Thrombolytic therapy in older patients

The Comparison of the Outcomes between Primary PCI, Fibrinolysis, and No Reperfusion in Patients ≥ 75 Years Old with ST-Segment Elevation Myocardial Infarction: Results from the Chinese Acute Myocardial Infarction (CAMI) Registry

Background

Only a few randomized trials have analyzed the clinical outcomes of elderly ST-segment elevation myocardial infarction (STEMI) patients (≥ 75 years old). Therefore, the best reperfusion strategy has not been well established. An observational study focused on clinical outcomes was performed in this population.

Methods

Based on the national registry on STEMI patients, the in-hospital outcomes of elderly patients with different reperfusion strategies were compared. The primary endpoint was defined as death. Secondary endpoints included recurrent myocardial infarction, ischemia driven revascularization, myocardial infarction related complications, and major bleeding. Multivariable regression analysis was performed to adjust for the baseline disparities between the groups.

Results

Patients who had primary percutaneous coronary intervention (PCI) or fibrinolysis were relatively younger. They came to hospital earlier, and had lower risk of death compared with patients who had no reperfusion. The guideline recommended medications were more frequently used in patients with primary PCI during the hospitalization and at discharge. The rates of death were 7.7%, 15.0%, and 19.9% respectively, with primary PCI, fibrinolysis, and no reperfusion (P < 0.001). Patients having primary PCI also had lower rates of heart failure, mechanical complications, and cardiac arrest compared with fibrinolysis and no reperfusion (P < 0.05). The rates of hemorrhage stroke (0.3%, 0.6%, and 0.1%) and other major bleeding (3.0%, 5.0%, and 3.1%) were similar in the primary PCI, fibrinolysis, and no reperfusion group (P > 0.05). In the multivariable regression analysis, primary PCI outweighs no reperfusion in predicting the in-hospital death in patients ≥ 75 years old. However, fibrinolysis does not.

Conclusions

Early reperfusion, especially primary PCI was safe and effective with absolute reduction of mortality compared with no reperfusion. However, certain randomized trials were encouraged to support the conclusion.

Primary percutaneous coronary intervention in octogenarians

BACKGROUND

Limited data are available on the outcome of primary percutaneous coronary intervention (PCI) in octogenarian patients, as the elderly are under-represented in randomized trials. This study aims to provide insights on clinical characteristics, management and outcome of the elderly and very elderly presenting with STEMI.

METHODS

2225 STEMI patients ≥70years old (mean age 76.8±5.1years and 53.8% men) were admitted into the network of the ISACS-TC registry. Of these patients, 72.8% were ≥70 to 79years old (elderly) and 27.2% were ≥80years old (very-elderly). The primary end-point was 30-day mortality.

RESULTS

Thirty-day mortality rates were 13.4% in the elderly and 23.9% in the very-elderly. Primary PCI decreased the unadjusted risk of death both in the elderly (OR: 0.32, 95% CI: 0.24-0.43) and very-elderly patients (OR: 0.45, 95% CI 0.30-0.68), without significant difference between groups. In the very-elderly hypertension and Killip class ≥2 were the only independent factors associated with mortality; whereas in the elderly female gender, prior stroke, chronic kidney disease and Killip class ≥2 were all factors independently associated with mortality. Factors associated with the lack of use of reperfusion were female gender and atypical chest pain in the very-elderly and in the elderly; in the elderly, however, there were some more factors, namely: history of diabetes, current smoking, prior stroke, Killip class ≥2 and history chronic kidney disease.

CONCLUSIONS

Age is relevant in the prognosis of STEMI, but its importance should not be considered secondary to other major clinical factors. Primary PCI appears to have beneficial effects in the octogenarian STEMI patients.

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

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

A Review of Current Diagnosis, Investigation, and Management of Acute Coronary Syndromes in Elderly Patients

The elderly constitute a sizeable proportion of the acute coronary syndrome (ACS) population, and this population is continually increasing in number. Guideline-directed therapy is frequently underutilized in the elderly due to concerns about patient safety. However, studies suggest that this subgroup could benefit from many of the conventional and newer therapies available. This paper reviews current literature in the context of contemporary American and European guidance.

Treatment choices in elderly patients with ST: elevation myocardial infarction-insights from the Vital Heart Response registry

BACKGROUND

Management of elderly patients with ST elevation myocardial infarction (STEMI) is challenging and they are under-represented in trials. Accordingly, we analysed reperfusion strategies and their effectiveness in patients with STEMI ≥75 years compared to <75 years within a comprehensive inclusive registry.

METHODS

Consecutive patients with STEMI admitted to hospital and tracked within a regional registry (2006-2011) were analysed comparing reperfusion strategy (primary percutaneous coronary intervention (PPCI), fibrinolysis and no reperfusion) between patients ≥75 vs <75 years old as well as across the reperfusion strategies in those ≥75 years.

RESULTS

There were 3588 patients with STEMI with 646 (18%) ≥75 years old. Elderly patients were more likely female (46.9% vs 18.4%) and had more prior: angina (28.2% vs 17.2%), myocardial infarction (MI; 22.8% vs 13.9%), hypertension (67.6% vs 44.2%), heart failure (2.3% vs 0.3%) and atrial fibrillation (2.2% vs 0.5%) (all p<0.001). The reperfusion strategy for patients ≥75 vs <75: PPCI 45.3% vs 41.2%, fibrinolysis 24.8% vs 45.7%, and no reperfusion 29.9% vs 13.1% (p<0.001). Time from symptoms to first medical contact (median, 93 vs 78 min p=0.008) and PPCI (median, 166 vs 136 min (p<0.001) were longer for ≥75 years. In those ≥75 years outcomes by reperfusion (PPCI, fibrinolysis and none) were: in-hospital death 13.3%, 9.4% and 19.7% (p=0.018), and composite of death, recurrent-MI, cardiogenic shock and congestive heart failure 28%, 20% and 33.2% (p=0.022).

CONCLUSIONS

Elderly patients have more comorbidities, worst in-hospital clinical outcomes and are less likely to receive reperfusion. Acknowledging physician selection of the reperfusion strategy; outcomes appear favourable in the elderly receiving fibrinolysis.

Percutaneous coronary intervention in the elderly with ST-segment elevation myocardial infarction

As a result of increased life expectancy, octogenarians constitute an increasing proportion of patients admitted to hospital for ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention is currently the treatment of choice for octogenarians presenting with STEMI. The recent literature on this topic has yielded controversial results, even though advances in drug-eluting stents and new types of antithrombotic agents are improving the management of STEMI and postoperative care. In this paper, we review the current status of percutaneous coronary intervention in the elderly with STEMI, including the reasons for their high mortality and morbidity, predictors of mortality, and strategies to improve outcomes.

One-year clinical outcomes in invasive treatment strategies for acute ST-elevation myocardial infarction complicated by cardiogenic shock in elderly patients

Objective

To investigate the clinical outcomes of an invasive strategy for elderly (aged ≥ 75 years) patients with acute ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

Methods

Data on 366 of 409 elderly CS patients from a total of 6,132 acute STEMI cases enrolled in the Korea Acute Myocardial Infarction Registry between January 2008 and June 2011, were collected and analyzed. In-hospital deaths and the 1-month and 1-year survival rates free from major adverse cardiac events (MACE; defined as all cause death, myocardial infarction, and target vessel revascularization) were reported for the patients who had undergone invasive (n = 310) and conservative (n = 56) treatment strategies.

Results

The baseline clinical characteristics were not significantly different between the two groups. There were fewer in-hospital deaths in the invasive treatment strategy group (23.5% vs. 46.4%, P < 0.001). In addition, the 1-year MACE-free survival rate after invasive treatment was significantly lower compared with the conservative treatment (51% vs. 66%, P = 0.001).

Conclusions

In elderly patients with acute STEMI complicated by CS, the outcomes of invasive strategy are similar to those in younger patients at the 1-year follow-up.

Safety, effectiveness, and outcomes of cardiac catheterization in nonagenarians

With an aging population, nonagenarians (≥90 years of age) are increasingly being considered for cardiac catheterization. Because of the paucity of outcomes data in this population, we sought to evaluate the acute and intermediate outcomes of nonagenarians undergoing cardiac catheterization. A retrospective cohort of 44 nonagenarians undergoing 53 cardiac catheterizations from 2002 to 2010 was identified. Mean age was 91 years (range 90 to 96) with 57% of patients being women. Thirteen percent presented with ST-segment elevation myocardial infarction, 32% with non-ST-segment elevation myocardial infarction, 14% with unstable angina, 25% with chronic angina, and 16% with aortic stenosis. Eighteen percent had left main coronary artery disease and 73% had multivessel coronary disease. Complications occurred in 6 of 44 patients (3 with acute kidney injury, 2 with atrial fibrillation, 1 with femoral artery pseudoaneurysm). Twenty patients were treated with medical management, 1 patient underwent coronary artery bypass surgery, and 2 patients underwent aortic valve replacement. Twenty-one patients underwent percutaneous coronary intervention in 27 different vessels. There was procedural success in 93% of these patients. There were no major adverse cardiac events. Five complications occurred after the intervention (4 atrial fibrillations, 1 femoral artery pseudoaneurysm). Cumulative mortalities at 1 month and 6 and 12 months were 0%, 9%, and 20% respectively. In patients who underwent percutaneous coronary intervention or surgery, mortalities were 0%, 0%, and 13% at 1 month and 6 and 12 months, respectively.

Why Does Primary Angioplasty Not Work in Registries? Quantifying the Susceptibility of Real-World Comparative Effectiveness Data to Allocation Bias

Background—

Meta-analysis of registries (comparative effectiveness research) shows that primary angioplasty and fibrinolysis have equivalent real-world survival. Yet, randomized, controlled trials consistently find primary angioplasty superior. Can unequal allocation of higher-risk patients in registries have masked primary angioplasty benefit?

Methods and Results—

First, we constructed a model to demonstrate the potential effect of allocation bias. We then analyzed published registries (55022 patients) for allocation of higher-risk patients (Killip class ≥1) to determine whether the choice of reperfusion therapy was affected by the risk level of the patient. Meta-regression was used to examine the relationship between differences in allocation of high-risk patient to primary angioplasty or fibrinolysis and mortality. Initial modeling suggested that registry outcomes are sensitive to allocation bias of high-risk patients. Across the registries, the therapy receiving excess high-risk patients had worse mortality. Unequal distribution of high-risk status accounted for most of the between-registry variance (adjusted R 2 meta =83.1%). Accounting for differential allocation of higher-risk patients, primary angioplasty gave 22% lower mortality (odds ratio, 0.78; 95% confidence interval, 0.64–0.97; P =0.029). We derive a formula, called the number needed to abolish, highlighting situations in which comparative effectiveness studies are particularly vulnerable to this bias.

Conclusions—

In ST-segment elevation myocardial infarction, clinicians’ preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.

Reperfusion strategies and quality of care in 5339 patients age 80 years or older presenting with ST-elevation myocardial infarction: analysis from get with the guidelines-coronary artery disease

BACKGROUND

Data regarding reperfusion strategies, adherence to national guidelines, and in-hospital mortality in ST-elevation myocardial infarction (STEMI) patients age ≥80 years are limited. The aim of this study was to determine current reperfusion trends, medical treatment, and in-hospital mortality during STEMI in older adults.

HYPOTHESIS

Among patients aged 80 or above presenting with STEMI, adherence to guidelines, length of stay, and in-hospital mortality would be better in those receiving reperfusion versus those who did not.

METHODS

Using the Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) database, we examined care and in-hospital outcomes of STEMI patients ≥80 years old. Use of evidence-based therapies and quality measures were analyzed by reperfusion strategies.

RESULTS

A total of 5339 patients age ≥80 years hospitalized with STEMI were included. Of these, 42.8% (n = 2285) underwent primary percutaneous coronary intervention (PPCI), 4.8% (n = 255) underwent thrombolysis (TL), and 52.4% (n = 2799) received no reperfusion (NR). Patients with NR were more likely to be older, female, have lower body mass index, and higher prevalence of renal insufficiency and heart failure compared with PPCI or TL patients. During the last decade, there was a significant increase in the use of PPCI compared with TL as the main reperfusion strategy in this population. Adjusted in-hospital mortality in PPCI patients was lower compared with NR patients (odds ratio [OR]: 0.41, 95% confidence interval [CI]: 0.35-0.49); also, patients undergoing PPCI or TL had lower mortality compared with NR patients (OR: 0.47, 95% CI: 0.40-0.55).

CONCLUSIONS

Among patients ≥80 years old admitted with STEMI to GWTG-CAD hospitals, less than half undergo mechanical or pharmacological reperfusion. However, the proportion of patients undergoing PPCI has increased substantially over the 8-year study period. Patients undergoing PPCI or TL had lower in-hospital mortality compared with the NR strategy.

ST Elevation Myocardial Infarction in the elderly

Acute coronary syndromes (ACS) are the leading causes of death in the elderly. The suspicion and diagnosis of ACS in this age group is more difficult, since typical angina is less frequent. The morbidity and mortality is greater in older age patients presenting ACS. Despite the higher prevalence and greater risk, elderly patients are underrepresented in major clinical trials from which evidence based recommendations are formulated. The authors describe, in this article, the challenges in the diagnosis and management of ST elevation myocardial infarction in the elderly, and discuss the available evidence.

Primary percutaneous coronary interventions in nonagenarians

BACKGROUND

The optimal treatment of very elderly patients with ST elevation myocardial infarction (STEMI) is not yet defined. The aim of this study is to present the feasibility and safety of primary percutaneous coronary interventions (PCI) in nonagenarians.

METHODS

A retrospective analysis of all patients who underwent primary PCI due to STEMI between 2004 and 2008 was performed. Patients age 90 years or older at the time of the procedure were identified and studied.

RESULTS

Twenty-two patients fulfilled the study criteria (median age 92 years; range, 90-97 years; 50% women). The procedural success rate was 82%. Bare metal stent implantation was performed in 82% of the procedures, whereas only balloon angioplasty was performed on the rest of them. One patient experienced a minor bleeding complication. Procedural mortality was 9% (2 out of 22 patients), and it was due to "no flow" phenomenon in both patients. In-hospital mortality was 27% (6/22 patients) and 30-day mortality was 32% (7/22 patients). All 3 patients with Killip class III-IV on admission died within 30 days compared with 4 of the 19 patients with Killip class I-II (P = 0.023). Furthermore, of 11 patients with anterior infarction, 7 died within 30 days compared with none of the 11 patients with infarction of other location (P = 0.004).

CONCLUSIONS

Although primary PCI is feasible in patients 90 years or older suffering from STEMI, the short-term mortality rate is high especially in patients with anterior infarct location and/or severely depressed myocardial function.

Impact of age on treatment and outcomes in ST-elevation myocardial infarction

OBJECTIVES

We hypothesized that older patients in a regional ST-elevation myocardial infarction (STEMI) transfer program would attain comparable treatment to younger patients.

BACKGROUND

Older patients have been either excluded or underrepresented in STEMI clinical trials. Observational studies suggest that these patients are less likely to receive adjunctive pharmacologies and reperfusion therapy-thrombolysis or percutaneous coronary intervention (PCI)-and therapy is frequently delayed.

METHODS

We identified a consecutive series of 2,262 STEMI patients (March 2003-December 2008) who either presented or were transferred to Abbott Northwestern Hospital for PCI (<65 years [n = 1285], 65-74 years [n = 436], 75-84 years [n = 381], and ≥85 years [n = 160]). Main outcome measures included time-to-reperfusion therapy, adjunctive medications received, and all-cause mortality.

RESULTS

Overall time-to-reperfusion therapy was similar across age strata-94 minutes (<65 years), 101 minutes (65-74 years), 106 minutes (75-84 years), and 103 minutes (≥85 years). No difference in adjunctive antiplatelet or anticoagulant medications was seen at hospital admission, and only slight differences in standard post-myocardial infarction medication use were seen by age at hospital discharge. Age was an independent predictor of in-hospital and yearly mortality up to 5 years (1-year mortality 3.4% [<65 years], 9.2% [65-74 years], 15.2% [75-84 years], and 28.9% [≥85 years]; P < .0001).

CONCLUSIONS

Older patients receive similar care to younger patients when treated in a regional STEMI transfer program. Although all-cause mortality in the elderly is increased, the absolute rates are lower than previously established. Our data suggest primary PCI (including transfer) can be applied to all appropriate STEMI patients, regardless of age.

Primary angioplasty vs. fibrinolysis in very old patients with acute myocardial infarction: TRIANA (TRatamiento del Infarto Agudo de miocardio eN Ancianos) randomized trial and pooled analysis with previous studies

Aims

To compare primary percutaneous coronary intervention (pPCI) and fibrinolysis in very old patients with ST-segment elevation myocardial infarction (STEMI), in whom head-to-head comparisons between both strategies are scarce.

Methods and results

Patients ≥75 years old with STEMI <6 h were randomized to pPCI or fibrinolysis. The primary endpoint was a composite of all-cause mortality, re-infarction, or disabling stroke at 30 days. The trial was prematurely stopped due to slow recruitment after enroling 266 patients (134 allocated to pPCI and 132 to fibrinolysis). Both groups were well balanced in baseline characteristics. Mean age was 81 years. The primary endpoint was reached in 25 patients in the pPCI group (18.9%) and 34 (25.4%) in the fibrinolysis arm [odds ratio (OR), 0.69; 95% confidence interval (CI) 0.38–1.23; P = 0.21]. Similarly, non-significant reductions were found in death (13.6 vs. 17.2%, P = 0.43), re-infarction (5.3 vs. 8.2%, P = 0.35), or disabling stroke (0.8 vs. 3.0%, P = 0.18). Recurrent ischaemia was less common in pPCI-treated patients (0.8 vs. 9.7%, P< 0.001). No differences were found in major bleeds. A pooled analysis with the two previous reperfusion trials performed in older patients showed an advantage of pPCI over fibrinolysis in reducing death, re-infarction, or stroke at 30 days (OR, 0.64; 95% CI 0.45–0.91).

Conclusion

Primary PCI seems to be the best reperfusion therapy for STEMI even for the oldest patients. Early contemporary fibrinolytic therapy may be a safe alternative to pPCI in the elderly when this is not available.

Clinicaltrials.gov # NCT00257309.

Ischemic preconditioning in the aging heart: from bench to bedside

Coronary artery disease is the leading cause of death in industrialized countries for people older than 65 years of age. The reasons are still unclear. A reduction of endogenous mechanisms against ischemic insults has been proposed to explain this phenomenon. Cardiac ischemic preconditioning represents the most powerful endogenous protective mechanism against ischemia. Brief episodes of ischemia are able to protect the heart against a following more prolonged ischemic period. This protective mechanism seems to be reduced with aging both in experimental and clinical studies. Alterations of mediators release and/or intracellular pathways may be responsible for age-related ischemic preconditioning reduction. Opposite studies are questionable for the experimental model used, the timing of ischemic preconditioning, and the selection of elderly patients. Several pharmacological stimuli failed to mimic ischemic preconditioning in the aging heart but exercise training and caloric restriction separately, and more powerfully taken together, are able to completely preserve and/or restore the age-related reduction of ischemic preconditioning.

Review of the treatment of acute coronary syndrome in elderly patients

Advances in treatment and early revascularization have led to improved outcomes for patients with acute coronary syndrome (ACS). However, elderly ACS patients are less likely to receive evidence-based treatment, including revascularization therapy, due to uncertainty of the associated benefits and risks in this population. This article addresses key issues regarding medical and revascularization therapy in elderly ACS patients based on a review of the medical literature and in concordance with clinical practice guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

Mortality of patients admitted to hospital with acute ST-elevation myocardial infarction, before and after the opening of primary percutaneous coronary intervention unit in Szombathely

Az akut szívizominfarktus kezelési stratégiája alapvetően megváltozott az elmúlt időszakban. Továbbra is vita tárgya a két reperfúziós stratégia, a primer percutan coronariaintervenció és a fibrinolízis összehasonlítása. Ha primer percutan coronariaintervenció elérhető, akkor ez a választandó kezelési stratégia ST-szegment-elevációval járó myocardialis infarctusban. Cél: Jelen cikkben a Szombathely városból ST-szegment-elevációval járó akut szívinfarktussal kórházba került betegek 3 hónapos halálozását vizsgáltuk. Módszer: Két időszakot hasonlítottunk össze, 2005-öt, amikor nem volt helyben percutan coronariaintervencióra alkalmas szívkatéteres laboratórium és 2008-at, amikor helyben rendelkezésre állt a primer percutan coronariaintervenció. Eredmények: A 12 órás ischaemiás időszaknál rövidebb betegcsoportban a 3 hónapos halálozás 2008-ban lényegesen alacsonyabb volt a 2005-ös évhez képest (3,6% versus 15,6%). Elsősorban a fibrinolízissel kezelt betegcsoport magas, három hónapos mortalitása volt felelős a különbségért. Ugyancsak fontos, hogy 2008-ban csökkent a 12 órán túli betegek aránya 2005-höz képest. Következtetés: A szívkatéteres labor létrehozása kedvező hatással volt Szombathely város ST-elevációs infarktusos betegeinek kórlefolyására.

Comparison of Primary Percutaneous Coronary Intervention and Fibrinolytic Therapy in ST-Segment-Elevation Myocardial Infarction

Background— Published meta-analyses comparing primary percutaneous coronary intervention with fibrinolytic therapy in patients with ST-segment-elevation myocardial infarction include only randomized controlled trials (RCTs). We aim to obviate the limited applicability of RCTs to real-world settings by undertaking meta-analyses of both RCTs and observational studies.

Methods and Results— We included all RCTs and observational studies, without language restriction, published up to May 1, 2008. We completed separate bayesian hierarchical random-effect meta-analyses for 23 RCTs (8140 patients) and 32 observational studies (185 900 patients). Primary percutaneous coronary intervention was associated with reductions in short-term (≤6-week) mortality of 34% (odds ratio, 0.66; 95% credible interval, 0.51 to 0.82) in randomized trials, and 23% lower mortality (odds ratio, 0.77; 95% credible interval, 0.62 to 0.95) in observational studies. Primary percutaneous coronary intervention was associated with reductions in stroke of 63% in RCTs and 61% in observational studies. At long-term follow-up (≥1 year), primary percutaneous coronary intervention was associated with a 24% reduction in mortality (odds ratio, 0.76; 95% credible interval, 0.58 to 0.95) and a 51% reduction in reinfarction (odds ratio, 0.49; 95% credible interval, 0.32 to 0.66) in RCTs. However, there was no conclusive benefit of primary percutaneous coronary intervention in the long term in the observational studies.

Conclusions— Compared with fibrinolytic therapy, primary percutaneous coronary intervention was associated with short-term reductions in mortality, reinfarction, and stroke in ST-segment-elevation myocardial infarction. Primary percutaneous coronary intervention was associated with long-term reductions in mortality and reinfarction in RCTs, but there was no conclusive evidence for a long-term benefit in mortality and reinfarction in observational studies.

Consequence and factors related to not offering reperfusion therapy in STEMI

INTRODUCTION

Varied reasons existed for not offering reperfusion therapy in ST elevation myocardial infarction and results in poor outcomes, and if related factors could be delineated, corrective measures can be attempted.

METHOD

We compared variables between participants not receiving reperfusion therapy and those receiving single reperfusion therapy. Multivariate analysis examined the contribution of non-reperfusion therapy to death and factors related to it.

RESULTS

Non-reperfusion therapy was older and had a lower frequency of typical chest pain, but more dyspnea, and post cardiac resuscitation. They had more heart failure and death. Non-reperfusion therapy was an independent factor related to cardiac death, and factors related to non-reperfusion therapy were age, type of hospital, presenting features on admission (dyspnea and post cardiac resuscitation), lack of typical chest pain, and not being referred to.

CONCLUSION

Non-reperfusion therapy had 2 to 3 times higher in-hospital mortality. Factors related to not offering reperfusion therapy, aside from age, appeared to be amendable to better management.

[Acute coronary syndrome in the elderly. Optimal revascularisation strategies]

Although there are accepted guidelines for treatment of acute coronary syndromes and ST-segment elevation myocardial infarction, elderly patients may have a variety of conditions that can complicate the decision making process about the best therapy. For fear of adverse effects many elderly patients do not receive potentially lifesaving treatments, such as percutaneous coronary intervention or thrombolytic therapy. Appropriate revascularisation therapy also often will be received too late in the course of the infarct, when irreversible myocardial damage has occurred. Many studies, however, show that older patients will benefit substantially from these therapies and early treatment improves outcome in this population, despite a higher risk of complications. In this review, the evidence regarding medical and revascularisation therapies in acute coronary syndromes in the elderly is critically examined.

Optimal revascularization strategies for ST-segment elevation myocardial infarction in the elderly patient

Patients older than 75 years account for >60% of all deaths from acute myocardial infarction. Although there are accepted guidelines for treatment of acute ST-segment elevation myocardial infarction, elderly patients tend to have a variety of conditions that can complicate decisions about the best therapy. Many elderly patients do not receive potentially lifesaving treatments, such as percutaneous coronary intervention or thrombolytic therapy, for fear of an adverse event. Those who do receive appropriate revascularization therapy often receive it later in the course of the infarct, when irreversible damage has occurred. Yet studies show that patients older than 75 years will benefit substantially from these therapies. Early treatment improves outcomes in this population, as in younger patients, despite a higher risk of complications. In this review, the evidence regarding medical and revascularization therapies in ST-segment elevation myocardial infarction is critically examined.

Acute Coronary Care in the Elderly, Part II

Background— Age is an important determinant of outcomes for patients with acute coronary syndromes. However, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients who would stand to benefit. Limited trial data are available to guide care of older adults, which results in uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age and complex health status.

Methods and Results— Part II of this American Heart Association scientific statement summarizes evidence on presentation and treatment of ST-segment–elevation myocardial infarction in relation to age (<65, 65 to 74, 75 to 84, and ≥85 years). The purpose of this statement is to identify areas in which the evidence is sufficient to guide practice in the elderly and to highlight areas that warrant further study. Treatment-related benefits should rise in an elderly population, yet data to confirm these benefits are limited, and the heterogeneity of older populations increases treatment-associated risks. Elderly patients with ST-segment–elevation myocardial infarction more often have relative and absolute contraindications to reperfusion, so eligibility for reperfusion declines with age, and yet elderly patients are less likely to receive reperfusion even if eligible. Data support a benefit from reperfusion in elderly subgroups up to age 85 years. The selection of reperfusion strategy is determined more by availability, time from presentation, shock, and comorbidity than by age. Additional data are needed on selection and dosing of adjunctive therapies and on complications in the elderly. A “one-size-fits-all” approach to care in the oldest old is not feasible, and ethical issues will remain even in the presence of adequate evidence. Nevertheless, if the contributors to treatment benefits and risks are understood, guideline-recommended care may be applied in a patient-centered manner in the oldest subset of patients.

Conclusions— Few trials have adequately described treatment effects in older patients with ST-segment–elevation myocardial infarction. In the future, absolute and relative risks for efficacy and safety in age subgroups should be reported, and trials should make efforts to enroll the elderly in proportion to their prevalence among the treated population. Outcomes of particular relevance to the older adult, such as quality of life, physical function, and independence, should also be evaluated, and geriatric conditions unique to this age group, such as frailty and cognitive impairment, should be considered for their influence on care and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed within the health context of the elderly patient.

An Invasive Strategy Is Associated With Decreased Mortality in Patients 80 Years and Older With Acute Myocardial Infarction

The value of invasive therapy in elderly patients with acute myocardial infarction is controversial. The authors performed a retrospective chart review of 140 consecutive patients 80 years and older who were hospitalized with acute myocardial infarction. Hospital outcomes and long-term survival were compared in 79 patients referred for cardiac catheterization during hospitalization with outcomes in 61 patients managed conservatively. Vital status as of December 2003 was determined from the Social Security Death Index. Propensity analysis was used to limit confounding from 13 variables. After a mean follow-up of 333 days, unadjusted mortality was lower in the invasive group (16.5% vs 50.8%; P<.001). The multivariable propensity-adjusted hazard ratio for death was 0.30 (95% confidence interval, 0.11-0.76; P=.01), favoring the invasive group. These data suggest that in patients 80 years and older who are hospitalized with acute myocardial infarction, an invasive strategy confers a significant survival advantage during the first year after hospital discharge.

Outcome of elderly patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

AIM

To investigate the outcome of primary percutaneous coronary interventions (PCI) in elderly patients (>/=>/=75 years) with ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

Between 1995 and 2003, a total of 319 consecutive patients with acute ST-elevation myocardial infarction presenting within 6-12 hr after onset of symptoms were prospectively enrolled in a registry. Of 296 patients undergoing primary PCI, 40 patients were >/=>/=75 years old (group A) and 256 patients younger than 75 years (group B). Elderly patients presented with a lower ejection fraction (49 +/- 14% vs. 53 +/- 13%, P = 0.046) and a higher number of cardiovascular risk factors. PCI success was achieved in 80% (group A) and 91% (group B, P = 0.031), respectively with comparable door-to-balloon times (87 +/- 49 and 95 +/- 79 min, P = ns). Periprocedural complications in both groups were low and major adverse cardiac events (death, myocardial infarction, target vessel revascularization and cardiac rehospitalization) after 6 months amounted to 23% (group A) and 20% (group B, P = ns), respectively.

CONCLUSIONS

Clinical outcome of elderly patients (>/=>/=75 years) with acute STEMI is favorable and comparable with the middle-aged population. However, procedural success was significantly lower in elderly (80%) compared to younger patients (90%). Acute percutaneous coronary intervention appears to be safe and not associated with higher periprocedural complications, in elderly patients.

Primary percutaneous interventions for acute myocardial infarction in octogenarians: a single-center experience

BACKGROUND

The majority of cardiovascular deaths occur in the elderly. The safety and results of primary infarct intervention in octogenarians is not well characterized.

HYPOTHESIS

The purpose of this study was to compare the results of primary infarct intervention in octogenarians with those in younger patients during 1997-1998 and to compare these results to those obtained in octogenarians treated in 1991-1994.

METHODS

During 1997-1998, 40 octogenarians were treated with primary infarct intervention and were compared with 60 randomly selected patients aged < 80 years treated during the same time period. The results in octogenarians were compared with the results in a group of 37 patients of similar age treated in 1991-1994. The baseline characteristics, procedural results, and hospital outcome were obtained from a prospectively designed interventional database at a busy single-center program.

RESULTS

There was no significant difference in hospital survival between the two groups of patients treated in 1997-1998 although there was a trend toward higher mortality in the octogenarian group. Length of stay and use of intra-aortic balloon pumps were greater in the octogenarian group. When the results in octogenarians treated in 1997-1998 were compared with the group of 37 patients treated in 1991-1994, the hospital mortality declined from 27 to 10% (p = 0.05).

CONCLUSIONS

There has been improvement in hospital mortality over the past decade for patients aged > or = 80 years treated with primary infarct intervention. Hospital resources and length of stay are greater for the octogenarian group. Ongoing research studies are comparing the results of thrombolytic therapy and primary intervention in aged patients.

Hospital Delays in Reperfusion for ST-Elevation Myocardial Infarction

Background— It has been suggested that the survival benefit associated with primary percutaneous coronary intervention (PPCI) in ST-segment elevation myocardial infarction may be attenuated if door-to-balloon (DB) time is delayed by >1 hour beyond door-to-needle (DN) times for fibrinolytic therapy. Whereas DB times are rapid in randomized trials, they are often prolonged in routine practice. We hypothesized that in clinical practice, longer DB-DN times would be associated with higher mortality rates and reduced PPCI survival advantage. We also hypothesized that in addition to PPCI delays, patient risk factors would significantly modulate the relative survival advantage of PPCI over fibrinolysis.

Methods and Results— DB-DN times were calculated by subtracting median DN time from median DB time at a hospital using data from 192 509 patients at 645 National Registry of Myocardial Infarction hospitals. Hierarchical models that adjusted simultaneously for both patient-level risk factors and hospital-level covariates were used to evaluate the relationship between PCI-related delay, patient risk factors, and in-hospital mortality. Longer DB-DN times were associated with increased mortality ( P <0.0001). The DB-DN time at which mortality rates with PPCI were no better than that of fibrinolysis varied considerably depending on patient age, symptom duration, and infarct location.

Conclusions— As DB-DN times increase, the mortality advantage of PPCI over fibrinolysis declines, and this advantage varies considerably depending on patient characteristics. As indicated in the American College of Cardiology/American Heart Association guidelines, both the hospital-based PPCI-related delay (DB-DN time) and patient characteristics should be considered when a reperfusion strategy is selected.

Regional outcomes after admission for high-risk non-ST-segment elevation acute coronary syndromes

PURPOSE

An analysis of reginal variation across the United States in the treatment and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) has not been previously performed.

SUBJECTS AND METHODS

We assessed contemporary practice and outcomes in 56,466 high-risk patients with NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes) admitted to 310 hospitals across four defined regions in the United States from January 1, 2001, to September 30, 2003. Patient clinical characteristics, acute (<24 hours) and discharge medications, in-hospital procedures, and in-hospital case-fatality rates were evaluated.

RESULTS

Statistically significant but clinically small differences in baseline characteristics including age, gender, rates of diabetes, hypertension, and smoking, as well as medical treatment, including a greater than 5% variation in acute use of beta-blockers, clopidogrel, and statins use, were noted across regions. Adjusted rates of revascularization were similar across regions. Overall in-hospital case-fatality rate was 4.1%, with the highest rates in the Midwest (4.6%) and the lowest in the Northeast (3.5%). Adjusted odds ratios (OR) (95% confidence interval [CI] for death were significantly higher in the Midwest (OR 1.42, CI 1.19-1.70), West (OR 1.40 CI 1.05-1.87), and South (OR 1.33, CI 1.08-1.62), compared with the Northeast.

CONCLUSIONS

Management of high-risk patients with NSTE ACS is relatively uniform across the United States. However, in-hospital case-fatality rates vary significantly by region, and the differences are not explained by adjustment for standard clinical variables.

Special issues when caring for the older person with acute coronary syndromes

Persons 75 years of age or older constitute 6% of the US population but account for more than one third of those with acute coronary syndromes (ACS). Unfortunately, most randomized clinical trials have enrolled few older persons, and, as a result, few data are available to guide clinical practice. As in younger patients, aspirin, beta-blockers, nitrates, clopidogrel, heparin, statins, and angiotensin-converting enzyme inhibitors are useful, beginning with lower doses and carefully observing the patient for symptoms of toxicity. Similarly, older patients should not be denied the benefit of reperfusion therapy and early invasive strategy because of their age. Although primary angioplasty is an optimal reperfusion strategy, thrombolytic therapy is a beneficial alternative in carefully selected older patients. Although glycoprotein IIb/IIIa inhibitors appear to be beneficial in select cases, bleeding concerns exist. Despite a growing body of evidence in support of aggressive ACS care in older persons, evidence-based therapy is underused in older patients. Continued efforts are required to improve the quality of care to this high-risk cohort of ACS patients.

Poor outcomes after fibrinolytic therapy for ST-segment elevation myocardial infarction: impact of age (a meta-analysis of a decade of trials)

BACKGROUND

Fibrinolysis for ST-segment elevation myocardial infarction (STEMI) reduces mortality, but its relative efficacy and risks are age-dependent. We aimed to quantify the outcomes of fibrinolysis and adjunctive antithrombin therapy for STEMI stratified by age.

METHODS

We performed a meta-analysis of 11 published (1992-2001) randomized clinical trials of fibrinolysis in STEMI (sample size >or=3,000, no age limit, no placebo-controlled arms) identified by MEDLINE through June 2005. Event rates and odds ratios (OR) in elderly vs. younger patients were calculated for mortality, intracranial hemorrhage (ICH) and total stroke (CVA). Elderly patients were defined as >or=75 years (GUSTO I, TIMI 9B, GUSTO III, COBALT, ASSENT-2, InTIME-II TIMI-17, ASSENT-3, GUSTO V, and HERO-2), except when defined as >65 or >or=70 years by the study (INJECT and ISIS-3).

RESULTS

Elderly (n = 24,531) vs. younger (n = 123,568) patients had increased rates of mortality (19.7% vs. 5.5%), ICH (1.4% vs. 0.5%) and CVA (3.5 vs. 1.2%) by 30-35 days; the excess risk for these events was substantial (OR mortality 4.37, 95% CI 4.16-4.58; ICH 2.83, 2.47-3.24; CVA 2.92, 2.62-3.25; p < 0.001 for all).

CONCLUSIONS

Despite established mortality reductions with fibrinolysis for STEMI, elderly compared with younger patients, still have a three to four fold increased risk of mortality and adverse events when treated with fibrinolysis and antithrombin therapy in the modern era. These robust estimates of the anticipated rates for mortality, ICH, and CVA can be used as benchmarks to monitor the efficacy and safety of therapies in ongoing and newly completed clinical trials. We aimed to quantify the outcomes of death, intracranial hemorrhage (ICH), and total cerebrovascular accidents (CVA) in elderly compared with younger patients treated with fibrinolysis for STEMI based on a meta-analysis of 11 randomized clinical trials (1992-2001) of more than 3,000 patients. Elderly (n = 24,531) vs. younger (n = 123 568) patients had increased rates of mortality, ICH and CVA by 30-35 days; the excess risk was substantial (OR 4.37, 2.83, and 2.92 respectively, p < 0.001 for all). These robust estimates can be used as benchmarks to monitor the efficacy and safety of therapies in ongoing and newly completed clinical trials.

Delivery of primary percutaneous coronary intervention for the management of acute ST segment elevation myocardial infarction: summary of the Cardiac Care Network of Ontario Consensus Report

Tremendous debate has developed over the efficacy of primary percutaneous coronary intervention (PCI) compared with fibrinolysis as the preferred treatment for acute ST segment elevation myocardial infarction (STEMI). In 2002, the Ontario Ministry of Heath and Long-Term Care commissioned the Cardiac Care Network of Ontario to develop consensus recommendations regarding the provincial coordination and provision of urgent PCI for STEMI patients. The panel's work has provided important insights into the acute treatment of STEMI that may be useful to other jurisdictions and may provide a reference for other regions considering the implementation of primary PCI for the management of STEMI patients in their community. In the present report, the evidence for primary PCI is reviewed, the important barriers to implementing this strategy are summarized and several recommendations and models of care for the delivery of primary PCI for STEMI on a wide scale are presented.

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

BACKGROUND

Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined.

METHODS

Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated risk-adjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status.

RESULTS

Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P<0.001). The number rather than the type of pre-existing conditions inversely correlated with the use of reperfusion therapy. While the impact of baseline risk and pre-existing conditions was additive, pre-existing conditions exerted a greater impact on the nonuse of reperfusion therapy than did baseline risk.

CONCLUSIONS

A treatment-risk paradox is demonstrable even within a cohort of lower risk patients with ST segment elevation myocardial infarction. These findings are consistent with the view that these clinical decisions are more likely to be attributable to concerns about patient frailty or side effects than to a misunderstanding of treatment benefits.

Factors Affecting the Management of Outcome in Elderly Patients with Acute Myocardial Infarction Particularly with Regard to Reperfusion

BACKGROUND

Acute myocardial infarction (AMI) in elderly patients is often unrecognized and associated with poor prognosis.

OBJECTIVES

To investigate management and efficacy of reperfusion therapy to the elderly patients with AMI.

METHODS

From the January 1, 2001 to October 31, 2002, 964 patients with AMI were included in the French regional RICO survey. The patients were divided into three groups: younger (<70 years old), elderly (70-79 years old) and very elderly (>or=80 years old).

RESULTS

Distribution of groups was 56, 27, and 16%, respectively. The longest time delay to first request for medical attention was found in the very elderly group (30 and 55 vs. 90 min, respectively, p < 0.05). Rate of lysis fell significantly with increasing age (35, 22 and 9%, respectively, p < 0.001) but the time delay to lysis was similar for the 3 groups. The proportion of patients who benefited from primary percutaneaous transluminal coronary angioplasty decreased with age (21, 15, 11%, respectively, p < 0.001), but time delay to balloon angioplasty was similar and no difference in mortality rate was observed between the three groups after reperfusion. The incidence of in-hospital cardiovascular events (cardiogenic shock and recurrent myocardial infarction/ischemia) and in-hospital mortality increased with age (5, 13, 17%, respectively, p < 0.001). Moreover, multivariate analysis showed that only ejection fraction and Killip >1 were independent predictive factors for in-hospital cardiovascular mortality, respectively (OR 5.15, 95% CI 2.08-12.74, p < 0.0001 and OR 3.81, 95% CI 1.90-7.65, p < 0.0001), whereas age, sex, diabetes and anterior location were not significant.

CONCLUSION

Our data in an unselected population indicate that very elderly patients were characterized by increased pre-hospital delays and less frequent utilization of reperfusion therapy, although no difference in the mortality in reperfused patients could be observed between the three age groups.

[Prehospital management of acute myocardial infarction. Data from a consecutive cohort of 115 patients in a French region in 2002]

The treatment of acute myocardial infarction is in evolution. Several strategies are utilized ranging from thrombolysis to percutaneous angioplasty (PCI), and the combination of both treatments; the latter providing an interesting compromise between treatment delay and efficiency of early myocardial reperfusion. We reviewed the early treatment strategies of acute myocardial infarctions undertaken by Samu in region 6 (south west of France) in 2002. Of a cohort of 115 patients, 83 patients (72.1%) had a revascularisation strategy: 56 (48.7%) had a primary PCI, and 27 (23.4%) had thrombolysis (92.6% being performed in the prehospital treatment). In those undergoing thrombolysis, 13 patients (48%) had ongoing features of ischaemia; excluding 4 patients who died during transport, all had a PCI at the admission in hospital. For the 14 patients with successful thrombolysis, 5 had facilitated PCI at the admission, 8 had a delayed angioplasty and 1 patient did not have angiography. Although the number of patients receiving thrombolysis in this study was small, this treatment was begun 62 minutes before primary PCI. There are important intra and extra hospital delays to the commencement of PCI. The easy utility of thrombolysis together with the potential to PCI argue in favour for a strategy of prehospital thrombolysis associated with a facilitated angioplasty.

Delay in Time to Receipt of Thrombolytic Medication Among Medicare Patients With Kidney Disease

BACKGROUND

Patients with kidney disease and acute myocardial infarction (AMI) receive standard therapy, including thrombolytic medication, less frequently than patients with normal kidney function. Our goal is to identify potential differences in thrombolytic medication delays and thrombolytic-associated bleeding events by severity of kidney disease.

METHODS

This is a retrospective cohort analysis of Cooperative Cardiovascular Project data for all Medicare patients with AMI from 4,601 hospitals. Outcome measures included time to administration of thrombolytic medication censored at 6 hours and bleeding events.

RESULTS

Of 109,169 patients (mean age, 77.4 years; 50.6% women), 13.9% received thrombolysis therapy. Average time to thrombolytic therapy was longer in patients with worse kidney function. Adjusted hazard ratios for minutes to thrombolytic therapy were 0.83 (95% confidence interval [CI], 0.79 to 0.87) for patients with a serum creatinine level of 1.6 to 2.0 mg/dL (141 to 177 micromol/L) and 0.58 (95% CI, 0.53 to 0.63) for patients with a creatinine level greater than 2.0 mg/dL (>177 micromol/L) or on dialysis therapy compared with those with normal kidney function. Odds ratios for bleeding events in patients administered thrombolytics versus those who were not decreased with worse kidney function: adjusted odds ratios, 2.28 (95% CI, 2.16 to 2.42) in patients with normal kidney function and 1.84 (95% CI, 1.09 to 3.10) in dialysis patients.

CONCLUSION

Patients with worse kidney function experienced treatment delays, but were not at greater risk for thrombolysis-associated excess bleeding events. Physician concerns of thrombolytic-associated bleeding may not be sufficient reason to delay the administration of thrombolytic medication.

Performance of the Thrombolysis in Myocardial Infarction (TIMI) ST-elevation myocardial infarction risk score in a national cohort of elderly patients

BACKGROUND

The TIMI ST-elevation myocardial infarction (STEMI) score was developed and validated in a randomized controlled trial population. We sought to assess its accuracy in a community-based cohort of elderly patients hospitalized with STEMI.

METHODS

We evaluated the TIMI STEMI score in 47,882 patients aged > or = 65 years hospitalized with STEMI in US hospitals from 1994 to 1996. We assessed TIMI STEMI score discrimination and calibration for 30-day mortality and compared observed and published TIMI mortality rates.

RESULTS

The cohort's median TIMI score was 6 (25th-75th percentile 4, 8). Thirty-day mortality rates were higher among patients with higher TIMI scores (TIMI score 2: 4.4% vs TIMI score > 8: 35.6%, P < .0001 for trend). However, the TIMI score provided only modest discrimination (c = 0.67) and calibration (goodness-of-fit P < .0001). Mortality rates for TIMI scores differed between patients who did and did not receive reperfusion therapy (P < .0001 for TIMI score x reperfusion therapy interaction). Thirty-day mortality rates in the cohort were higher than published TIMI estimates (P = .001; eg, TIMI score 2: 4.4% cohort vs 2.2% published rate).

CONCLUSIONS

The TIMI score provided modest prognostic discrimination and calibration among elderly patients with STEMI. Our findings highlight the difficulties in applying risk scores developed in randomized controlled trial cohorts to elderly patients.

Overview of contemporary reperfusion strategies in acute ST-elevation myocardial infarction

The rupture of an atherosclerotic plaque in an epicardial coronary artery with subsequent occlusive coronary thrombosis has been established as the decisive event in the pathogenesis of an acute coronary syndrome, which encompasses the clinical entities of unstable angina, non-ST- and ST-elevation myocardial infarction. This article focuses on contemporary treatment strategies for patients with acute ST-elevation myocardial infarction and reviews the role of pharmacologic thrombolysis and mechanical reperfusion by percutaneous transluminal approaches. Statements of the latest guidelines for the treatment of ST-elevation myocardial infarction are included, as well as some recently distributed information not covered by the guideline publications. Finally, some future perspectives for the treatment of acute ST-elevation myocardial infarction are outlined.

T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction

OBJECTIVES

Reperfusion therapy for acute myocardial infarction (AMI) is indicated in the presence of ST elevation (STE) and ischemic symptoms. Previous MI may present with persistent STE or "left ventricular aneurysm" (LVA) morphology that mimics AMI. Hypothesis A high ratio of T amplitude to QRS amplitude best distinguishes AMI from LVA.

METHODS

This was a retrospective cohort analysis. Patients with anatomical LVA by echocardiography were identified and those who presented to the ED with ischemic symptoms and STE of at least 1 mm in 2 consecutive leads and ruled out for acute left anterior descending coronary artery (LAD) occlusion were selected. Electrocardiograms (ECGs) were compared with a control group of 37 consecutive anterior AMI (aAMI) with proven acute LAD occlusion. Bundle-branch block was excluded. Various ECG measurements and ratios were compared.

RESULTS

Twenty patients with LVA met the inclusion criteria. The best discriminator was T amplitude sum to QRS amplitude sum ratio V1-V4, misclassifying only 4 (6.8%) of 59 cases at a cutoff of >0.22 for AMI. For aAMI and LVA, respectively, mean (+/-95% CI) ratio of the sum of T amplitudes in V 1 to V 4 to the sum of QRS amplitude in V1-V4 was 0.54+/-0.085 and 0.16+/-0.021 (P<.00012). Thirty-five of 37 aAMI had a ratio>0.22; the false negatives (ratio<0.22) had 11.5 and 6 hours of symptoms before the ECG. Twenty of 22 LVA had a ratio<or=0.22. Mean highest T/QRS ratio in V1-V4 was 1.1+/-0.29 for an AMI and 0.26+/-0.056 for LVA (P<10(-7)).

CONCLUSION

T amplitude/QRS amplitude ratio best distinguishes aAMI from LVA in ECGs that meet STE criteria for reperfusion therapy. A high ratio is associated with an AMI.

Effect of thrombolytic therapy on the risk of cardiac rupture and mortality in older patients with first acute myocardial infarction†

AIMS

To evaluate the effect of thrombolysis on mortality and its causes in older patients with acute myocardial infarction (AMI).

METHODS AND RESULTS

An analysis of 706 consecutive patients > or =75 years old with a first AMI enrolled in the PPRIMM75 registry showed that although there were important differences in baseline characteristics among patients treated with thrombolysis, primary angioplasty (PA) and those who did not receive reperfusion therapy, 30 day mortality did not differ (29, 25, and 32%, respectively). The main cause of death in patients treated with thrombolysis was cardiac rupture (54%), whereas most of the other patients died in cardiogenic shock. Patients who received thrombolysis had a higher (P<0.0001) incidence of free wall rupture (FWR) (17.1%) compared with those who did not receive reperfusion therapy (7.9%) or who underwent PA (4.9%). By multivariable analysis, patients treated with thrombolytic therapy (TT) showed an excess risk of FWR (OR, 3.62; 95% CI, 1.79-7.33), a hazard not observed in patients who underwent PA. When compared with patients who did not receive reperfusion therapy, the odds ratio of 30 day mortality was 1.07 (95% CI, 0.65-1.76) for patients treated with thrombolysis and 0.78 (95% CI, 0.45-1.34) for those who underwent PA. The figures for 24 month mortality were 0.78 (95% CI, 0.65-1.76) and 0.67 (95% CI, 0.28-0.81), respectively.

CONCLUSION

Treatment of first AMI with TT increases the risk of FWR in very old patients, a risk not observed in patients treated with PA.