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Hu M, Lang X, Yang J, Wang Y, Li W, Gao X, Yang Y. The prevalence and outcomes in STEMI patients aged ≥75 undergoing primary percutaneous coronary intervention in China. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 21:200251. [PMID: 38464698 PMCID: PMC10921244 DOI: 10.1016/j.ijcrp.2024.200251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
Objective To investigate the prevalence and outcomes of primary percutaneous coronary intervention (PCI) in Chinese patients with ST-segment elevation myocardial infarction (STEMI) aged ≥75 years. Methods We identified STEMI patients aged ≥75 years between 2013 and 2014 from a multicenter registry. The primary outcome was all-cause mortality. The secondary outcome was major adverse cardiac and cerebrovascular event (MACCE) including a composite of all-cause mortality, cardiac death, recurrent MI, stroke, revascularization, and major bleeding. Hazard ratios (HR) and associated 95% confidence interval (CI) were calculated. Results Approximately 32.9% (n = 999) patients received primary PCI. Primary PCI was associated with lower risks of two-year all-cause mortality (18.0% vs. 36.4%; adjusted HR: 0.54, 95% CI: 0.45 to 0.65, P < 0.0001), MACCE (28.7% vs. 43.5%; adjusted HR: 0.68, 95% CI: 0.59 to 0.80, P < 0.0001), and cardiac death (10.0% vs. 23.6%; adjusted HR: 0.49, 95% CI: 0.38 to 0.62, P < 0.0001) relative to no reperfusion (n = 2041) in patients aged ≥75 years. The better outcomes in two-year all-cause mortality, MACCE, and cardiac death were consistently observed in STEMI patients aged ≥85 years. No differences were observed in recurrent MI, stroke, revascularization, and major bleeding between the two groups. Additionally, in patients with relatively high-risk profiles such as cardiogenic shock or delaying hospital admission, primary PCI was also superior to no reperfusion. Conclusion Primary PCI may decrease two-year all-cause mortality, MACCE, and cardiac death in STEMI patients aged ≥75 years, even in these with age ≥85 years, cardiogenic shock, or delaying hospital admission. However, primary PCI was underutilized in Chinese clinical practice.
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Affiliation(s)
- Mengjin Hu
- Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Xinyue Lang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Jingang Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Xiaojin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
| | - for the China Acute Myocardial Infarction Registry Investigators
- Xuanwu Hospital, Capital Medical University, Beijing 100053, China
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100037, China
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Hu M, Li X, Yang Y. Invasive Versus Conservative Management of NSTEMI Patients Aged ≥ 75 Years. Arq Bras Cardiol 2023; 120:e20220658. [PMID: 37255135 PMCID: PMC10484564 DOI: 10.36660/abc.20220658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND The efficiency of invasive management in older patients (≥75 years) with non-ST-segment elevation myocardial infarction (NSTEMI) remains ambiguous. OBJECTIVES To assess the efficiency of invasive management in older patients with NSTEMI based on meta-analysis and trial sequential analysis (TSA). METHODS Relevant randomized controlled trials (RCT) and observational studies were included. The primary outcomes were all-cause death, myocardial infarction, stroke, and major bleeding. Pooled odd ratio (OR) and 95% confidence interval (CI) were calculated. P <0.05 was considered statistically significant. RESULTS Five RCTs and 22 observational studies with 1017374 patients were included. Based on RCT and TSA results, invasive management was associated with lower risks of myocardial infarction (OR: 0.51; 95% CI: 0.40-0.65; I2=0%), major adverse cardiovascular events (MACE; OR: 0.61; 95% CI: 0.49-0.77; I2=27.0%), and revascularization (OR: 0.29; 95% CI: 0.15-0.55; I2=5.3%) compared with conservative management. Pooling results from RCTs and observational studies with multivariable adjustment showed consistently lower risks of all-cause death (OR: 0.57; 95% CI: 0.50-0.64; I2=86.4%), myocardial infarction (OR: 0.63; 95% CI: 0.56-0.71; I2=0%), stroke (OR: 0.59; 95% CI: 0.51-0.69; I2=0%), and MACE (OR: 0.64; 95% CI: 0.54-0.76; I2=43.4%). The better prognosis associated with invasive management was also observed in real-world scenarios. However, for patients aged ≥85 years, invasive management may increase the risk of major bleeding (OR: 2.68; 95% CI: 1.12-6.42; I2=0%). CONCLUSIONS Invasive management was associated with lower risks of myocardial infarction, MACE, and revascularization in older patients with NSTEMI, yet it may increase the risk of major bleeding in patients aged ≥85 years.
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Affiliation(s)
- Mengjin Hu
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
- Xuanwu HospitalCapital Medical UniversityBeijingChinaXuanwu Hospital, Capital Medical University, Beijing – China
| | - Xiaosong Li
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
| | - Yuejin Yang
- Fuwai HospitalState Key Laboratory of Cardiovascular DiseaseBeijingChinaFuwai Hospital State Key Laboratory of Cardiovascular Disease, Beijing – China
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Onnis C, Muscogiuri G, Cademartiri F, Fanni D, Faa G, Gerosa C, Mannelli L, Suri JS, Sironi S, Montisci R, Saba L. Non-invasive coronary imaging in elderly population. Eur J Radiol 2023; 162:110794. [PMID: 37001255 DOI: 10.1016/j.ejrad.2023.110794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023]
Abstract
Age is a non-modifiable cardiovascular risk factor, which leads to development and progression of chronic conditions, such as coronary artery disease, by promoting atherosclerosis. Aging is responsible for morphological structure changes of the coronary arteries and specific atherosclerotic plaque features, which can be studied with non-invasive coronary imaging techniques, particularly coronary CT angiography. The aim of this review is to evaluate current knowledge on this technique applied to the elderly population, and to describe CAD manifestation and plaque features of coronary atherosclerosis in this particular set of patients. We also discuss the clinical implication of frailty assessment and customization of diagnostic strategies in order to shift the approach from disease-centered to patient-centered care.
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Management and Outcomes in the Elderly with Non-ST-Elevation Acute Coronary Syndromes Admitted to Spoke Hospitals with No Catheterization Laboratory Facility. J Clin Med 2022; 11:jcm11206179. [PMID: 36294500 PMCID: PMC9605530 DOI: 10.3390/jcm11206179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational−retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82−89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25−87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7−27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0−4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.
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Comparison of 3-Year Outcomes between Early and Delayed Invasive Strategies in Older and Younger Adults with Non-ST-Segment Elevation Myocardial Infarction Undergoing New-Generation Drug-Eluting Stent Implantation. J Clin Med 2022; 11:jcm11164780. [PMID: 36013019 PMCID: PMC9410439 DOI: 10.3390/jcm11164780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/01/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
We evaluated the 3-year clinical outcomes of early invasive (EI) and delayed invasive (DI) strategies in older and younger adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stent (DES) implantation to reflect current real-world practice. Overall, 4513 patients with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health and divided into two groups according to age: group A (age ≥ 65 years, n = 2253) and group B (age < 65 years, n = 2260). These two groups were further divided into two subgroups: group EI (A1 and B1) and DI (A2 and B2). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined as all-cause death, recurrent MI (re-MI), any repeat coronary revascularization, or stroke. The secondary clinical outcome was definite or probable stent thrombosis (ST). In both groups A and B, after multivariable-adjusted and propensity score-adjusted analyses, MACCE (group A, p = 0.137 and p = 0.255, respectively; group B, p = 0.171 and p = 0.135, respectively), all-cause death, cardiac death (CD), non-CD, re-MI, any repeat revascularization, stroke, and ST rates were similar between the EI and DI groups. When including only those with complex lesions, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. In the era of new-generation DESs, major clinical outcomes were not significantly different between the EI and DI strategies in both older and younger adults with NSTEMI.
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Kim YH, Her AY, Rha SW, Choi CU, Choi BG, Kim JB, Park S, Kang DO, Park JY, Park SH, Jeong MH. Outcomes of early versus delayed invasive strategy in older adults with non-ST-segment elevation myocardial infarction. Sci Rep 2022; 12:11429. [PMID: 35794207 PMCID: PMC9259558 DOI: 10.1038/s41598-022-15593-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/27/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractWe evaluated the 3-year clinical outcomes following early invasive (EI) and delayed invasive (DI) strategies in older adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stents (DESs) implantation to reflect current real-world practice. Overall, 2437 older adults (age, ≥ 65 years) with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health. They were divided into two groups: EI (n = 1750) and DI (n = 687). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined by all-cause death, recurrent MI, any repeat coronary revascularization, and stroke. The secondary clinical outcome was stent thrombosis (ST). After multivariable-adjusted and propensity score-matched analyses, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. Even after the analysis was confined to those having complex lesions, these major clinical outcomes were similar between these two groups. The EI and DI strategies in older adults with NSTEMI receiving new-generation DES showed comparable results.Clinical Trial Registration: URL: http://cris.nih.go.kr/cris/en/; Unique identifier: KCT0000863.
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Abusnina W, Radaideh Q, Al-Abdouh A, Ismayl M, Algheriani H, Lee J, Alam M, Ben-Dor I, Jimenez E, Azrin M, Paul TK, Dahal K. Routine Invasive Strategy in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome: An Updated Systematic Review and Meta-analysis of Randomized Trials. Curr Probl Cardiol 2022; 47:101304. [PMID: 35803333 DOI: 10.1016/j.cpcardiol.2022.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 06/28/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. AIM To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. METHODS AND RESULTS We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70-1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P=0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). CONCLUSION This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.
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Affiliation(s)
- Waiel Abusnina
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE.
| | - Qais Radaideh
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, KY
| | - Mahmoud Ismayl
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
| | | | - Juyong Lee
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Mahboob Alam
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington DC
| | - Enrique Jimenez
- Section of Cardiology, Overton Brooks Veterans Affairs Medical Center, Shreveport, LA
| | - Michael Azrin
- Division of interventional cardiology, University of Connecticut Health Center, Farmington, CT
| | - Timir K Paul
- Department of medical education, University of Tennessee at Nashville, Nashville, TN
| | - Khagendra Dahal
- Division of Cardiovascular Diseases, Creighton University School of Medicine, Omaha, NE
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Grinberg T, Hammer Y, Wiessman M, Perl L, Ovdat T, Tsafrir O, Kogan Y, Beigel R, Orvin K, Kornowski R, Eisen A. Management and outcomes over time of acute coronary syndrome patients at particularly high cardiovascular risk : the ACSIS registry-based retrospective study. BMJ Open 2022; 12:e060953. [PMID: 35410940 PMCID: PMC9003597 DOI: 10.1136/bmjopen-2022-060953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Some patients following acute coronary syndrome (ACS) are at particularly increased risk for recurrent cardiovascular events. We aimed to examine temporal trends in the management and outcomes across the spectrum of these particularly high-risk patients. DESIGN AND SETTING A retrospective study based on the ACS Israeli survey (ACSIS) registry, a multicentre prospective national registry, taking place biennially in 25 cardiology departments in Israel. Temporal trends were examined in the early (2002-2008) and late (2010-2018) time periods. PARTICIPANTS Consecutive patients with ACS enrolled in the ACSIS registry were stratified according to the Thrombolysis in Myocardial Infarction Risk Score for secondary prevention (TRS2°P) to high (TRS2°p=3), very high (TRS2°p=4) or extremely high risk (TRS2°p=5-9). Patients with TRS2°p<3 were excluded. From the initial 15 196 patients enrolled, 5359 patients were eventually included.Clinical outcome measures included 30-day major adverse cardiovascular events (MACE) and 1-year mortality. RESULTS Among 5359 patients (50% high risk, 30% very high risk and 20% extremely high risk), those with a higher risk were older, had more comorbidities, presented more with non-ST elevation myocardial infarction, and were treated less often with guideline-recommended pharmacotherapy and percutaneous coronary intervention. Over time, treatment has improved in all risk strata, and the rate of 30-day MACE has significantly decreased in all risk groups (from 21% to 10%, from 22% to 15%, and from 26% to 16%, in high, very high and extremely high-risk groups, respectively, p<0.001 for each). However, 1-year mortality decreased only among high and very high-risk patients, and not among extremely high-risk patients in whom 1-year mortality rates remained very high (28.7% vs 28.9%, p=1). CONCLUSION Within a particularly high-risk cohort of patients with ACS, treatment has significantly progressed over almost 2 decades. While short-term outcomes have improved in all risk groups, 1-year mortality has remained unchanged in extremely high-risk patients with ACS.
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Affiliation(s)
- Tzlil Grinberg
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Hammer
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Wiessman
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Ovdat
- Heart Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Or Tsafrir
- Cardiology Department, Western Galilee Medical Center, Nahariya, Israel
| | - Yoni Kogan
- Cardiology Department, Assuta Medical Center, Ashdod, Israel
| | - Roy Beigel
- Heart Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Katia Orvin
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Cardiology Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zhang D, Xing YL, Wang H, Wang S, Miao Y, Huang W, Zhang K, Li HW, Sun Y, Chen H. Invasive treatment strategy in patients aged 80 years or older with non-ST-elevation acute coronary syndromes: a retrospective cohort study. Cardiovasc Diagn Ther 2022; 12:229-240. [PMID: 35433346 PMCID: PMC9011088 DOI: 10.21037/cdt-21-650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Invasive treatment is commonly recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the efficacy of this approach in patients aged ≥80 years remains uncertain. METHODS We retrospectively assessed consecutive NSTE-ACS patients ≥80 years of age who were hospitalized at our cardiovascular center from December 2012 to July 2019. Patients were divided into two groups based on whether they received invasive treatment (coronary angiography and, if indicated, revascularization) or not. Patients who died in the first 3 days after admission without receiving invasive treatment were excluded. The effect of invasive timed treatment was also explored by dividing patients into timely invasive or delayed invasive groups according to their risk classification. Multivariate COX regression, invasive probability weighting and propensity score matching were used to adjust for confounding variables. The primary outcome was all-cause death during follow-up. RESULTS A total of 1,201 patients with a median age of 82.0 (IQR, 81.0-84.0) were divided into two groups: 656 (54.6%) patients in the invasive group and 545 (45.4%) patients in the conservative group. Follow-up survival information was available for up to 6 years (median 3.0 years). During the follow-up, 296 (24.6%) patients died. After adjusting for confounding variables, the invasive treatment strategy was significantly associated with a lower risk of long-term mortality (HR =0.70, 95% CI: 0.54-0.92, P=0.010). No difference was found between timely invasive and delayed invasive interventions with mortality (HR =0.92, 95% CI: 0.57-1.47, P=0.725). CONCLUSIONS Invasive treatment was associated with lower mortality in patients ≥80 years of age with NSTE-ACS over a median of a 3-year follow-up. The invasive intervention time did not impact the outcome.
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Affiliation(s)
- Dai Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yun-Li Xing
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Huan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shan Wang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ye Miao
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wei Huang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Kan Zhang
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong-Wei Li
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Ying Sun
- Department of Geriatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Ferrero TG, Álvarez BÁ, Cordero A, Martínez JM, Antonio CC, Muiños PA, Casas CAJ, García ÓO, Arias FGR, Dominguez MP, Fortuny AT, Álvarez DI, Bermejo RA, Veloso PR, Alvarez BC, Acuña JMG, Zuazola P, Escribano D, Lage R, Sampedro FG, Juanatey JRG. Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry. Int J Cardiol 2021; 351:8-14. [PMID: 34942303 DOI: 10.1016/j.ijcard.2021.12.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/08/2021] [Accepted: 12/17/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. METHODS This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75 years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75 years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24 h vs. coronarography >24 h) after the diagnosis of NSTEACS. RESULTS Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46 months (interquartile range 18-71 months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. CONCUSIONS In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. BRIEF SUMMARY In this real-world retrospective observational study that included 2451 patients older than 75 years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.
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Affiliation(s)
- Teba González Ferrero
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV).
| | - Belén Álvarez Álvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Alberto Cordero
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - Jesús Martinón Martínez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carla Cacho Antonio
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pablo Antúnez Muiños
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Charigan Abou Jokh Casas
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Óscar Otero García
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Federico García-Rodeja Arias
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Marta Pérez Dominguez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Abel Torrelles Fortuny
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Diego Iglesias Álvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Rosa Agra Bermejo
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pedro Rigueiro Veloso
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Belén Cid Alvarez
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - José María García Acuña
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Pilar Zuazola
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - David Escribano
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV); Cardiology Department, University Hospital of San Juan, Alicante. Spain
| | - Ricardo Lage
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
| | - Francisco Gude Sampedro
- Epidemiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - José Ramón González Juanatey
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain; Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV)
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11
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Coronary stent fracture in an octogenarian patient: from bad to worse. J Geriatr Cardiol 2021; 18:968-972. [PMID: 34908931 PMCID: PMC8648541 DOI: 10.11909/j.issn.1671-5411.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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12
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Wang H, Shi L, Tian W, Zhao S. Invasive versus conservative strategy in the very elderly with non-ST-elevation acute coronary syndrome: A meta-analysis of randomized controlled trials. Geriatr Gerontol Int 2021; 22:36-41. [PMID: 34796611 DOI: 10.1111/ggi.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/11/2021] [Accepted: 11/01/2021] [Indexed: 11/30/2022]
Abstract
AIM To investigate the optimal treatment strategy in patients older than 80 years with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS All published randomized, placebo-controlled trials (RCTs) reporting on comparisons between invasive and conservative strategies for patients aged 80 years or older with NSTE-ACS were identified. The literature search was performed using PubMed, EMBASE, Cochrane Library, and the ISI Web of Science, from their establishment to July 2021 with no language restriction. The pooled risk ratios (RRs) with 95% confidence intervals (CI) for dichotomous outcomes were calculated. RESULTS Three RCTs involving a total of 893 cases met the inclusion criteria. Compared with the conservative group, the invasive strategy could significantly improve the incidence rate of composite endpoint (I2 = 21.9%; RR 0.727, 95% CI 0.619 to 0.855, P < 0.001), recurrent myocardial infarction (MI) (I2 = 0.0%; RR 0.585, 95% CI 0.441 to 0.776, P < 0.001) and revascularization (I2 = 0.0%; RR 0.239, 95% CI 0.126 to 0.455, P < 0.001). However, no benefits were observed on outcomes of all-cause death (I2 = 0.0%; RR 0.888, 95% CI 0.681 to 1.160, P = 0.384), cardiac death (I2 = 0.0%; RR 0.769, 95% CI 0.412 to 1.433, P = 0.408) and stroke (I2 = 0.0%; RR 0.778, 95% CI 0.392 to 1.543, P = 0.473). The major bleeding events were comparable between the two groups (I2 = 0.0%; RR 1.582, 95% CI 0.622 to 4.025, P = 0.336). CONCLUSIONS Compared with a conservative strategy, the invasive treatment could reduce the incidence of composite endpoint, recurrent MI, and revascularization in the very elderly with NSTE-ACS. However, no benefits were observed on mortality. Geriatr Gerontol Int 2021; ••: ••-••.
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Affiliation(s)
- Haiyan Wang
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Liye Shi
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Wen Tian
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Shijie Zhao
- Department of Geriatric Cardiology, First Affiliated Hospital, China Medical University, Shenyang, China
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13
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Grinberg T, Bental T, Hammer Y, Assali A, Vaknin-Assa H, Wiessman M, Perl L, Kornowski R, Eisen A. Management and outcome across the spectrum of high-risk patients with myocardial infarction according to the thrmobolysis in myocardial infarction (TIMI) risk-score for secondary prevention. Clin Cardiol 2021; 44:1535-1542. [PMID: 34469003 PMCID: PMC8571543 DOI: 10.1002/clc.23715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/14/2021] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Patients with myocardial infarction (MI) are at increased risk for recurrent cardiovascular events, yet some patients, such as the elderly and those with prior comorbidities, are particularly at the highest risk. Whether these patients benefit from contemporary management is not fully elucidated. Methods Included were consecutive patients with MI who underwent percutaneous coronary intervention (PCI) in a large tertiary medical center. Patients were stratified according to the thrombolysis in myocardial infarction (TIMI) risk score for secondary prevention (TRS2°P) to high (TRS2°P = 3), very high (TRS2°P = 4), or extremely high‐risk (TRS2°P = 5–9). Excluded were low and intermediate‐risk patients (TRS2°P < 3). Outcomes included 30‐day/1‐year major adverse cardiac events (MACE) and 1‐year mortality. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time‐periods. Results Among 2053 patients, 50% were high‐risk, 30% very high‐risk and 20% extremely high‐risk. Extremely high‐risk patients were older (age 74 ± 10 year) and had significant comorbidities (chronic kidney disease 68%, prior CABG 40%, heart failure 78%, peripheral artery disease 29%). Drug‐eluting stents and potent antiplatelets were more commonly used over time in all risk‐strata. Over time, 30‐day MACE rates have decreased, mainly attributed to the very high (11.3% to 5.1%, p = .006) and extremely high‐risk groups (15.9% to 8.0%, p = .016), but not the high‐risk group, with similar quantitative results for 1‐year MACE. The rates of 1‐year mortality remained unchanged in either group. Conclusion Within a particularly high‐risk cohort of MI patients who underwent PCI, the implementation of guideline‐recommended therapies has improved over time, with the highest‐risk groups demonstrating the greatest benefit in outcomes.
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Affiliation(s)
- Tzlil Grinberg
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
| | - Tamir Bental
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Hammer
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Abid Assali
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hana Vaknin-Assa
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Maya Wiessman
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
| | - Leor Perl
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Eisen
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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14
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Chest pain and acute coronary syndrome in octogenarians admitted to the Emergency Department. Aging Clin Exp Res 2021; 33:2213-2221. [PMID: 33099674 DOI: 10.1007/s40520-020-01737-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although chest pain and acute coronary syndrome (ACS) are among the most common complaints in the Emergency Departments (ED), little is known about this topic in the octogenarian population. OBJECTIVES This study aimed to describe the clinical presentation and to evaluate survival time according to the ACS type in a group of 80-year-old or over patients admitted for chest pain to an ED. METHODS Patients were classified according to the discharge diagnosis. A multivariable Cox regression analysis was done to assess the association between ACS type and mortality with the non-ACS chest pain group as the reference category. RESULTS ACS was diagnosed in 170 of the 391 patients analyzed and 51% of ACS patients were female. Within the ACS patients, 18.8% presented STEMI, 57% NSTEMI, and 24% unstable angina (UA). Most of the patients were treated conservatively. In the adjusted analysis, the incidence of death at 40 months of follow-up was higher in patients with STEMI (HR 3.24; CI 1.59-6.56) than NSTEMI (HR 2.53; CI 1.56-4.11). There was no difference between patients with UA and the non-ACS group (HR 0.64; CI 0.26-1.58), and myocardial revascularization was associated with reduced mortality risk (HR 0.45; CI 0.22-0.92). CONCLUSIONS A high prevalence of ACS was found among octogenarians admitted to the ED with chest pain, and the ACS type behaved as an independent predictor of mortality. Patients with UA diagnosis had a similar prognosis to patients with non-ACS chest pain, but this needs to be demonstrated by a prospective study.
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15
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Kosyakovsky LB, Austin PC, Ross HJ, Wang X, Abdel-Qadir H, Goodman SG, Farkouh ME, Croxford R, Lawler PR, Spertus JA, Lee DS. Early invasive coronary angiography and acute ischaemic heart failure outcomes. Eur Heart J 2021; 42:3756-3766. [PMID: 34331056 PMCID: PMC8491058 DOI: 10.1093/eurheartj/ehab423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/11/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022] Open
Abstract
Aims While myocardial ischaemia plays a major role in the pathogenesis of heart failure (HF), the indications for coronary angiography during acute HF are not established. We determined the association of early coronary angiography during acute HF hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization. Methods and results In a two-stage sampling process, we identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010 to March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, we defined a cohort with acute ischaemic HF as patients with at least one factor suggesting underlying ischaemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. We oversampled patients undergoing angiography. We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7239 patients with acute HF, 2994 met inclusion criteria [median age 75 (interquartile range 65–83) years; 40.9% women]. Early angiography was performed in 1567 patients (52.3%) and was associated with lower all-cause mortality [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.61–0.90, P = 0.002], cardiovascular death (HR 0.72, 95% CI 0.56–0.93, P = 0.012), and HF readmissions (HR 0.84, 95% CI 0.71–0.99, P = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR 2.58, 95% CI 1.73–3.86, P < 0.001) and coronary artery bypass grafting (HR 2.94, 95% CI 1.75–4.93, P < 0.001) within 2 years. Conclusions Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischaemia.
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Affiliation(s)
| | - Peter C Austin
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Xuesong Wang
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Women's College Hospital, University of Toronto, 76 Grenville St, Toronto, ON, M5S 1B2, Canada
| | - Shaun G Goodman
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, 36 Queen St E, Toronto, ON, M5B 1W8, Canada
| | - Michael E Farkouh
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Ruth Croxford
- ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada
| | - Patrick R Lawler
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John A Spertus
- Division of Cardiology, St. Luke's Mid-America Health Institute/UMKC and Department of Biomedical and Health Informatics at UMKC, 4401 Wornall Road, 9th Floor, Kansas City, MO 64111, USA
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,ICES, 2075 Bayview Ave, Rm G-106, Toronto, ON, M4N 3M5, Canada.,Division of Cardiology, Peter Munk Cardiac Centre and Ted Rogers Centre for Heart Research, University Health Network, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
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16
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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de Belder A, Myat A, Blaxill J, Haworth P, O'Kane P, Hatrick R, Aggarwal R, Davie A, Smith W, Gerber R, Byrne J, Adamson D, Witherow F, Alsanjari O, Wright J, Robinson D, Hildick-Smith D. Revascularisation or medical therapy in elderly patients with acute anginal syndromes: the RINCAL randomised trial. EUROINTERVENTION 2021; 17:67-74. [PMID: 33226000 PMCID: PMC9724962 DOI: 10.4244/eij-d-20-00975] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Historically the elderly have been under-represented in non-ST-elevation myocardial infarction (NSTEMI) management trials. AIMS The aim of this trial was to demonstrate that an intervention-guided strategy is superior to optimal medical therapy (OMT) alone for treating NSTEMI in elderly individuals. METHODS Patients (≥80 years, chest pain, ischaemic ECG, and elevated troponin) were randomised 1:1 to an intervention-guided strategy plus OMT versus OMT alone. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial reinfarction at 1 year. Ethics approval was obtained by the institutional review board of every recruiting centre. RESULTS From May 2014 to September 2018, 251 patients (n=125 invasive vs n=126 conservative) were enrolled. Almost 50% of participants were female. The trial was terminated prematurely due to slow recruitment. A Kaplan-Meier estimate of event-free survival revealed no difference in the primary endpoint at 1 year (invasive 18.5% [23/124] vs conservative 22.2% [28/126]; p=0.39). No significant difference persisted after Cox proportional hazards regression analysis (hazard ratio 0.79, 95% confidence interval 0.45-1.35; p=0.39). There was greater freedom from angina at 3 months (p<0.001) after early intervention but this was similar at 1 year. Both non-fatal reinfarction (invasive 9.7% [12/124] vs conservative 14.3% [18/126]; p=0.22) and unplanned revascularisation (invasive 1.6% [2/124] vs conservative 6.4% [8/126]; p=0.10) occurred more frequently in the OMT alone cohort. CONCLUSIONS An intervention-guided strategy was not superior to OMT alone to treat very elderly NSTEMI patients. The trial was underpowered to demonstrate this definitively. Early intervention resulted in fewer cases of reinfarction and unplanned revascularisation but did not improve survival.
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Affiliation(s)
| | - Aung Myat
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | | | - Peter Haworth
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Peter O'Kane
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, United Kingdom
| | - Robert Hatrick
- Western Sussex Hospitals NHS Foundation Trust, Worthing, United Kingdom
| | | | - Andrew Davie
- Golden Jubilee National Hospital and Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Robert Gerber
- East Sussex Healthcare NHS Trust, Hastings, United Kingdom
| | - Jonathan Byrne
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Dawn Adamson
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | - Fraser Witherow
- Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom
| | | | - Juliet Wright
- Brighton and Sussex Medical School, Brighton, United Kingdom
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18
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2584] [Impact Index Per Article: 861.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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19
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Kunniardy P, Koshy AN, Meehan G, Murphy AC, Ramchand J, Clark DJ, Farouque O, Yudi MB. Invasive versus Conservative Management in Patients ≥85 years presenting with Non-ST Elevation Myocardial Infarction. Intern Med J 2021; 52:1167-1173. [PMID: 33647172 DOI: 10.1111/imj.15258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/12/2021] [Accepted: 02/23/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines recommend early coronary angiography (CA) in patients with non-ST-elevation myocardial infarction (NSTEMI), irrespective of age. However, elderly patients are less likely to be treated according to these guidelines due to their perceived high risk and medical comorbidities. Whether an invasive strategy is associated with improved survival in patients aged ≥85 years remains uncertain due to their exclusion from randomised trials. METHODS Consecutive patients aged ≥85 years presenting to a tertiary centre with NSTEMI between 2008-18 were included in this retrospective cohort study. Patients were stratified based on whether they underwent invasive management with CA with a view to revascularisation versus conservative management. The primary outcome was long-term mortality. RESULTS Of 7,591 patients with NSTEMI, 1052 patients ≥85years were included. 99(9.4%) patients underwent CA. Those undergoing CA were more likely to be younger, male, live independently, without mobility or cognitive issues (all p<0.01). Overall, 495(47%) patients died during a mean follow-up of 1.3±1 year. On Cox regression, after adjusting for age, pre-morbid functional status, cognition and cardiovascular risk factors, invasive management was the strongest predictor for survival (HR 0.47; 95%CI 0.26-0.85; p=0.01). Invasive management was associated with a trend to increased risk of in-hospital bleeding (6.1% vs 2.6%, p=0.054) with no significant difference in stroke (2.0% vs 3.8%, p=0.37). CONCLUSION In patients aged ≥85 years who presented with NSTEMI, invasive management was associated with improved survival without significant differences in bleeding or stroke. A randomised controlled study assessing the efficacy and safety of invasive management in very elderly patients with NSTEMI is warranted. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Phelia Kunniardy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Anoop N Koshy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Georgie Meehan
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Alexandra C Murphy
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jay Ramchand
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.,Heart and Vascular Institute, Cleveland Clinic Miller Family Heart and Vascular Institute, Cleveland, Ohio, USA
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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20
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Gaede L, Möllmann H. [The elderly patient with acute coronary syndrome]. Dtsch Med Wochenschr 2021; 146:48-57. [PMID: 33395727 DOI: 10.1055/a-1212-9393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The elderly patient with acute coronary syndrome (ACS) is often not treated on an evidence based basis due to age, previous illnesses and also an increased risk of bleeding. This applies to both drug and interventional therapy. However, valid data clearly show that elderly patients in particular benefit from guideline-adherent therapy, especially interventional revascularisation.
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21
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Rondano E, Bertolazzi M, Galluzzo A, Maltese L, Caccianotti P, Macciò S, Mazza S, Ruocco MVD, Favretto S, Occhetta E, Rametta F. Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction. World J Cardiol 2020; 12:513-525. [PMID: 33312437 PMCID: PMC7701903 DOI: 10.4330/wjc.v12.i11.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/28/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Elderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting.
AIM To describe the clinical features, in-hospital management and outcomes of “elderly” patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.
METHODS This study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.
RESULTS Of the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients.
CONCLUSION In this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.
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Affiliation(s)
- Elisa Rondano
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | | | - Ludovica Maltese
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | - Sergio Macciò
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | - Stefano Mazza
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | - Serena Favretto
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | - Eraldo Occhetta
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
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22
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Biscaglia S, Guiducci V, Santarelli A, Amat Santos I, Fernandez-Aviles F, Lanzilotti V, Varbella F, Fileti L, Moreno R, Giannini F, Colaiori I, Menozzi M, Redondo A, Ruozzi M, Gutiérrez Ibañes E, Díez Gil JL, Maietti E, Biondi Zoccai G, Escaned J, Tebaldi M, Barbato E, Dudek D, Colombo A, Campo G. Physiology-guided revascularization versus optimal medical therapy of nonculprit lesions in elderly patients with myocardial infarction: Rationale and design of the FIRE trial. Am Heart J 2020; 229:100-109. [PMID: 32822656 PMCID: PMC7434365 DOI: 10.1016/j.ahj.2020.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 08/11/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Myocardial infarction (MI) in elderly patients is associated with unfavorable prognosis, and it is becoming an increasingly prevalent condition. The prognosis of elderly patients is equally impaired in ST-segment elevation (STE) or non-STE (NSTE), and it is markedly worsened by the common presence of multivessel disease (MVD). Given the limited evidence available for elderly patients, it has not yet been established whether, as for younger patients, a complete revascularization strategy in MI patients with MVD should be advocated. We present the design of a dedicated study that will address this research gap. METHODS AND DESIGN The FIRE trial is a prospective, randomized, international, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients aged 75 years and older, with MI (either STE or NSTE), MVD at coronary artery angiography, and a clear culprit lesion will be randomized to culprit-only treatment or to physiology-guided complete revascularization. The primary end point will be the patient-oriented composite end point of all-cause death, any MI, any stroke, and any revascularization at 1 year. The key secondary end point will be the composite of cardiovascular death and MI. Quality of life and physical performance will be evaluated as well. All components of the primary and key secondary outcome will be tested also at 3 and 5 years. The sample size for the study is 1,400 patients. IMPLICATIONS The FIRE trial will provide evidence on whether a specific revascularization strategy should be applied to elderly patients presenting MI and MVD to improve their clinical outcomes.
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23
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Kaura A, Sterne JAC, Trickey A, Abbott S, Mulla A, Glampson B, Panoulas V, Davies J, Woods K, Omigie J, Shah AD, Channon KM, Weber JN, Thursz MR, Elliott P, Hemingway H, Williams B, Asselbergs FW, O'Sullivan M, Lord GM, Melikian N, Johnson T, Francis DP, Shah AM, Perera D, Kharbanda R, Patel RS, Mayet J. Invasive versus non-invasive management of older patients with non-ST elevation myocardial infarction (SENIOR-NSTEMI): a cohort study based on routine clinical data. Lancet 2020; 396:623-634. [PMID: 32861307 PMCID: PMC7456783 DOI: 10.1016/s0140-6736(20)30930-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI. METHODS Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure. FINDINGS Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82-89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2-4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55-0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48-0·93). INTERPRETATION The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. FUNDING NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.
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Affiliation(s)
- Amit Kaura
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan A C Sterne
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK; Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Adam Trickey
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Sam Abbott
- Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Abdulrahim Mulla
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Benjamin Glampson
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Vasileios Panoulas
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Jim Davies
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kerrie Woods
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joe Omigie
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Anoop D Shah
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Keith M Channon
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jonathan N Weber
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Mark R Thursz
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Paul Elliott
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Harry Hemingway
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Bryan Williams
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Folkert W Asselbergs
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Michael O'Sullivan
- National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Graham M Lord
- National Institute for Health Research Manchester Biomedical Research Centre, University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Narbeh Melikian
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Thomas Johnson
- National Institute for Health Research Bristol Biomedical Research Centre, University of Bristol and University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Darrel P Francis
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Ajay M Shah
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK; Institute of Health Informatics, Health Data Research UK, London, UK
| | - Divaka Perera
- National Institute for Health Research King's Biomedical Research Centre, King's College London, Guy's and St Thomas' NHS Foundation Trust and King's College Hospital NHS Foundation Trust, London, UK
| | - Rajesh Kharbanda
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Riyaz S Patel
- National Institute for Health Research University College London Biomedical Research Centre, University College London and University College London Hospitals NHS Foundation Trust, London, UK
| | - Jamil Mayet
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, London, UK.
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Gonçalves FF, Guimarães JP, Borges SC, Mateus PS, Moreira JI. Impact of coronary angioplasty in elderly patients with non-ST-segment elevation myocardial infarction. J Geriatr Cardiol 2020; 17:449-454. [PMID: 32952520 PMCID: PMC7475221 DOI: 10.11909/j.issn.1671-5411.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/28/2020] [Accepted: 08/14/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND As treatment of coronary artery disease improved over the last years, management of elder patients remained a matter of debate since this age group has been underrepresented in most trials. The study aimed to evaluate a population of patients with ≥ 85 years old with non-ST-segment elevation myocardial infarction (NSTEMI) and compare the prognosis according to coronary revascularization execution. METHODS We retrospectively studied 324 patients included in a national multicenter registry between October 2010 and October 2018, who underwent coronary angiography and had at least one stenosis ≥ 50%. RESULTS In this population, 73.1% of the patients underwent percutaneous coronary intervention (PCI) and 26.9% of the patients underwent optimized medical treatment (OMT). The OMT group had more past history of diabetes, stroke and dementia. On coronary angiography, the PCI group used more often the femoral artery access and single-vessel lesions were also more common. Three-vessel disease was more common in the OMT group. During hospitalization, there were more major bleeding events and death in the PCI group. During the one-year follow-up, there were no significant differences in all-cause mortality rate. CONCLUSIONS Very old patients with NSTEMI submitted to OMT had more comorbidities and more three-vessel disease, factors that could have influenced the therapeutic decision. Patients undergoing PCI had more in-hospital major bleeding events and mortality, with no significant differences after one year.
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Affiliation(s)
- Fernando F. Gonçalves
- />Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - José P. Guimarães
- />Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Sara C. Borges
- />Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Pedro S. Mateus
- />Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - José I. Moreira
- />Cardiology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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Non-ST elevation acute coronary syndrome in patients aged 80 years or older in Vietnam: An observational study. PLoS One 2020; 15:e0233272. [PMID: 32542011 PMCID: PMC7295222 DOI: 10.1371/journal.pone.0233272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/01/2020] [Indexed: 12/02/2022] Open
Abstract
Background There is limited evidence of non-ST elevation acute coronary syndrome (NSTE-ACS) in patients aged 80 or older in Vietnam. Aim To describe the clinical characteristics of patients aged≥80 with NSTE-ACS in Vietnam, and to examine the effect of percutaneous coronary intervention (PCI) on adverse outcomes. Methods Consecutive patients aged ≥80 with a diagnosis of NSTE-ACS admitted to two tertiary hospitals in Vietnam from 12/2018 to 06/2019 were recruited. The major outcomes were: (1) the composite of all-cause mortality, recurrent myocardial infarction and stroke, (2) re-admission rate during 3 months. Cox proportional-hazards regressions were conducted to examine the impact of PCI on the study outcomes, with results presented as hazard ratios (HR) and 95% confidence intervals (CI). Results There were 120 participants, mean age 84.8 ± 3.8, 50% were female. Angiography and PCI were performed in 42 participants (35.0%). Most of the participants had multimorbidity and multiple coronary vessel disease. Compared to participants who did not receive PCI, participants who received PCI had significantly lower rates of adverse events during hospitalisation and during 3 months of follow up. Cox proportional hazards models adjusted to age and GRACE score show that PCI was significantly associated with reduced the composite outcome of all-cause mortality, recurrent myocardial infarction and stroke during 3 months follow-up (adjusted HR 0.32, 95%CI 0.12–0.86). PCI was also associated with reduced re-admission. Conclusions The rate of PCI was low in the very elderly patients with NSTE-ACS in this study, although PCI was significantly associated with reduced adverse outcomes.
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26
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Age, knowledge, preferences, and risk tolerance for invasive cardiac care. Am Heart J 2020; 219:99-108. [PMID: 31733450 DOI: 10.1016/j.ahj.2019.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/13/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND/OBJECTIVES The extent to which individual knowledge, preferences, and priorities explain lower use of invasive cardiac care among older vs. younger adults presenting with acute coronary syndrome (ACS) is unknown. We directly surveyed a group of patients to ascertain their preferences and priorities for invasive cardiovascular care. DESIGN We performed a prospective cohort study of adults hospitalized with ACS. We surveyed participants regarding their knowledge, preferences, goals, and concerns for cardiac care, as well as their risk tolerance for coronary artery bypass grafting (CABG). SETTING Single academic medical center. PARTICIPANTS Six hundred twenty-eight participants (373 <75 years old; 255 ≥75 years old). MEASUREMENTS We compared baseline characteristics, knowledge, priorities, and risk tolerance for care across age strata. We also assessed pairwise differences with 95% confidence intervals (CI) between age groups for key variables of interest. RESULTS Compared with younger patients, older participants had less knowledge of invasive care; were less willing to consider cardiac catheterization (difference between 75-84 and< 65 years old: -7.8%, 95% CI: -14.4%,-1.3%; for ≥85 vs. <65: -15.7%, 95% CI: -29.8%,-1.6%), percutaneous coronary intervention (difference between 75-84 and< 65 years old: -12.8%, 95% CI: -20.8%,-4.8%; for ≥85 vs. <65: -24.8%, 95% CI: -41.2%,-8.5%), and CABG (difference between 75-84 and< 65 years old: -19.0%, 95% CI: -28.2%,-9.9%; for ≥85 vs. <65: -39.1%, 95% CI: -56.0%,-22.2%); and were more risk averse for CABG surgery (p < .001), albeit with substantial inter-individual variability and individual outliers. Many patients who stated they were not initially willing to undergo an invasive cardiovascular procedure actually ended up undergoing the procedure (49% for cardiac catheterization and 22% for PCI or CABG). CONCLUSION Age influences treatment goals and willingness to consider invasive cardiac care, as well as risk tolerance for CABG. Individuals' willingness to undergo invasive cardiovascular procedures loosely corresponds with whether that procedure is performed after discussion with the care team.
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Chien DK, Lee SY, Hung CL, Sun FJ, Lin MR, Chang WH. Do patients with non-ST-elevation myocardial infarction without chest pain suffer a poor prognosis? Taiwan J Obstet Gynecol 2019; 58:788-792. [PMID: 31759528 DOI: 10.1016/j.tjog.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Previous studies have discussed acute myocardial infarction (AMI) patients without chest pain, but have not focused on non-ST-elevation myocardial infarction (NSTEMI). MATERIALS AND METHODS This 1-year study investigated whether chest pain presence relates to demographics, risk factors, and outcomes in NSTEMI patients. We retrospectively reviewed 194 patients, 73 without chest pain vs. 121 with chest pain, and compared the differences between clinical presentations, risk factors, medical management, and outcomes of these two groups. RESULTS Compared to patients with chest pain, patients without chest pain were significantly older, had lower SBP, higher HR, more cerebrovascular disease, less ischemic heart disease, higher delay to ED (emergency department) visit, lower ED medication prescriptions, lower percutaneous cardiac intervention, and higher in-hospital and one-year mortality rate. In a multivariate logistic regression, the adjusted odds ratios (OR) of patients without chest pain were 4.38 for the elderly, 0.99 for every 1 mmHg increase in SBP, 1.02 for every beat/min HR increase, 0.37 for those with ischemic heart disease, and 5.09 for those with cerebrovascular disease. The adjusted OR of in-hospital mortality were 3.09 for patients without chest pain, 0.32 for those with hypertension, 0.32 for smokers, 3.98 for those with shock, and 0.16 for those with percutaneous cardiac intervention. Finally, the only significantly adjusted OR of one-year mortality was 5.37 for patients without chest pain. CONCLUSION NSTEMI patients without chest pain were significantly older, had lower SBP, more tachycardia, more cerebrovascular disease, but less ischemic heart disease. They also experienced higher in-hospital and one-year mortality rates.
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Affiliation(s)
- Ding-Kuo Chien
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan; Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan; Department of Medicine, Mackay Memorial College, Taipei, Taiwan
| | - Shih-Yi Lee
- Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Fang-Ju Sun
- Assistant Research, Department of Medical Research, MacKay Memorial Hospital, Taipei, Taiwan
| | - Mau-Roung Lin
- Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan
| | - Wen-Han Chang
- Department of Emergency Medicine, MacKay Memorial Hospital, Taipei, Taiwan; Mackay Medicine, Nursing and Management College, Taipei, Taiwan; Graduate Institute of Injury Prevention and Control, Taipei Medical University, Taipei, Taiwan; Institute of Mechatronic Engineering, National Taipei University of Technology, Taipei, Taiwan; Department of Medicine, Mackay Memorial College, Taipei, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan.
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Kvakkestad KM, Gran JM, Eritsland J, Holst Hansen C, Fossum E, Andersen GØ, Halvorsen S. Long-Term Survival after Invasive or Conservative Strategy in Elderly Patients with non-ST-Elevation Myocardial Infarction: A Prospective Cohort Study. Cardiology 2019; 144:79-89. [PMID: 31689705 DOI: 10.1159/000503442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 09/18/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The optimal management of elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) is still discussed. We aimed to study short- and long-term survival in NSTEMI patients ≥75 years managed with an invasive or a conservative strategy. METHODS NSTEMI patients admitted to Oslo University Hospital Ulleval during 2005-2011 were included consecutively in a prospective registry. Vital status until December 31, 2013, was obtained from the Norwegian Cause of Death Registry. Patients ≥75 years were identified, and 30-day and 7-year survival were analyzed. Logistic- and Cox regression was used to estimate OR and hazard ratio (HR) for death in the invasive versus conservative group, adjusting for registered confounders. RESULTS There were 2,064 NSTEMI patients ≥75 years (48.2% women); 1,200 (58.1%) were treated with an invasive strategy, and were younger, more likely to be male and previously revascularized compared to 864 (41.9%) patients treated conservatively (p < 0.0001 for all). Survival at 30-day was 94.9% in the invasive and 76.6% in the conservative group. For 30-day survivors, 7-year survival was 47.4% (95% CI 42.9-51.8) and 11.6% (95% CI 8.3-15.6), respectively. After multivariate adjustment, an invasive strategy was associated with lower long-term risk (adjusted HR [aHR] 0.49 [95% CI 0.41-0.59]). Actual revascularization was associated with lower risk of long-term mortality compared to angiography only (aHRPCI 0.73 [95% CI 0.59-0.90], aHRCABG 0.43 [95% CI 0.28-0.65]). CONCLUSION In this real-life cohort of NSTEMI patients ≥75 years, 30-day survival was 95%, and 7-year survival was 47% with an invasive strategy. Revascularized patients had a superior long-term prognosis. With a conservative strategy, short- and long-term survival was lower, probably due to selection bias and unmeasured confounding.
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Affiliation(s)
- Kristin Marie Kvakkestad
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway, .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway, .,Department of Medicine, Østfold Hospital, Kalnes, Grålum, Norway,
| | - Jon Michael Gran
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jan Eritsland
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Eigil Fossum
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Dou Q, Wang W, Wang H, Ma Y, Hai S, Lin X, Liu Y, Zhang X, Wu J, Dong B. Prognostic value of frailty in elderly patients with acute coronary syndrome: a systematic review and meta-analysis. BMC Geriatr 2019; 19:222. [PMID: 31416442 PMCID: PMC6694517 DOI: 10.1186/s12877-019-1242-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 08/05/2019] [Indexed: 02/05/2023] Open
Abstract
Background Frailty is common and associated with poorer outcomes in the elderly, but its prognostic value in acute coronary syndromes (ACS) requires clarification. We thus undertook a systematic review and meta-analysis to evaluate the relationship between frailty and poor prognosis in patients with ACS. Methods We systematically searched PubMed, Embase to find literatures which studied the prognostic value of frailty in elderly patients with ACS. Our main endpoints were the all-cause mortality, cardiovascular disease (CVD), major bleeding and readmissions. We pooled studies using random-effect generic inverse variance method, and conducted three pre-specified subgroup analyses. Results Of 1216 identified studies, 15 studies were included in our analysis. Compared with the normal group, frailty (HR = 2.65; 95%CI: 1.81–3.89, I2 = 60.2%) and pre-frailty (HR = 1.41; 95%CI: 1.19–1.66, I2 = 0%) were characterized by a higher risk of mortality after adjustment. Frailty also was associated with increased risk of any-type CVD, major bleeding and hospital readmissions in elderly patients with ACS. The pooled effect sizes in frail patients were 1.54 (95%CI: 1.32–1.79), 1.51 (95%CI: 1.14–1.99) and 1.51 (95%CI: 1.09–2.10). Conclusions Frailty provides quantifiable and significant prognostic value for mortality and adverse events in elderly ACS patients, helping doctors to appraise the comprehensive prognosis risk and to applicate appropriate management strategies. Electronic supplementary material The online version of this article (10.1186/s12877-019-1242-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qingyu Dou
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Wen Wang
- Chinese Evidence-based Medicine Center and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, Sichuan, China
| | - Hui Wang
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Yao Ma
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Shan Hai
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Xiufang Lin
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Ying Liu
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Xinjun Zhang
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China
| | - Jinhui Wu
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China.
| | - Birong Dong
- National Clinical Research Center of Geriatrics, Geriatric Medicine Center, West China Hospital, Sichuan University, No. 38, Guoxue Rd, Wuhou District, Chengdu, 610041, China.
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Outcomes of a routine invasive strategy in elderly patients with non-ST-segment elevation myocardial infarction from 2005 to 2014. Coron Artery Dis 2019; 30:326-331. [DOI: 10.1097/mca.0000000000000708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Couture EL, Farand P, Nguyen M, Allard C, Wells GA, Mansour S, Rinfret S, Afilalo J, Eisenberg M, Montigny M, Kouz S, Afilalo M, Lauzon C, Dery JP, L'Allier P, Schampaert E, Tardif JC, Huynh T. Impact of an invasive strategy in the elderly hospitalized with acute coronary syndrome with emphasis on the nonagenarians. Catheter Cardiovasc Interv 2018; 92:E441-E448. [PMID: 30269415 DOI: 10.1002/ccd.27877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/12/2018] [Accepted: 08/26/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Published data about nonagenarians with acute coronary syndrome (ACS) were mainly descriptive and limited by small sample sizes and unadjusted outcomes. We aim to describe the characteristics, management, and the impact of an invasive strategy on major adverse events in elderly patients hospitalized with ACS with focus on the nonagerians. METHODS AND RESULTS We analyzed data collected as part of the AMI-OPTIMA study, a cluster-randomized study of knowledge translation intervention versus usual care on optimal discharge medications in patients admitted with ACS at 24 Canadian hospitals. To determine whether an invasive strategy improved outcomes in the elderly, we used inverse probability weighting to adjust for confounders between patients who underwent invasive versus conservative strategies. Of 4,569 consecutive patients: 2,395 (52%) were <70 years old, 1,031 (23%) were septuagenarians, 941 (21%) were octogenarians, and 202 (4.4%) were nonagenarians. An invasive strategy was associated with reduced in-hospital all-cause mortality in all age groups: 1.1% versus 3.8% in patients <70 years old (P < 0.001), 2.9% versus 7.4% in septuagenarians (P < 0.001), 5.1% versus 14.7% in octogenarians (P < 0.001), and 12.0% versus 25.1% in nonagenarians (P = 0.001). An invasive strategy was also associated with higher thrombolysis in myocardial infarction major bleeds in the nonagenarians (9.0% vs. 2.0%; P = 0.003). CONCLUSIONS The reduction in in-hospital mortality associated with an invasive strategy in elderly and nonagenarians presented with ACS is generating hypothesis and merits further studies to confirm these benefits and to guide clinicians in the management of these high-risk patients.
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Affiliation(s)
- Etienne L Couture
- University of Ottawa Heart Institute, Ottawa (ON), Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Paul Farand
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Michel Nguyen
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Catherine Allard
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - George A Wells
- University of Ottawa Heart Institute, Ottawa (ON), Canada
| | - Samer Mansour
- Centre Hospitalier Universitaire de l'Universite de Montreal, Montréal (QC), Canada
| | | | | | | | | | - Simon Kouz
- Centre Hospitalier Regional de Lanaudiere, Saint-Charles-Borromée (QC), Canada
| | - Marc Afilalo
- McGill Health University Center, Montreal (QC), Canada
| | - Claude Lauzon
- Centre Hospitalier de l'Amiante, Thedford Mines (QC), Canada
| | | | | | | | | | - Thao Huynh
- McGill Health University Center, Montreal (QC), Canada
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Chen X, Barywani SB, Sigurjonsdottir R, Fu M. Improved short and long term survival associated with percutaneous coronary intervention in the elderly patients with acute coronary syndrome. BMC Geriatr 2018; 18:137. [PMID: 29898676 PMCID: PMC6001043 DOI: 10.1186/s12877-018-0818-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 05/16/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) are increasingly used in daily clinical practice in elderly patients with acute coronary syndrome (ACS) despite limited evidence. The purpose of this study was to assess the impact of PCI on short and long term survivals in a large cohort of elderly patients with ACS from a "real world". METHODS We enrolled 491 patients aged ≥70 years admitted to our institution with ACS from 2006 to 2012. Effect of PCI on short and long term survival was evaluated in both overall and a propensity score-matched cohort. RESULTS The mean age of the overall cohort is 83 ± 6 years. Among them, 285 were treated with PCI, whereas 206 were not. Patients treated with PCI were younger (82 ± 5 vs. 85 ± 6), more males (67% vs. 46%), with lower heart rate (77 ± 22 vs. 84 ± 21), higher eGFR (58 ± 20 vs. 47 ± 23), and less with heart failure (29% vs. 15%) (all p < 0.001). In both overall and propensity-matched population, improved survival was associated with PCI-treatment at 1 and 3 years (p < 0.001 for all comparisons). Furthermore, by using multivariate Cox proportional-hazards regression model following factors were identified as independent predictors of 3-year all-cause mortality: age (HR 1.08, 95% CI 1.00-1.16), heart rate (HR 1.02, 95% CI 1.01-1.03), eGFR (HR 3.07, 95% CI 1.63-5.77), malignancy (HR 2.03, 95% CI 1.27-4.57), prior CABG (HR 2.033, 95% CI 1.27-4.57), medication with statin (HR 0.40, 95% CI 0.19-0.86) in PCI group, whereas age (HR 1.08, 95% CI 1.03-1.13), heart rate (HR 1.01, 95% CI 1.01-1.02), hypertension (HR 1.87, 95% CI 1.01-3.49) and using of ACEI/ARB (HR 0.46, 95% CI 0.28-0.76) in non-PCI group. CONCLUSIONS In elderly ACS patients, PCI-treatment was associated with improved 1 and 3-year survival and PCI-treated patients had different prognostic profile compared to those without PCI treatment.
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Affiliation(s)
- Xiaojing Chen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. .,Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China. .,Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, 416 50, Göteborg, SE, Sweden.
| | - Salim Bary Barywani
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Runa Sigurjonsdottir
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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De Rosa R, Palmerini T, De Servi S, Belmonte M, Crimi G, Cornara S, Calabrò P, Cattaneo M, Maffeo D, Toso A, Bartorelli A, Palmieri C, De Carlo M, Capodanno D, Genereux P, Angiolillo D, Piscione F, Galasso G. High on-treatment platelet reactivity and outcome in elderly with non ST-segment elevation acute coronary syndrome - Insight from the GEPRESS study. Int J Cardiol 2018; 259:20-25. [DOI: 10.1016/j.ijcard.2018.01.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/09/2017] [Accepted: 01/15/2018] [Indexed: 11/16/2022]
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Walker DM, Gale CP, Lip G, Martin-Sanchez FJ, McIntyre HF, Mueller C, Price S, Sanchis J, Vidan MT, Wilkinson C, Zeymer U, Bueno H. Editor's Choice - Frailty and the management of patients with acute cardiovascular disease: A position paper from the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:176-193. [PMID: 29451402 DOI: 10.1177/2048872618758931] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Frailty is increasingly seen among patients with acute cardiovascular disease. A combination of an ageing population, improved disease survival, treatable long-term conditions as well as a greater recognition of the syndrome has accelerated the prevalence of frailty in the modern world. Yet, this has not been matched by an expansion of research. National and international bodies have identified acute cardiovascular disease in the frail as a priority area for care and an entity that requires careful clinical decisions, but there remains a paucity of guidance on treatment efficacy and safety, and how to manage this complex group. This position paper from the Acute Cardiovascular Care Association presents the latest evidence about frailty and the management of frail patients with acute cardiovascular disease, and suggests avenues for future research.
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Affiliation(s)
| | - C P Gale
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - G Lip
- 3 Institute for Cardiovascular Sciences, University of Birmingham, UK.,4 Aalborg Thrombosis Research Unit, Aalborg University, Denmark
| | | | | | - C Mueller
- 6 Cardiovascular Research Institute Basel, University of Basel, Switzerland
| | - S Price
- 7 Royal Brompton Hospital, UK
| | - J Sanchis
- 8 Department of Cardiology, University of Valencia, Spain.,9 University of Valencia, CIBER CV, Spain
| | - M T Vidan
- 10 Department of Geriatrics, Universidad Complutense de Madrid Dr Esquerdo, Spain
| | - C Wilkinson
- 2 Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | - U Zeymer
- 11 Klinikum Ludwigshafen und Institut for Herzinfarktforschung, Germany
| | - H Bueno
- 12 National Centre for Cardiovascular Research, Spain
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Koukkunen H, Havulinna AS, Lehto S, Ketonen M, Mustonen J, Airaksinen JK, Ukkola O, Kesäniemi YA, Salomaa V. Case fatality of acute coronary events is improving even among elderly patients; the FINAMI study 1995-2012. Ann Med 2018; 50:35-45. [PMID: 28927303 DOI: 10.1080/07853890.2017.1382713] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AIM To examine trends in incidence and 28-day case fatality of myocardial infarction (MI) in persons aged 75-99 years in four areas of Finland. METHODS AND RESULTS The Finnish Acute Myocardial Infarction (FINAMI) register is a population-based MI register study, which during 1995-2012 recorded 30561 suspected acute coronary syndromes in persons aged ≥75 years. Of them, 16229 fulfilled the American Heart Association criteria for a definite, probable or possible MI or coronary death. This age-group contributed 56.8% of all MIs of which 62.7% occurred in women. The incidence of MI decreased by -3.3%/year (95% CI -4.2; -2.4) in women aged 75-84 years, and by -1.2%/year (-1.9; -0.5) in women aged 85-99 years, but among men in these age-groups, only a non-significant reduction occurred. The 28-day case fatality of MI was high. In the age-group 75-84 years, it decreased non-significantly by -1.6%/year in men, and significantly by -2.4%/year (-3.9; -0.8) in women. In the age-group 85-99 years, the decrease was more remarkable: -5.1%/year (-7.8; -2.3) and -3.9%/year (-5.5; -2.2), respectively. CONCLUSIONS In Finland, more than half of MIs occur in the age-group 75-99 years, and most of them in women. The incidence of MI decreased significantly in elderly women but non-significantly in elderly men. The 28-day case fatality decreased especially in the age-group 85-99 years. Key Messages In Finland, more than one half of all myocardial infarctions (MIs) occur in the age-group of 75 years or older. Furthermore, 62.7% of MIs among elderly patients occur among women, although 58.0% of the elderly population are women. The incidence of MI decreased significantly in elderly women but not in elderly men. The 28-day case fatality in elderly patients was high but decreased significantly during the study period 1995-2012. This study provides population-based data on treatment strategies and trends in incidence, event rate, mortality and case fatality of MI in elderly individuals. Elderly patients with acute coronary syndromes still present a remarkable burden to the healthcare system in Finland as well as in many other developed countries. Especially considering the modern trend of reducing hospital resources and shifting patient care to outpatient clinics, the epidemiology of MI in elderly patients remains an important issue for the future planning of the healthcare system.
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Affiliation(s)
- Heli Koukkunen
- a Department of Medicine , Kuopio University Hospital , Kuopio , Finland.,b Department of Medicine , University of Eastern Finland , Kuopio , Finland
| | - Aki S Havulinna
- c Department of Health , National Institute for Health and Welfare (THL) , Helsinki , Finland
| | - Seppo Lehto
- b Department of Medicine , University of Eastern Finland , Kuopio , Finland
| | - Matti Ketonen
- d Department of Medicine , North Karelia Central Hospital , Joensuu , Finland
| | - Juha Mustonen
- d Department of Medicine , North Karelia Central Hospital , Joensuu , Finland
| | - Juhani K Airaksinen
- e Heart Center , Turku University Hospital and University of Turku , Turku , Finland
| | - Olavi Ukkola
- f Research Unit of Internal Medicine, Medical Research Center Oulu , Oulu University Hospital and University of Oulu , Oulu , Finland
| | - Y Antero Kesäniemi
- f Research Unit of Internal Medicine, Medical Research Center Oulu , Oulu University Hospital and University of Oulu , Oulu , Finland
| | - Veikko Salomaa
- c Department of Health , National Institute for Health and Welfare (THL) , Helsinki , Finland
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Saraswat A, Rahman A, Singh K. An Invasive vs a Conservative Approach in Elderly Patients with Non-ST-Segment Elevation Myocardial Infarction: Systematic Review and Meta-Analysis. Can J Cardiol 2017; 34:274-280. [PMID: 29395710 DOI: 10.1016/j.cjca.2017.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/09/2017] [Accepted: 11/26/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Elderly (≥ 75 years) patients form a large sub-group of non-ST-segment elevation myocardial infarction (NSTEMI) population but are vastly under-represented in trials. Thus, the benefits of an early angiography in the elderly remain unclear. In this systematic review, we compared outcomes of "invasive" and "conservative" strategies of NSTEMI management in elderly patients. METHODS A comprehensive search of major databases was performed. We included comparative studies of any design that enrolled patients ≥ 75 years, and where outcomes of both strategies of NSTEMI management were available. RESULTS Among the included studies (3 randomized and 6 observational), there were 6340 patients in the "invasive" group and 13,358 patients in the "conservative" group. The 12-month mortality rate (odds ration [OR], 0.45; p < 0.00001), the 30-day mortality (OR, 0.50; p = 0.0009), and events of stroke (OR, 0.42; p < 0.00001) were significantly lower in the invasive group. Major bleeding was higher in the invasive cohort (OR, 1.63; p = 0.03). Analysis of randomised studies showed lower reinfarction with invasive approach at 12 months (p = 0.0001). Significant heterogeneity was noted among studies according to study design. CONCLUSION The overall benefit with invasive strategy comes from the data of observational studies that are prone to selection bias. We believe that there is a need for a large randomized study in the elderly patients regarding management of NSTEMI.
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Affiliation(s)
- Avadhesh Saraswat
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Atifur Rahman
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia; Department of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Kuljit Singh
- Department of Cardiology, Gold Coast University Hospital, Gold Coast, Queensland, Australia; Department of Medicine, Griffith University, Gold Coast, Queensland, Australia; Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
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Dégano IR, Subirana I, Fusco D, Tavazzi L, Kirchberger I, Farmakis D, Ferrières J, Azevedo A, Torre M, Garel P, Brosa M, Davoli M, Meisinger C, Bongard V, Araújo C, Lekakis J, Francès A, Castell C, Elosua R, Marrugat J. Percutaneous coronary intervention reduces mortality in myocardial infarction patients with comorbidities: Implications for elderly patients with diabetes or kidney disease. Int J Cardiol 2017; 249:83-89. [DOI: 10.1016/j.ijcard.2017.07.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/30/2017] [Accepted: 07/11/2017] [Indexed: 12/22/2022]
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Second-generation drug-eluting stents in the elderly patients with acute coronary syndrome: the in-hospital and 12-month follow-up of the all-comer registry. Aging Clin Exp Res 2017; 29:885-893. [PMID: 27832467 PMCID: PMC5590486 DOI: 10.1007/s40520-016-0649-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 10/12/2016] [Indexed: 11/21/2022]
Abstract
Background Katowice–Zabrze registry provides data that can be used to evaluate clinical outcomes of percutaneous coronary interventions in elderly patients (≥70 y/o) treated with either first- (DES-I) or second-generation (DES-II) drug-eluting stents (DES). Methods The registry consisted of data from 1916 patients treated with coronary interventions using either DES-I or DES-II stents. For our study, we defined patients ≥70 years of age as elderly. We evaluated any major adverse cardiac and cerebral events (MACCE) at 12-month follow-up. Results Coronary angiography revealed a higher incidence of multivessel coronary artery disease in this elderly patient population. There were no differences in acute and subacute stent thrombosis (0.4 vs. 0.6%, p = 0.760; 0.4 vs. 0.4%; p = 0.712). Elderly patients experienced more in-hospital bleeding complications requiring blood transfusion (2.0 vs. 0.9%; p = 0.003). Resuscitated cardiac arrests (2.0 vs. 0.9%; p = 0.084) were observed more often in this elderly patients during hospitalization. The composite in-hospital MACCE rates did not differ statistically between both groups (1.4 vs. 1.1%; p = 0.567). Data from a twelve-month follow-up disclosed that mortality was higher (7.1 vs. 1.8%; p < 0.001) in the elderly, with no difference in TVR (7.2 vs. 9.9%, p = 0.075), MI (6.0 vs. 4.8%, p = 0.300), stroke (0.8 vs. 0.6%, p = 0.600) and composite MACCE (15.0 vs. 13.4%, p = 0.324). The age of 70 years or over was an independent predictor of death [HR = 2.55 (95% CI 1.49–4.37); p < 0.001]. The use of DES-II reduced the risk of MI [HR = 0.40 (95% CI 0.19–0.82); p = 0.012] in the elderly. Conclusion This elderly patient population had an increased risk of in-hospital bleeding complications requiring blood transfusion and a higher risk of death at 12-month follow-up. The use of new-generation DES reduced the risk of MI in the elderly population.
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Sappa R, Grillo MT, Cinquetti M, Prati G, Spedicato L, Nucifora G, Perkan A, Zanuttini D, Sinagra G, Proclemer A. Short and long-term outcome in very old patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention. Int J Cardiol 2017; 249:112-118. [PMID: 28935461 DOI: 10.1016/j.ijcard.2017.09.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 07/04/2017] [Accepted: 09/08/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although octogenarians constitute a fast-growing portion of cardiovascular patients, few data are available on the outcome of patients aged ≥85 years with ST-Elevation Myocardial Infarction (STEMI). METHODS AND RESULTS We analyzed 126 consecutive patients aged ≥85 years (age 88±2 years) with STEMI, undergoing primary percutaneous coronary intervention (pPCI) within 12 hours from symptoms onset. Long-term follow-up (median 898 days) was obtained for the 102 patients surviving the index-hospitalization. In-hospital mortality rate was 19%. Nonagenarians, diabetes mellitus, severe left ventricular systolic dysfunction and intra-aortic balloon pumping were significantly and independently correlated to in-hospital mortality at the multivariate analysis. A low rate of complications was detected. Among patients surviving the index hospitalization, 32 (31%) patients died during follow-up. 55 patients (54%) had re-hospitalization due to cardiovascular causes. The univariate analysis identified chronic renal failure, Killip class ≥ 3, TIMI Risk Score >8 and very high risk of bleeding as predictors of long-term overall mortality. At the multivariate analysis only chronic renal failure and very high risk of bleeding were significantly and independently correlated to long-term all-cause mortality. Renal function and anterior myocardial infarction were significantly and independently associated with the combined end-point of cardiac mortality and re-hospitalization due to cardiovascular disease at the multivariate analysis. CONCLUSIONS PPCI in patients ≥85 years old is relatively safe. In this population, pPCI is associated with a good long-term survival, although still worse than in younger patients, despite a considerable incidence of re-hospitalization due to cardiovascular events.
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Affiliation(s)
- Roberta Sappa
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy.
| | - Maria Teresa Grillo
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy
| | - Martino Cinquetti
- Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Giulio Prati
- Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Leonardo Spedicato
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy
| | - Gaetano Nucifora
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy
| | - Andrea Perkan
- Cardiovascular Department, "Azienda Sanitaria Universitaria Integrata" of Trieste, Italy
| | - Davide Zanuttini
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy
| | - Gianfranco Sinagra
- Postgraduate School of Cardiovascular Sciences, University of Trieste, Trieste, Italy; Cardiovascular Department, "Azienda Sanitaria Universitaria Integrata" of Trieste, Italy
| | - Alessandro Proclemer
- Cardiothoracic Department, "Azienda Sanitaria Universitaria Integrata" of Udine, Italy
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Jobs A, Mehta SR, Montalescot G, Vicaut E, Van't Hof AWJ, Badings EA, Neumann FJ, Kastrati A, Sciahbasi A, Reuter PG, Lapostolle F, Milosevic A, Stankovic G, Milasinovic D, Vonthein R, Desch S, Thiele H. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 2017; 390:737-746. [PMID: 28778541 DOI: 10.1016/s0140-6736(17)31490-3] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/01/2017] [Accepted: 05/03/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. METHODS We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). FINDINGS We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. INTERPRETATION An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. FUNDING None.
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Affiliation(s)
- Alexander Jobs
- University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck, Germany; German Centre for Cardiovascular Research, Lübeck, Germany
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpetrière, Institut de Cardiologie, Paris, France
| | - Eric Vicaut
- Sorbonne Université Paris 6, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpetrière, Institut de Cardiologie, Paris, France
| | - Arnoud W J Van't Hof
- Department of Cardiology, Isala Klinieken, Zwolle, Netherlands; Department of Cardiology Research, Deventer Hospital, Deventer, Netherlands
| | - Erik A Badings
- Department of Cardiology Research, Deventer Hospital, Deventer, Netherlands
| | - Franz-Josef Neumann
- Universitäts-Herzzentrum Freiburg-Bad Krozingen, Klinik für Kardiologie und Angiologie II, University of Freiburg, Bad Krozingen, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Klinik für Kardiologie, München, Germany
| | | | - Paul-Georges Reuter
- AP-HP, Urgences-Samu 93, Hôpital Avicenne, Université Paris 13, 93000 Bobigny, France; Inserm U942, Université Paris 7-Denis Diderot, Paris, France
| | - Frédéric Lapostolle
- AP-HP, Urgences-Samu 93, Hôpital Avicenne, Université Paris 13, 93000 Bobigny, France; Inserm U942, Université Paris 7-Denis Diderot, Paris, France
| | | | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dejan Milasinovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Lübeck, Germany; ZKS Lübeck, Universität zu Lübeck, Lübeck, Germany
| | - Steffen Desch
- University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck, Germany; German Centre for Cardiovascular Research, Lübeck, Germany
| | - Holger Thiele
- Heart Center Leipzig - University of Leipzig, Leipzig, Germany; German Centre for Cardiovascular Research, Lübeck, Germany.
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Ma W, Liang Y, Zhu J. Early Invasive Versus Initially Conservative Strategy in Elderly Patients Older Than 75 Years with Non-ST-Elevation Acute Coronary Syndrome: A Meta-Analysis. Heart Lung Circ 2017; 27:611-620. [PMID: 28802810 DOI: 10.1016/j.hlc.2017.06.725] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 04/11/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fear of complications related to the procedure and unclear benefits in elderly patients are common reasons for invasive angiography being withheld. METHODS We searched PubMed and Embase from inception until February 2016 for studies that enrolled individuals older than 75 years with non-ST-elevation acute coronary syndrome (NSTE-ACS) and allocated patients to either an invasive or conservative strategy. RESULTS Thirteen studies (four randomised controlled trials (RCTs) and nine observational studies) enrolling 832,007 elderly NSTE-ACS patients were analysed. Compared with the conservative treatment, the early invasive approach does significantly reduce the risk of death at follow-up from 6 months to 5 years (risk ratio [RR] 0.65, 95% confidence interval [CI] 0.59-0.73, p<0.001); the definite benefit was mainly observed in observational studies (RR 0.63, 95% CI 0.57-0.70, p<0.001), and the risk of death also showed a strong trend toward reduction with invasive approach (RR 0.82, 95% CI 0.64-1.05, p=0.119) in RCTs. For the outcome of bleeding complications, there was a higher risk of any bleeding occurring in-hospital (RR 2.51, 95% CI 1.53-4.11, p<0.001) in patients treated with invasive strategy than those treated with conservative strategy. However, no difference of in-hospital major bleeding (RR 1.78, 95% CI 0.31-10.13, p=0.514) was observed between the two strategies. CONCLUSION Elderly patients with NSTE-ACS might benefit from an early invasive strategy but with increasing risk of any bleeding complications. More RCTs are needed to assess early invasive strategies in the elderly.
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Affiliation(s)
- Wenfang Ma
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Yan Liang
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Jun Zhu
- State Key Laboratory of Cardiovascular Disease, Emergency and Critical Care Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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Wei CC, Lee SH. Predictors of Mortality in Elderly Patients with Non-ST Elevation Acute Coronary Syndrome - Data from Taiwan Acute Coronary Syndrome Full Spectrum Registry. ACTA CARDIOLOGICA SINICA 2017; 33:377-383. [PMID: 29033508 PMCID: PMC5534417 DOI: 10.6515/acs20170126a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 01/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Some difficulties and variations remain associated with the care of elderly patients with non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS We included 1470 patients from a Taiwan nationwide registry who fulfilled the criteria of NSTE-ACS, and stratified these patients by age and evaluated the treatment, complications and outcomes in different age groups. Furthermore, we analyzed risk factors and standards of care to determine the predictors of mortality. RESULTS Patients ≥ 75 years of age (n = 396) had significantly higher incidences of 90-day mortality [odd ratio (OR) = 4.5 (1.2-16.3), p = 0.023] and 1-year mortality [OR = 4.9 (2.0-12.3), p = 0.001] compared with those patients 45-64 years of age (n = 595). In the patients ≥ 75 years of age, previous myocardial infarction (MI) [OR = 3.3 (1.1-9.8), p = 0.035], statins [OR = 0.35 (0.1-0.9), p = 0.037], left ventricular ejection fraction (LVEF) < 35% [OR = 3.9 (1.5-10.4), p = 0.006] were associated with 90-day mortality. Furthermore, previous MI [OR = 4.0 (1.3-12.6), p = 0.019] was an independent predictor of 90-day mortality. Age [OR = 1.1 (1.03-1.2), p = 0.002], previous MI [OR = 2.2 (1.1-4.4), p = 0.034], angiotensin-converting enzyme inhibitor or angiotensin receptor blocker [OR = 0.5 (0.3-0.9), p = 0.028], and LVEF < 35% [OR = 4.3 (1.9-9.5), p < 0.001] were associated with 1-year mortality. Furthermore, previous MI [OR = 2.6 (1.1-6.5), p = 0.037], LVEF < 35% [OR = 4.7 (1.5-14.4), p = 0.007] and percutaneous coronary intervention(PCI) or not [OR = 0.3 (0.1-0.9), p = 0.021] were independent predictors of 1-year mortality. CONCLUSIONS Previous MI, LVEF < 35% and PCI or not could predict 1-year mortality in advanced elderly patients with NSTE-ACS. Despite their elevated morbidities and complications, PCI was still beneficial for these patients.
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Affiliation(s)
- Cheng-Chun Wei
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho Su Memorial Hospital, Taipei
| | - Shih-Huang Lee
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho Su Memorial Hospital, Taipei
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Affiliation(s)
- Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Riccardo Liga
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Gnanenthiran SR, Kritharides L, D’Souza M, Lowe HC, Brieger DB. Revascularisation compared with initial medical therapy for non-ST-elevation acute coronary syndromes in the elderly: a meta-analysis. Heart 2017. [DOI: 10.1136/heartjnl-2017-311233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Do elderly females have a higher risk of acute myocardial infarction? A retrospective analysis of 329 cases at an emergency department. Taiwan J Obstet Gynecol 2017; 55:563-7. [PMID: 27590383 DOI: 10.1016/j.tjog.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Acute myocardial infarction (AMI) is a medical emergency; a missed or delayed diagnosis of this disease may contribute to a poor outcome and even death. Several studies have found elderly patients with AMI have atypical presentations for diagnosis, therefore we undertook this study to determine the risks among the elderly population, especially in female patients. MATERIALS AND METHODS In this one-year retrospective study, we reviewed the cases of AMI patients who had visited the emergency department at Mackay Memorial Hospital, Taiwan, and who had either been discharged or had died following a diagnosis of AMI (ICD code 410). We compared the differences between the clinical presentations of these two groups as well as the risk factors, medical management, and outcomes. RESULTS In our study, only 329 patients (164 elderly; 165 adults) met the defined criteria. The most common symptom of AMI was chest pain, and this was more common in adult patients than in elderly patients (81.8% vs. 60.4%, p < 0.001). In comparison with patients in the adult group, the patients in the elderly group had a significantly higher proportion of females (46.3% vs. 12.7%), non-ST-elevation myocardial infarction (NSTEMI) (71.3% vs. 46.7%), presenting with no chest pain (39.6% vs. 18.2%), shortness of breath (17.7% vs. 8.8%), nausea/vomiting/dizziness (7.9% vs. 2.4%), abdominal pain (4.3% vs. 0.6%), diabetes mellitus (45.1% vs. 26.1%), cerebrovascular disease (22.6% vs. 6.1%), longer hospital stays (18.2 ± 31.0 days vs. 9.8 ± 8.2 days), and increased in-hospital mortality rates (15.9% vs. 6.7%). CONCLUSION Compared with the adult AMI group, the elderly AMI group had a higher proportion of females, electrocardiography with NSTEMI and no chest-pain complaints, and a larger proportion of elderly patients with diabetes, ischemic heart disease, heart attacks at home and cardiac shock, which had longer hospital stays, and higher mortality rates.
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Staged versus "one-time" multivessel intervention in elderly patients with non-ST-elevation acute coronary syndrome. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:760-767. [PMID: 27899940 PMCID: PMC5122501 DOI: 10.11909/j.issn.1671-5411.2016.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Objective To evaluate the clinical outcomes of “one-time” versus staged multivessel stenting in elderly (≥ 60 years) patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). Methods We analyzed data of consecutive NSTE-ACS patients with multivessel percutaneous coronary intervention (PCI) who were enrolled in General Hospital of Shenyang Military Region between 2008 and 2012. A total of 1090 eligible patients aged ≥ 60 were further categorized into “one-time” group (n = 623) and staged PCI group (n = 467) according to intervention strategy. The primary endpoint was composite outcome of myocardial infarction (MI) or cardiac death during 3-year follow-up. Results The estimated 3-year composite rate of cardiac death or MI was 7.0% in the staged PCI group and 9.5% in the “one-time” group (P = 0.110). Multivariate analysis confirmed the benefit of staged PCI on the primary events in the elderly (HR: 0.638, 95% CI: 0.408–0.998, P = 0.049). In a propensity score matched cohort, staged PCI was associated with lower rates of primary events (6.1% vs. 10.4%, P = 0.046) and MI (3.4% vs. 7.4%, P = 0.037) at three years. In addition, there were reduced trends in the stent thrombosis at 30 days (0.3% vs. 1.4%, P = 0.177) and at three years (1.1% vs. 2.4%, P = 0.199) in the staged PCI group. There was no significant difference in the 3-year target vessel revascularization (15.5% vs. 14.4%, P = 0.746). Conclusions In elderly NSTE-ACS patients with MVD, staged PCI might be an optimal strategy associated with reduced long-term cardiac death or MI compared with “one-time” PCI strategy, which needs further confirmation.
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Yazji K, Abdul F, Elangovan S, Ossei-Gerning N, Choudhury A, Cockburn J, Anderson R, Mamas M, Kinnaird T. Comparison of the Effects of Incomplete Revascularization on 12-Month Mortality in Patients <80 Compared With ≥80 Years Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2016; 118:1164-1170. [PMID: 27553100 DOI: 10.1016/j.amjcard.2016.07.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/10/2016] [Accepted: 07/10/2016] [Indexed: 11/24/2022]
Abstract
Although randomized trial data suggest that complete revascularization improves outcomes after percutaneous coronary intervention (PCI), the impact of differing revascularization strategies in octogenarians is not well defined. We performed a retrospective analysis, which was conducted of 9,628 consecutive patients who underwent PCI at a large UK center. Octogenarians were more likely to have significant co-morbidity, a higher Mehran bleed risk score (24.5 ± 6.8 vs 13.3 ± 7.4, p <0.0001), and more complex disease (baseline SYNTAX score 18.7 ± 11.0 vs 13.1 ± 8.9, p = 0.002) than younger patients. During PCI, octogenarians were more likely to undergo left main or proximal LAD intervention, but despite this, significantly less likely to receive drug-eluting stents (66.5% vs 80.1%, p <0.001). Postprocedurally, octogenarians had greater residual disease burden (residual SYNTAX score 10.1 ± 8.7 vs 1.6 ± 3.3, p <0.0001). At 12 months, adverse outcomes (definite stent thrombosis 3.3% vs 1.1%, p <0.001, clinically driven in-stent restenosis PCI 3.7% vs 2.6%, p = 0.005, and 12-month mortality 12.8% vs 4.2%, p <0.0001) were all more frequent in octogenarians. Although age, shock, diabetes, and BMS use were independently predictive of increased 12-month mortality, incomplete revascularization was not. In conclusion, octogenarians are a complex group to treat balancing high-risk bleeding profile and complex coronary disease. However, in multivariate analysis, incomplete revascularization was not independently predictive of adverse outcomes. These data support a conservative target lesion-only DES-driven revascularization strategy.
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Affiliation(s)
- James Cockburn
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Adam de Belder
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2016; 2016:CD004815. [PMID: 27226069 PMCID: PMC8568369 DOI: 10.1002/14651858.cd004815.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI. OBJECTIVES To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era. SEARCH METHODS We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions. SELECTION CRITERIA We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI. DATA COLLECTION AND ANALYSIS Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables. MAIN RESULTS Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias. AUTHORS' CONCLUSIONS In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.
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Affiliation(s)
- Jonathon P Fanning
- The Prince Charles HospitalSchool of Medicine, The University of QueenslandRode RoadChermsideBrisbaneAustralia4032
| | - Jonathan Nyong
- FARR Institute UCLClinical Epidemiology222 Euston RoadLondonGreater LondonUKNW1 2DA
| | - Ian A Scott
- Princess Alexandra HospitalInternal Medicine Department and Clinical Services Evaluation UnitBrisbaneAustralia
| | - Constantine N Aroney
- The Prince Charles HospitalDepartment of CardiologyRode RdChermsideBrisbaneAustralia
| | - Darren L Walters
- The Prince Charles HospitalExecutive Chair Prince Charles Heart and Lung InstituteRoad RdBrisbaneQueenslandAustralia4032
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