Octogenarians were less likely to have a normal left ventricular function during follow-up (48.3 vs. 66.7%). New York Heart Association (NYHA) class and recurrence rate of myocardial infarction was higher among octogenarians.Conclusion. Technical success rate during primary PCI was as good for octogenarians as in younger patients, but 30-day mortality, though acceptable, was higher among the elderly. After 30 days, age-adjusted mortality was comparable in both groups. (Neth Heart J 2010;18:129-34.).

The impact of age on effects of pre-hospital initiation of high bolus dose of tirofiban before primary angioplasty for ST-elevation myocardial infarction

PURPOSE

Glycoprotein IIb/IIIa inhibitors are favourable in ST-elevation myocardial infarction (STEMI) patients, and the additional value of early pre-hospital high bolus dose tirofiban has recently been established. The aim of this study was to determine the impact of age on myocardial reperfusion and clinical outcomes of pre-hospital administration of high bolus dose tirofiban.

METHODS

This is a pre-specified sub-analysis of the multicentre, double-blind, placebo-controlled, randomised On-TIME 2 trial and it's open label phase. The primary endpoint was mean residual ST segment deviation 1 h after primary PCI and was evaluated in three age groups.

RESULTS

Of the 466 patients in the highest tertile (≥68 years), median age was 74.4 years (IQR 71.3-78.6 years) and 231 (50%) were randomised to tirofiban. Mean residual ST segment deviation 1 h after PCI was significantly lower in elderly patients pre-treated with tirofiban compared to elderly patients without tirofiban pre-treatment (4.2 ± 5.2 mm vs 6.4 ± 7.5 mm, p = 0.001). Furthermore, elderly patients pre-treated with tirofiban had a non-significantly higher rate of 30-day major or minor bleeding compared to elderly patients without tirofiban pre-treatment (14.2% vs 9.0%, p = 0.088). 30-day net adverse clinical events in elderly patients with- or without tirofiban was not significantly different (11.9% vs 15.2%, p = 0.300).

CONCLUSION

The effect of pre-hospital initiation of high bolus dose tirofiban on myocardial reperfusion, as determined by ST-segment resolution is highest in the elderly patients. However, this was associated with a trend towards more bleeding complications, resulting in a balanced clinical effect after 30-day follow-up. Future studies should evaluate whether the elderly STEMI patient may benefit from highly effective and safer antiplatelet therapy.

Time trend and age-period-cohort effects on acute myocardial infarction mortality in Korean adults from 1988 to 2007

We examined time trend and age-period-cohort effects on acute myocardial infarction (AMI) mortality in Korean adults from 1988 to 2007. Annual AMI mortality data and population statistics from 1988 to 2007 were obtained from the STATISTICS KOREA website. Age adjusted mortality for four 5-yr calendar periods (1988-1992 to 2003-2007) was calculated by direct standardization using the Year 2000 WHO world standard population. A log-linear Poisson regression model was used to estimate age, period, and cohort effects on AMI mortality. In both genders, age-adjusted AMI mortality increased from period one (1988-1992) to period three (1998-2002) but decreased in period four (2003-2007). An exponential age effect was noted in both genders. The rate ratio of the cohort effect increased up to the 1943 birth cohort and decreased gradually thereafter, and the rate ratio of the period effect increased up to period three (1998-2002) and decreased thereafter. Our results suggest that AMI mortality in Korean adults has decreased since the period 1998-2002 and age, period, and cohort effects have influenced on AMI mortality.

Classification and Regression Trees on Aggregate Data Modeling: An Application in Acute Myocardial Infarction

Cardiologists are interested in determining whether the type of hospital pathway followed by a patient is predictive of survival. The study objective was to determine whether accounting for hospital pathways in the selection of prognostic factors of one-year survival after acute myocardial infarction (AMI) provided a more informative analysis than that obtained by the use of a standard regression tree analysis (CART method). Information on AMI was collected for 1095 hospitalized patients over an 18-month period. The construction of pathways followed by patients produced symbolic-valued observations requiring a symbolic regression tree analysis. This analysis was compared with the standard CART analysis using patients as statistical units described by standard data selected TIMI score as the primary predictor variable. For the 1011 (84, resp.) patients with a lower (higher) TIMI score, the pathway variable did not appear as a diagnostic variable until the third (second) stage of the tree construction. For an ecological analysis, again TIMI score was the first predictor variable. However, in a symbolic regression tree analysis using hospital pathways as statistical units, the type of pathway followed was the key predictor variable, showing in particular that pathways involving early admission to cardiology units produced high one-year survival rates.

Age and sex differences and 20-year trends (1986 to 2005) in prehospital delay in patients hospitalized with acute myocardial infarction

BACKGROUND

The prompt administration of coronary reperfusion therapy for patients with an evolving acute myocardial infarction (AMI) is crucial in reducing mortality and the risk of serious clinical complications in these patients. However, long-term trends in extent of prehospital delay and factors affecting patient's care-seeking behavior remain relatively unexplored, especially in men and women of different ages. The objectives of this study were to examine the overall magnitude and 20-year trends (1986 to 2005) in duration of prehospital delay in middle-aged and elderly men and women hospitalized with AMI.

METHODS AND RESULTS

The study sample consisted of 5967 residents of the Worcester, Mass, metropolitan area hospitalized at all greater Worcester medical centers for AMI between 1986 and 2005 who had information available about duration of prehospital delay. Compared with men <65 years, patients in other age-sex strata exhibited longer prehospital delays over the 20-year period under study. The multivariable-adjusted medians of prehospital delay were 1.96, 2.07, and 2.57 hours for men <65 years, men 65 to 74 years, and men ≥75 years and 2.08, 2.33, and 2.27 hours for women <65 years, women 65 to 74 years, and women ≥75 years, respectively. These age and sex differences have narrowed over time, which has been largely explained by changes in patient's comorbidity profile and AMI-associated characteristics.

CONCLUSIONS

Our results suggest that duration of prehospital delay in persons with symptoms of AMI has remained essentially unchanged during the 20-year period under study and elderly individuals are more likely to delay seeking timely medical care than younger persons.

Coupling vascular and myocardial inflammatory injury into a common phenotype of cardiovascular dysfunction: systemic inflammation and aging - a mini-review

The rising epidemic of cardiovascular (CV) disease is fuelled by obesity, hypertension and diabetes and, independently and cumulatively, by an aging population. Extensive research identified immunoinflammatory mechanisms as key drivers in the initiation and progression of the disease, from early asymptomatic stages of vascular and myocardial injury leading to the clinically manifest dysfunction and remodeling in advanced stages. Underlying processes include endothelial dysfunction and extracellular matrix restructuration leading to increased vascular stiffness, as well as myocardial remodeling with dilatation and wall thinning. In this, overproduction of tumor necrosis factor-α, amongst others, contributes to generalized CV injury and dysfunction. Moreover, recent insights into the involvement of innate and adaptive immunity in atherosclerosis have shed light on many interesting parallels with chronic systemic inflammatory conditions, such as rheumatoid arthritis, with aggravated inflammation-induced vascular and myocardial injury. Besides, chronologic age has been identified as a potent, independent risk for reduced CV capacity and a plethora of heart diseases, with other modifiable risk factors acting as accelerators. We discuss the available evidence and propose that characterization of inflammatory CV responses might reveal a distinctive CV inflammatory phenotype. A comprehensive noninvasive bio-signature, comprising immunomic biomarkers and integrated noninvasive imaging, may serve as a potential tool in the early diagnosis and prognostication of CV risk.

Age and sex differences in duration of prehospital delay in patients with acute myocardial infarction: a systematic review

BACKGROUND

Coronary heart disease is the leading cause of morbidity and mortality in American men and women. Although there have been dramatic changes in the management of patients hospitalized with acute myocardial infarction (AMI) over the past several decades, a considerable proportion of patients with AMI continue to delay seeking medical care in a timely manner. This review provides an overview of the published literature that has examined age and sex differences in extent of prehospital delay in patients hospitalized with AMI.

METHODS AND RESULTS

A systematic review of the literature from 1960 to 2008, including publications that provided data on duration of prehospital delay in patients hospitalized with AMI, was conducted. A total of 44 articles (42 studies) were included in the present analysis. The majority of studies showed that in patients hospitalized with AMI, women and older persons were more likely to arrive at the hospital later than men and younger persons. Several factors associated with duration of prehospital delay, including sociodemographic, medical history, clinical, and contextual characteristics differed according to sex.

CONCLUSIONS

The elderly and women were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of AMI compared with other groups. Further research is needed to more fully understand the reasons for delay in these vulnerable groups.

Therapeutic management in patients with renal failure who experience an acute coronary syndrome

BACKGROUND AND OBJECTIVES

Prior reports have suggested that patients with impaired renal function receive less aggressive care after an acute coronary syndrome (ACS). The aim of this study was to determine whether this held true in a contemporary cohort, after thorough adjustment for cotreatments/comorbidities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients who were admitted for an ACS in eight participating hospitals were stratified into three groups according to estimated creatinine clearance (CrC): less than 45 ml/min, 45 to 60 ml/min, and reference >60 ml/min.

RESULTS

During hospitalization, uses of reperfusion therapy in tertiary care centers [difference between CrC < or =45 ml/min and reference group (Delta): 4%, 95% confidence interval (CI): (-13%, 21%)] and systemic anticoagulation [Delta: 0%, CI (-5%, 5%)] were similar in the three groups. Coronary angiography was performed less often in patients with lower CrC [Delta: -16%, CI: (-31%, -1%)]. At discharge, nearly all patients received either an antiplatelet agent or warfarin regardless of CrC [Delta: -1%, CI: (-3%, 1%)]. Discharge use of angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers was comparable [Delta: 7%, CI: (-1%, 15%)]. beta-blockers [Delta: -9%, CI: (-17%, -1%)] and lipid-lowering drugs (LLDs) [Delta: -7%, CI: (-13%, -1%)] were used less frequently in patients with lower CrC. In multivariate analyses, decreased CrC predicted lower coronary angiography and LLD use, but not lower beta-blocker use at discharge.

CONCLUSIONS

These results suggest that in patients with ACS, the extent of undertreatment due to chronic kidney disease is less than reported previously, which is partially explained by more complete adjustment for cotreatments/comorbidities.

Prognostic value of N-terminal pro-brain natriuretic peptide in elderly people with acute myocardial infarction: prospective observational study

OBJECTIVE

To examine the influence of age on the predictive value of N-terminal pro-brain natriuretic (NT-proBNP) peptide assay in acute myocardial infarction.

DESIGN

Prospective observational study.

SETTING

All intensive care units in one French region.

PARTICIPANTS

3291 consecutive patients admitted for an acute myocardial infarction, from the RICO survey (a French regional survey for acute myocardial infarction).

MAIN OUTCOME MEASURE

Cardiovascular death at 1 year.

RESULTS

Among the 3291 participants, mean age was 68 (SD 14) years and 2356 (72%) were men. In the study population, the median NT-proBNP concentration was 1053 (interquartile range 300-3472) pg/ml. Median values for age quarters 1 to 4 were 367 (119-1050), 696 (201-1950), 1536 (534-4146), and 3774 (1168-9724) pg/ml (P<0.001). A multiple linear regression analysis was done to determine the factors associated with the pro-peptide concentrations in the overall population. NT-proBNP was mainly associated with age, left ventricular ejection fraction, creatinine clearance, female sex, hypertension, diabetes, and anterior wall infarction. At one year's follow-up, 384 (12%) patients had died from all causes and 372 (11%) from cardiovascular causes. In multivariate analysis, NT-proBNP remained strongly associated with the outcome, beyond traditional risk factors including creatinine clearance and left ventricular ejection fraction, in each age group except in the youngest one (<54 years) (P=0.29). The addition of NT-proBNP significantly improved the performance of the statistical model in the overall study population (-2log likelihood 3179.58 v 3099.74, P<0.001) and in each age quarter including the upper one (1523.52 v 1495.01, P<0.001).The independent discriminative value of NT-proBNP compared with the GRACE score was tested by a diagonal stratification using the median value of the GRACE score and NT-proBNP in older patients (upper quarter). Such stratification strikingly identified a high risk group-patients from the higher NT-proBNP group and with a high risk score-characterised by a risk of death of almost 50% at one year.

CONCLUSIONS

In this large contemporary non-selected cohort of patients with myocardial infarction, NT-proBNP concentration had incremental prognostic value even in the oldest patients, above and beyond the GRACE risk score and traditional biomarkers after acute myocardial infarction. These data further support the potential interest of clinical trials specifically assessing NT-proBNP measurement as a guide to current treatment strategies, as well as novel strategies, in older patients with acute myocardial infarction.

What do patients really want? Patients' preferences for treatment for angina

OBJECTIVE

To measure preferences for angina treatments among patients admitted from accident and emergency with acute coronary syndrome.

BACKGROUND

Evidence suggests variability in treatment allocations amongst certain socio-demographic groups (e.g. related to age and sex), although it is unclear whether this reflects patient choice, as research on patients' treatment preferences is sparse. Given current policy emphasis on 'patient choice', providers need to anticipate patients' preferences to plan appropriate and acceptable health services.

DESIGN

Self-administered questionnaire survey.

SETTING

In-patients in a UK hospital.

PARTICIPANTS

A convenience sample of 53 newly admitted patients with acute coronary syndrome. Exclusion criteria were: a previous cardiologist consultation (including previous revascularization); a clinical judgement of too ill to participate; post-admission death; non-cardiac reasons for chest pain.

MAIN OUTCOME MEASURES

Patients' preferences for coronary artery bypass graft (CABG); angioplasty; and two medication alternatives.

RESULTS

Angioplasty was the preferred treatment (for 80% of respondents), and CABG was second (most preferred by 19%, but second most preferred for 60%). The two least preferred (and least acceptable) treatments were medications. The majority of patients (83%) would 'choose treatment based on the extent of benefits' and 'accept any treatment, no matter how extreme, to return to health'. There were some differences in preference related to age (>70 years preferred medication to a greater degree than <70 years) and sex (males preferred CABG surgery more than females).

CONCLUSIONS

There was general preference for procedural interventions over medication, but most patients would accept any treatment, however extreme, to return to former health. There was some evidence of differences in preferences related to age and sex. Furthermore, most patients preferred to have some input into treatment choice (e.g. nearly half wanted to share decision responsibility with their doctor), with only 4% preferring to leave the decision entirely to their doctor. Given these findings, and past findings that suggest there may be variability in treatment allocation according to certain socio-demographic factors, this study suggests a need to develop and use preference measures, and makes a step towards this.

Clinical and procedural predictors of no-reflow phenomenon after primary percutaneous coronary interventions: experience at a single center

BACKGROUND

The aim of the study was to identify clinical factors, angiographic findings, and procedural features that predict no-reflow phenomenon (Thrombolysis In Myocardial Infarction (TIMI) flow grade < or =2) in patients with acute myocardial infarction (AMI) who undergo primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A series of 382 consecutive patients with AMI underwent primary PCI within 12 h of symptom onset. Patients with ischemic symptoms continuing for more than 12 h were also included. Clinical, angiographic and procedural data were collected for each subject. Ninety-three (24.3%) of the patients developed no-reflow phenomenon, and their findings were compared with those of the reflow group. Univariate analysis showed that advanced age (>60 years), delayed reperfusion (> or =4 h), low (< or =1) TIMI flow prior to PCI, cut-off type total occlusion, high thrombus burden on baseline angiography, long target lesion (>13.5 mm) and large vessel diameter all correlated with no-reflow (p<0.05 for all). Multiple logistic regression analysis identified that advanced age (odds ratio (OR) 1.04, p=0.001), delayed reperfusion (OR 1.4, p=0.0004), low TIMI flow before primary PCI (OR 1.1, p=0.0002), target lesion length (OR 5.1, p=0.0003) and high thrombus burden (OR 1.6, p=0.03) on angiography as independent predictors of no-reflow phenomenon.

CONCLUSION

The occurrence of no-reflow phenomenon after primary PCI can be predicted using simple clinical, angiographic and procedural features. In this selected group of patients, adjunctive pharmacotherapy and/or distal protection device may be of value.

Post-myocardial infarction beta-blocker therapy: the bradycardia conundrum. Rationale and design for the Pacemaker & beta-blocker therapy post-MI (PACE-MI) trial

Multiple clinical trials have demonstrated beta-blockers improving survival after myocardial infarction (MI). Patients with "bradycardia-related" contraindications to beta-blockers, such as those with asymptomatic bradycardia or AV conduction abnormalities, have been excluded from clinical trials of beta-blockers and continue to be excluded from post-MI beta-blocker therapy in routine clinical practice. These patients tend to be elderly and have a high 1-year mortality. If beta-blockers provide benefit to the post-MI patient independent of their heart rate-lowering effect, then these patients could benefit substantially from initiation of beta-blocker therapy. However, in this particular group of patients, beta-blockers can be safely initiated only if more severe or significant bradycardia can be prevented by pacemaker implantation. It is unclear whether adverse effects related to pacemaker implantation could also negate some or all of the hypothesized benefit of beta-blocker therapy. Although beta-blockers are particularly effective in the elderly, the benefit of beta-blocker therapy in patients with bradycardia-related contraindications to beta-blockers has not been established. The PACE-MI trial is a randomized controlled trial that will address whether beta-blocker therapy enabled by pacemaker implantation is superior to no beta-blocker and no pacemaker therapy after MI in patients with rhythm contraindications to beta-blockers or in those who have developed symptomatic bradycardia due to beta-blockers. The trial will randomize 1124 patients to standard therapy (not to include beta-blockers as patients must have a contraindication to be enrolled) or standard therapy plus pacemaker implantation and beta-blocker. The primary end point is the composite end point of total mortality plus nonfatal reinfarction.

Trends in Mortality from Acute Myocardial Infarction in the Coronary Care Unit

Introduction: The treatment and outcome of acute myocardial infarction (AMI) has evolved greatly over the past few decades. We compared the mortality and complication rates of patients with AMI admitted to the Coronary Care Unit (CCU) in 2002 to previously reported data. Materials and Methods: All data for AMI patients admitted to National Heart Centre CCU in 2002 were collected through the Singapore Cardiac Data Bank, including demographics, inhospital complications and mortality. These were compared to previous reports from the same institution in 1988, 1975 and 1967. Results: A total of 516 cases with AMI were identified. A higher proportion of patients were aged ≥70 years in 2002 (31.8%) compared to 1988 (25%), 1975 (11%) and 1967 (5.6%). Acute percutaneous transluminal coronary angioplasty (PTCA) was performed in 250 of 516 (48%) patients in 2002. The overall in-patient and age-standardised mortality was 14.7% and 10% respectively, compared to 20.6% and 17% respectively in 1988 (P = 0.06). For the 250 patients who underwent acute PTCA, overall mortality was 5.2% compared to 24% in those who did not (P <0.001). Common in-hospital complications included heart failure (38%), non-sustained ventricular tachycardia (8%), atrial fibrillation (8%) and complete heart block (6%). Age, heart failure, bundle branch block and sustained ventricular tachycardia were associated with higher mortality by univariate analysis. On multivariate analysis, older age, heart failure and the absence of percutaneous intervention were independently associated with higher mortality. Conclusion: In-hospital mortality for AMI patients admitted to the CCU declined from 1988 to 2002 despite a higher proportion of elderly patients. The introduction of new therapies including drugs and percutaneous intervention may have contributed to this decline. Key words: Primary percutaneous transluminal coronary angioplasty

Which doctors are influenced by a patient's age? A multi-method study of angina treatment in general practice, cardiology and gerontology

BACKGROUND

Elderly patients with cardiovascular disease are relatively undertreated and undertested.

OBJECTIVES

To investigate whether, and how, individual doctors are influenced by a patient's age in their investigation and treatment of angina.

DESIGN

Process-based judgment analysis using electronic patients, semistructured interviews.

SETTING

Primary Care, Care of the Elderly and Cardiology in England.

PARTICIPANTS

Eighty five doctors: 29 cardiologists, 28 care of the elderly specialists and 28 general practitioners (GPs).

MAIN OUTCOME MEASURES

Testing and treatment decisions on hypothetical patients.

RESULTS

Forty six per cent of GPs and care of the elderly doctors, and 48% of cardiologists treated patients aged 65+ differently to those under 65, independent of comorbidity. This effect was evident on several decisions: elderly patients were less likely to be prescribed a statin given a cholesterol test, referred to a cardiologist, given an exercise tolerance test, angiography and revascularisation; more likely to have their current prescriptions changed and to be given a follow-up appointment. There was no effect of specialty, gender or years of training on influence of patient age. Those doctors who were influenced by age were on average five years older than those who were not. Interviews revealed that some doctors saw old age as a contraindication to treat.

CONCLUSIONS

Age, independent of comorbidity, presentation and patients' wishes, directly influenced decision-making about angina investigation and treatment by half of the doctors in the primary and secondary care samples. Doctors explicitly reasoned about the direct influence of age and age-associated influences.

The Influence of Age on Acute Myocardial Infarction Symptoms and Patient Delay in Seeking Treatment

A secondary analysis was conducted from data gathered from 239 patients with acute myocardial infarction presenting to the emergency departments of three hospitals to explore the influence of age on delay time, experienced symptoms, and factors predicting a delay of >1 hour. During hospitalization, a structured interview about the patients' experience before hospital admission was completed and their medical records were reviewed. The median delay before seeking treatment was not significantly different between older (2.5 hours) and younger patients (2.1 hours). Older patients were significantly less likely to report classic pain in the center of the chest and other associated symptoms such as sweating and nausea; they also used fewer words to describe their discomfort compared with younger patients. Independent predictors of longer delay were: contacted physician, lacked similarity between experienced and expected symptoms, did not use 911 (older adults), lived alone, and contacted physician (younger adults). Primary care providers need to be aware that elderly persons are more likely to have mild or ambiguous acute myocardial infarction symptoms and education is needed for elderly persons regarding not only acute myocardial infarction symptoms but also rapid, action-centered decisions to attribute symptoms to heart problems and initiate ambulance use.

[Influence of comorbidity on admission management and pharmacological treatment prescribed at discharge in acute myocardial infarction]

BACKGROUND AND OBJECTIVE

The management of cardiac ischemic patients differs depending on their comorbidity. The Charlson Index (ChI) and its adaptations are well established and widely used tools to quantify a patient comorbidity. The aim of this study is to evaluate the influence of comorbidity quantified by the ChI in the treatment administered at admission and in the pharmacological treatment prescribed at discharge in the setting of an acute myocardial infarction with and without ST segment elevation.

PATIENTS AND METHOD

We studied a total of 955 patients consecutively admitted in our hospital with the diagnosis of acute myocardial infarction. Comorbidity was obtained at the first day of admission applying the ChI. According to this value patients were classified from minor to major in 2 subgroups (ChI <or= 2, ChI >or= 2) and differences in the admission and discharge treatments between both groups were analyzed.

RESULTS

Patients admitted with acute myocardial infarction without ST segment elevation and ChI > 2 received less frequently betablockers at discharge, but there were no significant differences in the use of ACE inhibitors, calcium channel blockers or statins. In addition they were submitted less frequently to revascularization procedures or treadmills, and no differences were found in the use of echocardiograms. Patients with ST segment elevation and ChI > 2 were less frequently treated with betablockers or statins at discharge, and were submitted to less treadmills or echocardiograms; furthermore, in these patients, there were no significant differences in the use of ACE inhibitors, calcium channel blockers, thrombolytics or revascularization procedures.

CONCLUSIONS

Comorbidity quantified on admission by the ChI is an independent factor that modifies in-hospital and ambulatory management of patients with acute myocardial infarction. There is a lower use of invasive techniques as well as a lower prescription of betablockers at discharge in patients with greater comorbidity.

Characteristics and outcome of acute myocardial infarction in young patients. The PRIAMHO II study

BACKGROUND

The objective was to analyze the incidence, risk factors, management, and complications of acute myocardial infarction (AMI) in the young patient in Spain.

METHODS

Clinical characteristics, treatment, and outcome were analyzed in patients younger than 45 years admitted with an AMI diagnosis to the Coronary Units of 58 Spanish hospitals from 15th May to 15th December 2000.

RESULTS

Six thousand two hundred and ten consecutive patients were registered, 7% out of them were <45 years old. Outcome was better in the younger group, with a lower mortality rate at 28 days (3.7 vs. 11.9%; p < 0.001), demonstrating that age <45 years is an independent protective factor for mortality (relative risk: 0.41; 95% CI: 0.23-0.73; p < 0.001). This difference remained at 1-year follow-up.

CONCLUSIONS

AMI in young patients presents distinct clinical characteristics, a different treatment, management and outcome with respect to the older group.

The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000-2002: findings from the National Registry of Myocardial Infarction-4

OBJECTIVES

The aim of this study was to determine the use of pre-hospital electrocardiogram (ECG) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing reperfusion therapy, and evaluate the effect of pre-hospital ECG on door-to-reperfusion times.

BACKGROUND

Although national guidelines recommend the use of pre-hospital ECG, there is limited contemporary information about its current use and effectiveness.

METHODS

Using data from the National Registry of Myocardial Infarction-4, we studied patients with STEMI or left bundle branch block who received acute reperfusion with either fibrinolytic therapy (n = 35,370) or primary percutaneous coronary intervention (PCI) (n = 21,277) within 6 h of admission. We determined the prevalence of pre-hospital ECG use, evaluated the association between pre-hospital ECG and door-to-reperfusion time, and estimated the incremental reduction in time to reperfusion using hierarchical models to adjust for differences in patient and hospital characteristics.

RESULTS

A pre-hospital ECG was performed in 4.5% of the fibrinolytic therapy cohort and in 8.0% of the PCI cohort. After adjusting for patient and hospital characteristics, the use of pre-hospital ECG was associated with a significantly shorter geometric mean door-to-drug time: 24.6 min (95% confidence interval [CI]: 23.7 to 25.5) vs. 34.7 min (95% CI: 34.2 to 35.3; p < 0.0001), and a significantly shorter geometric mean door-to-balloon time (94.0 min [95% CI: 91.8 to 96.3] vs. 110.3 min [95% CI: 108.7 to 112.0]; p < 0.0001).

CONCLUSIONS

The national use of pre-hospital ECG to diagnose and facilitate the treatment of STEMI remains low. When used, however, pre-hospital ECG is associated with a significantly shorter time to reperfusion.

Aging Adversely Affects Postinfarction Inflammatory Response and Early Left Ventricular Remodeling after Reperfused Acute Anterior Myocardial Infarction

BACKGROUND AND AIMS

We have demonstrated that an increased peak serum C-reactive protein (CRP) level after acute myocardial infarction (AMI) was a major predictor of left ventricular (LV) remodeling. We sought to clarify the effect of aging on the postinfarction inflammatory response and LV remodeling.

METHODS

We studied 102 patients who underwent primary angioplasty for a first anterior Q-wave AMI. Serum CRP levels, plasma neurohormones and interleukin-6 (IL-6) levels, and LV volume by left ventriculography were serially measured. Patients were divided into two groups according to their age (>or=70 years, n=33; <70 years, n=69).

RESULTS

There was no difference in use of cardiovascular drugs and coronary angiographic findings. Older patients had a greater increase in LV end-diastolic volume during 2 weeks after AMI (p=0.0007) and a higher peak CRP level (12.4+/-7.3 vs. 5.5+/-4.2 mg/dl, p<0.0001), although peak CK level was comparable between the two groups. Plasma atrial natriuretic peptide, brain natriuretic peptide and IL-6 levels were higher in older patients at 2 weeks and 6 months after AMI.

CONCLUSIONS

Augmented and prolonged activation of the inflammatory system after AMI was observed in older patients, in association with exaggerated LV remodeling. Aging may adversely affect LV remodeling through modification of the inflammatory response after AMI.

Changing trends in the long-term prognosis of patients with acute myocardial infarction: a population-based perspective

BACKGROUND

Little contemporary data exist describing changes over time in the postdischarge prognosis of hospital survivors of acute myocardial infarction (AMI). The purpose of our study was to examine recent and multidecade-long (1975-2001) trends in the long-term prognosis of greater Worcester (MA) residents discharged from all metropolitan Worcester hospitals after confirmed AMI.

METHODS

A total of 9827 greater Worcester residents with independently validated AMI discharged from all metropolitan Worcester hospitals during 13 annual periods between 1975 and 2001 comprised the study population. A variety of follow-up approaches were used to ascertain the survival status of discharged patients through the end of 2003.

RESULTS

Crude unadjusted 1-year postdischarge survival rates declined over time. Suggestions of modest improvements in the multivariable adjusted 1-year postdischarge survival rates were noted, however, in patients discharged from greater Worcester hospitals in the more recent (2001) (adjusted odds of surviving 1.23, 95% CI 0.97-1.55) as compared with earliest study periods (1975/1978). Advancing age, female sex, presence of prior diabetes, stroke, heart failure, or myocardial infarction and occurrence of several clinical complications during hospitalization were significantly related to an adverse postdischarge prognosis.

CONCLUSIONS

The results of this investigation provide contemporary insights into the long-term survival of patients with AMI from a more generalizable population-based perspective. Multivariable adjusted analyses revealed slight improvements in postdischarge survival over time. Our data identify several high-risk groups that should be targeted for more aggressive surveillance and increased use of effective cardiac therapies and interventions.