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Wilson T, Javaheri P, Finlay J, Hazlewood G, Wilton SB, Sajobi T, Levin A, Pearson W, Connolly C, James MT. Treatment Preferences for Cardiac Procedures of Patients With Chronic Kidney Disease in Acute Coronary Syndrome: Design and Pilot Testing of a Discrete Choice Experiment. Can J Kidney Health Dis 2021; 8:2054358120985375. [PMID: 33552527 PMCID: PMC7844446 DOI: 10.1177/2054358120985375] [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: 09/25/2020] [Accepted: 11/27/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Chronic kidney disease is associated with a high incidence of acute coronary syndrome and related morbidity and mortality. Treatment choices for patients with chronic kidney disease involve trade-offs in the potential benefits and harms of invasive management options. Objective: The objective was to quantify preferences of patients with chronic kidney disease toward invasive heart procedures. Design: Design and pilot a discrete choice experiment. Setting: We piloted the discrete choice experiment in 2 multidisciplinary chronic kidney disease clinics in Calgary, Alberta, using an 8-question survey. Patients: Eligible patients included those aged 18 years and older, an estimated glomerular filtration rate < 45 mL/min/1.73 m2, not currently receiving dialysis, and able to communicate in English. Measurements: Quantification of the average importances of key attributes of invasive heart procedures. Methods: We identified attributes most important to patients and physicians concerning invasive versus conservative management for acute coronary syndrome, using semi-structured qualitative interviews. Levels for each attribute were derived from analysis of early invasive versus conservative acute coronary syndrome management clinical trials and cohort studies, where subgroups of patients with chronic kidney disease were reported. We designed the pilot study with patient partners with relevant lived experience and considered statistical efficiency to estimate main effects and interactions, as well as response efficiency. Hierarchical Bayesian estimation was used to quantify average importances of attributes. Results: We recruited 43 patients with chronic kidney disease, mean (SD) age 67 (14) years, 67% male, and 35% with a history of cardiovascular disease, of whom 39 completed the survey within 2 weeks of enrollment. The results of the pilot revealed acute kidney injury requiring dialysis and permanent kidney replacement therapy, as well as death within 1 year were the most important attributes. Measures of internal validity for the pilot discrete choice experiment were comparable to those for other published discrete choice experiments. Limitations: Discrete choice experiments are complex instruments and often cognitively demanding for patients. This survey included multiple risk attributes which may have been challenging for some patients to understand. Conclusions: This pilot study demonstrates the feasibility of a discrete choice experiment to quantify preferences of patients with chronic kidney disease toward the benefits and trade-offs related to invasive versus conservative management for acute coronary syndrome. These preliminary findings suggest that patients with chronic kidney disease may be on average similarly risk averse toward kidney replacement therapy and death. This pilot information will be used to inform a larger discrete choice experiment that will refine these estimates of patient preferences and characterize subgroups with distinct treatment preferences, which should provide new knowledge that can facilitate shared decision-making between patients with chronic kidney disease and their care providers in the setting of acute coronary syndrome.
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Affiliation(s)
- T Wilson
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - P Javaheri
- Department of Medicine, University of Calgary, AB, Canada
| | - J Finlay
- Department of Medicine, University of Calgary, AB, Canada
| | - G Hazlewood
- Department of Medicine, University of Calgary, AB, Canada
| | - S B Wilton
- Department of Cardiac Sciences, University of Calgary, AB, Canada
| | - T Sajobi
- Department of Community Health Sciences, University of Calgary, AB, Canada
| | - A Levin
- Division of Nephrology, The University of British Columbia, Vancouver, Canada
| | - W Pearson
- Patient and Community Engagement Research Program, O'Brien Institute of Public Health, University of Calgary, AB, Canada
| | - C Connolly
- Department of Cardiac Sciences, University of Calgary, AB, Canada
| | - M T James
- Department of Medicine, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
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Tegn N, Eek C, Abdelnoor M, Aaberge L, Endresen K, Skårdal R, Berg ES, Gullestad L, Bendz B. Patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris randomised to an invasive versus conservative strategy: angiographic and procedural results from the After Eighty study. Open Heart 2020; 7:openhrt-2020-001256. [PMID: 32719073 PMCID: PMC7380709 DOI: 10.1136/openhrt-2020-001256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/17/2020] [Accepted: 05/27/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES We aimed to report the angiographic and procedural results of the After Eighty study (ClinicalTrials.gov, NCT01255540), and to identify independent predictors of revascularisation. METHODS Patients of ≥80 years old with non-ST-elevation myocardial infarction and unstable angina pectoris were randomised to an invasive or conservative strategy. Angiographic and procedural results were recorded. Univariate and multivariate analyses were performed to explore variables predicting revascularisation. RESULTS Among 229 patients in the invasive group, 220 underwent immediate coronary angiography (90% performed via the radial artery). Of these patients, 48% had three-vessel disease or left main stenosis, 18% two-vessel disease, 16% one-vessel disease, 17% minor coronary vessel wall changes and two patients had normal coronary arteries. Six patients (3%) underwent coronary artery bypass graft. Percutaneous coronary intervention (PCI) was performed in 107 patients (49%), with 57% treated with bare metal stents, 37% drug-eluting stents and 6% balloon angioplasty. On average, 1.7 lesions were treated and 2 stents delivered per patient. Complications included 1 major PCI-related bleeding (successfully treated), 2 minor access site-related bleedings, 3 side branch occlusions during PCI and 11 periprocedural myocardial infarctions (considered end points). Sex, bundle branch block and smoking were independent predictors of revascularisation. CONCLUSIONS PCI was performed in approximately half of the patients, similar to findings in younger populations. Procedural success was high, with few complications. TRIAL REGISTRATION NUMBER NCT01255540.
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Affiliation(s)
- Nicolai Tegn
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christian Eek
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Michael Abdelnoor
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Knut Endresen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rita Skårdal
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Erlend Sturle Berg
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Gerber RT, Arri SS, Mohamed MO, Dhillon G, Bandali A, Harding I, Gifford J, Sandler B, Corbo B, McWilliams E. Age is not a bar to PCI: Insights from the long-term outcomes from off-site PCI in a real-world setting. J Interv Cardiol 2017; 30:347-355. [DOI: 10.1111/joic.12400] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- Robert T. Gerber
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Satpal S. Arri
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Mohamed O. Mohamed
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Gurpreet Dhillon
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Alykhan Bandali
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Idris Harding
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Jeremy Gifford
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Belinda Sandler
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Ben Corbo
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
| | - Eric McWilliams
- Department of Cardiology; Conquest Hospital Hastings; East Sussex Healthcare NHS Trust; East Sussex UK
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Gayed M, Yadak N, Qamhia W, Daralammouri Y, Ohlow MA. Comorbidities and Complications in Nonagenarians Undergoing Coronary Angiography and Intervention. Int Heart J 2017; 58:180-184. [PMID: 28320990 DOI: 10.1536/ihj.16-083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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5
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Shammas NW, Shammas GA, Jerin M, Shanks C, Dvorak A, Serrano P, Harb C, Voelliger CM. Predictors of Long-Term Survival of Individuals with Acute Coronary Syndrome Aged 90 and Older Admitted to a Tertiary Care Center. J Am Geriatr Soc 2015; 63:2410-2. [PMID: 26603064 DOI: 10.1111/jgs.13806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Gail A Shammas
- Midwest Cardiovascular Research Foundation, Davenport, Iowa
| | - Michael Jerin
- Midwest Cardiovascular Research Foundation, Davenport, Iowa
| | - Carolyn Shanks
- Midwest Cardiovascular Research Foundation, Davenport, Iowa
| | - Amanda Dvorak
- Midwest Cardiovascular Research Foundation, Davenport, Iowa
| | | | - Christine Harb
- Midwest Cardiovascular Research Foundation, Davenport, Iowa
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Liang M, Liang J, Puri A, Pasupati S, Devlin G. Medium- to long-term outcomes in percutaneous coronary intervention in the very elderly population. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2015.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vandermolen S, Abbott J, De Silva K. What's Age Got to do with it? A Review of Contemporary Revascularization in the Elderly. Curr Cardiol Rev 2015; 11:199-208. [PMID: 25329923 PMCID: PMC4558351 DOI: 10.2174/1573403x10666141020110122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 09/10/2014] [Accepted: 10/12/2014] [Indexed: 01/05/2023] Open
Abstract
Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.
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Affiliation(s)
| | | | - Kalpa De Silva
- Specialist Registrar in Cardiology, St. Peter's Hospital, Surrey, UK.
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James MT, Tonelli M, Ghali WA, Knudtson ML, Faris P, Manns BJ, Pannu N, Galbraith PD, Hemmelgarn BR. Renal outcomes associated with invasive versus conservative management of acute coronary syndrome: propensity matched cohort study. BMJ 2013; 347:f4151. [PMID: 23833076 PMCID: PMC3702156 DOI: 10.1136/bmj.f4151] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the association of early invasive management of acute coronary syndrome with adverse renal outcomes and survival, and to determine whether the risks or benefits of early invasive management differ in people with pre-existing chronic kidney disease. DESIGN Propensity score matched cohort study. SETTING Acute care hospitals in Alberta, Canada, 2004-09. PARTICIPANTS 10,516 adults with non-ST elevation acute coronary syndrome. INTERVENTIONS Participants were stratified by baseline estimated glomerular filtration rate and matched 1:1 on their propensity score for early invasive management (coronary catheterisation within two days of hospital admission). MAIN OUTCOME MEASURES Risks of acute kidney injury, kidney injury requiring dialysis, progression to end stage renal disease, and all cause mortality were compared between those who received early invasive treatment versus conservative treatment. RESULTS Of 10,516 included participants, 4276 (40.7%) received early invasive management. After using propensity score methods to assemble a matched cohort of conservative management participants with characteristics similar to those who received early invasive management (n=6768), early invasive management was associated with an increased risk of acute kidney injury (10.3% v 8.7%, risk ratio 1.18, 95% confidence interval 1.03 to 1.36; P=0.019), but no difference in the risk of acute kidney injury requiring dialysis (0.4% v 0.3%, 1.20, 0.52 to 2.78; P=0.670). Over a median follow-up of 2.5 years, the risk of progression to end stage renal disease did not differ between the groups (0.3 v 0.4 events per 100 person years, hazard ratio 0.91, 95% confidence interval 0.55 to 1.49; P=0.712); however, early invasive management was associated with reduced long term mortality (2.4 v 3.4 events per 100 person years, 0.69, 0.58 to 0.82; P<0.001). These associations were consistent among people with pre-existing reduced estimated glomerular filtration rate and with alternate definitions for early invasive management. CONCLUSIONS Compared with conservative management, early invasive management of acute coronary syndrome is associated with a small increase in risk of acute kidney injury but not dialysis or long term progression to end stage renal disease.
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Affiliation(s)
- Matthew T James
- Department of Medicine, University of Calgary, Foothills Medical Centre, 1403 29th St NW, Calgary, Alberta T2N 2T9, Canada.
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Meier P, Fröhlich GM, Meller S, De Palma R, Lansky AJ. Selection and timing for invasive therapy in non-ST-segment-elevation acute coronary syndrome. Expert Rev Cardiovasc Ther 2013; 11:437-45. [PMID: 23570357 DOI: 10.1586/erc.13.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While outcomes for ST-segment-elevation myocardial infarction has significantly decreased over the last years, patients presenting with non-ST-segment-elevation acute coronary syndromes (NSTEACS) still have a rather high mortality. Longer term mortality over 4 years is about double the mortality after a ST-segment-elevation myocardial infarction. The reason for the poorer prognosis is unclear but is very likely to be partially explained by the generally older age of NSTEACS patients. The optimal therapy for NSTEACS is less well defined. In this review, the authors specifically discuss the role of coronary angiography, how to decide which patient should undergo this procedure and whether there is an optimal time point. The review provides an up-to-date discussion about the best treatment strategies for NSTEACS.
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Affiliation(s)
- Pascal Meier
- Cardiovascular Division, Yale Medical School, Division of Cardiology, New Haven, CT 06510, USA
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10
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Huang SS, Leu HB, Lu TM, Wu TC, Chen YH, Chen JW, Lin SJ, Chan WL. The Impacts of In-Hospital Invasive Strategy on Long-Term Outcome in Elderly Patients with Non-ST-Elevation Myocardial Infarction. ACTA CARDIOLOGICA SINICA 2013; 29:115-23. [PMID: 27122695 PMCID: PMC4804773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 02/06/2013] [Indexed: 06/05/2023]
Abstract
BACKGROUND The benefit of utilizing an invasive strategy in elderly Chinese patients with non-ST-elevation myocardial infarction (NSTEMI) remains unclear. The aim of this study was to determine whether in-hospital revascularization is associated with long-term prognosis in elderly Chinese patients with NSTEMI, as compared with younger patients. METHODS All patients were followed up for at least 3 years or until the occurrence of a major event. The primary endpoint was all-cause mortality, and the secondary endpoint was the combined occurrence of major adverse cardiovascular events (MACE), including death, nonfatal MI, and ischemic stroke. RESULTS A total of 343 consecutive NSTEMI patients (148 over the age of 75 years and 195 aged < 75 years) were enrolled. Coronary angiography was performed less frequently in elderly patients (66% vs. 76%; p = 0.027). Multiple logistic regression analysis confirmed the benefit of in-hospital revascularization in the elderly and younger patients, with a statistically significant reduction in the odds of all-cause death and MACE at 1 year and 3 years, respectively. In a multivariable Cox regression analysis, in-hospital revascularization was an independent predictor of future MACE not only in elderly patients [hazard ratio (HR), 0.61; 95% confidence interval (CI), 0.38-0.97] but also in younger patients as well (HR, 0.51; 95% CI, 0.31-0.84). CONCLUSIONS In Chinese patients with NSTEMI, in-hospital revascularization was associated with significant benefits at 1 year and 3 years in both younger and elderly groups. These results are consistent with the published literature and suggest that advanced age alone should not be regarded as a contraindication to invasive management following presentation with NSTEMI. KEY WORDS Elderly; Invasive strategy; Myocardial infarction.
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Affiliation(s)
- Shao-Sung Huang
- Healthcare and Management Center, Taipei Veterans General Hospital
- Institute of Clinical Medicine
| | - Hsin-Bnag Leu
- Healthcare and Management Center, Taipei Veterans General Hospital
- Institute of Clinical Medicine
| | - Tse-Min Lu
- Division of Cardiology, Department of Internal Medicine
- Institute of Clinical Medicine
| | - Tao-Cheng Wu
- Division of Cardiology, Department of Internal Medicine
- Institute of Clinical Medicine
| | - Ying-Hwa Chen
- Division of Cardiology, Department of Internal Medicine
- Institute of Clinical Medicine
| | - Jaw-Wen Chen
- Department of Medical Research and Education
- Institute and Department of Pharmacology, National Yang-Ming University, Taipei, Taiwan
| | - Shing-Jong Lin
- Department of Medical Research and Education
- Institute of Clinical Medicine
| | - Wan-Leong Chan
- Healthcare and Management Center, Taipei Veterans General Hospital
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Rittger H, Hochadel M, Behrens S, Hauptmann KE, Zahn R, Mudra H, Brachmann J, Senges J, Zeymer U. Age-related differences in diagnosis, treatment and outcome of acute coronary syndromes: results from the German ALKK registry. EUROINTERVENTION 2012; 7:1197-205. [PMID: 22334318 DOI: 10.4244/eijv7i10a191] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The elderly constitute an increasing proportion of all patients with acute coronary syndromes (ACS). However, increased age has been identified as an important risk factor for adverse events and complications of ACS and treatment. The purpose of this study was to investigate age-related differences in presentation and diagnostics, as well as contemporary treatment and outcome in a large series of elderly patients receiving an invasive strategy for ACS. METHODS AND RESULTS The present study is an analysis of all patients, who were enrolled in the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK) registry in 2008. To assess age-related differences, subjects were divided into three groups: (<75 yrs, 75 to 85 yrs and >85 yrs). Out of 19,708 consecutive patients who were admitted for the treatment of ACS and enrolled in the ALKK registry, 14,174 (71.9%) were <75 yrs, 4,685 (23.8%) were between 75 and 84 yrs and 849 (4.3%) patients were >85 yrs. Therapy recommendation after diagnostic angiography was conservative in 24.6% of the youngest, in 25.1% of the elderly, and in 25.3% of the very elderly patients. Interventional success rates were 95.2% in the youngest vs. 93.1% in the elderly and very elderly patient group (p<0.001). Overall in-hospital event rate increased significantly with age (3.4% vs. 7.4% vs. 8.3%, respectively; p<0.001). CONCLUSIONS Our analysis shows that there is a high success rate among the large proportion of elderly patients who are treated for ACS by an intervention. Complication rates increased significantly, however, with age.
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Affiliation(s)
- Harald Rittger
- Medizinische Klinik 2, Universitätsklinikum Erlangen, Erlangen, Germany. harald.rittger@arcor
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12
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Ohlow MA, Hassan A, Lotze U, Lauer B. Cardiac catheterisation in nonagenarians: Single center experience. J Geriatr Cardiol 2012; 9:148-52. [PMID: 22916061 PMCID: PMC3418904 DOI: 10.3724/sp.j.1263.2012.01042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 03/06/2012] [Accepted: 04/26/2012] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To explore the treatment, procedure related risks, and outcomes of patients older than 90 years of age undergoing cardiac catheterization. METHODS We retrospectively studied 32 patients ≥ 90 years (93.0 ± 1.2 years) who underwent cardiac catheterisation in a tertiary specialist hospital (0.2% of 14,892 procedures during three years). The results were compared to a patient cohort younger than 90 years of age. RESULTS Baseline characteristics revealed a higher prevalence of diabetes (P < 0.001), chronic obstructive pulmonary disease (P < 0.04), previous myocardial infarction (P < 0.02), and complex coronary anatomy (SYNTAX score 33 vs. 19) in nonagenarians. Patients < 90 years of age showed more hyperlipidemia (P < 0.01) and previous percutaneous coronary interventions (P < 0.015). Nonagenarians underwent coronary angiography more often for acute coronary syndrome (ACS) (P < 0.003), were presented more often in cardiogenic shock (P < 0.003), and were transferred faster to coronary angiography in cases of ACS (P < 0.0001). The observed in-hospital mortality rate (13% study group vs. 1% control group; P < 0.003) in nonagenarians was lower than the calculated rate of thrombolysis in myocardial infarction (TIMI) and global registry of acute cardiac events (GRACE) mortality and strongly influenced by the severity of clinical presentation and the presence of co-morbidities. CONCLUSION Despite the common scepticism that cardiac catheterisation exposes patients ≥ 90 years to an unwarranted risk, our data demonstrate an acceptable incidence of complications and mortality in this group of patients.
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Affiliation(s)
- Marc-Alexander Ohlow
- Department of Cardiology, Zentralklinik Bad Berka, Robert Koch-Allee 9, 99437 Bad Berka, Germany
| | - Aly Hassan
- Department of Cardiology, Faculty of Medicine, Alexandria University, El-Guish Road, El-Shatby, Alexandria 21526, Egypt
| | - Ulrich Lotze
- Department of Internal Medicine, DRK Krankenhaus Sonderhausen, Hospitalstrasse 2, 99706 Sondershausen, Germany
| | - Bernward Lauer
- Department of Cardiology, Zentralklinik Bad Berka, Robert Koch-Allee 9, 99437 Bad Berka, Germany
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13
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Schwarz AK, Zahn R, Hochadel M, Kerber S, Hauptmann KE, Glunz HG, Mudra H, Darius H, Zeymer U. Age-related differences in antithrombotic therapy, success rate and in-hospital mortality in patients undergoing percutaneous coronary intervention. Clin Res Cardiol 2011; 100:773-80. [DOI: 10.1007/s00392-011-0311-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 03/25/2011] [Indexed: 12/14/2022]
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Legrand V, Garg S, Serruys P, Virtanen K, Szurawitzki G, Voudris V, Fontanelli A, Endersen K, Kranjec I, Rademaker T, Stefanidis C, Wittebols K. Influence of age on the clinical outcomes of coronary revascularisation for the treatment of patients with multivessel de novo coronary artery lesions: sirolimus-eluting stent vs. coronary artery bypass surgery and bare metal stent, insight from the multicentre randomised Arterial Revascularisation Therapy Study Part I (ARTS-I) and Part II (ARTS-II). EUROINTERVENTION 2011; 6:838-45. [DOI: 10.4244/eijv6i7a144] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bauer T, Zeymer U. Impact of age on outcomes of percutaneous coronary intervention in acute coronary syndromes patients. Interv Cardiol 2010. [DOI: 10.2217/ica.10.27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rastan AJ, Thiele H, Schuler G, Mohr FW. Stellenwert der koronaren Bypass operation in der Therapie der akuten Koronarsyndrome. Herz 2010; 35:70-8. [DOI: 10.1007/s00059-010-3327-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Docherty A. Acute medical management of the non-ST-segment elevation acute coronary syndromes (NSTE-ACS) in older patients. Arch Gerontol Geriatr 2009; 51:129-34. [PMID: 19819566 DOI: 10.1016/j.archger.2009.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 09/07/2009] [Accepted: 09/10/2009] [Indexed: 11/17/2022]
Abstract
Older patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) represent many clinical challenges. For example diagnosis can be difficult, and comorbidities are common. Furthermore, NSTE-ACS is particularly common in older patients (>60% of acute myocardial infarctions occurring in patients aged 65 years or older) and the mortality associated with NSTE-ACS is particularly high. Despite these many concerns, evidence from clinical trials based on this group of patients is limited. Future prospective clinical trials should therefore more accurately reflect the NSTE-ACS patient population by including more elderly patients and including efficacy endpoints that are relevant for these patients. Furthermore, the lack of clear clinical evidence in this population means that the current treatment guidelines do not fully address the needs of elderly patients. Several recent clinical trials have highlighted some of the main considerations we should make when treating elderly patients with NSTE-ACS. Different therapy options in the pharmacological management of NSTE-ACS in this age group are also discussed.
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Affiliation(s)
- Andrew Docherty
- Wishaw General Hospital, 50 Netherton Street, Wishaw ML2 0DP, UK.
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Behan M, Dixon G, Haworth P, Blows L, Hildick-Smith D, Holmberg S, Debelder A. PCI in octogenarians--our centre 'real world' experience. Age Ageing 2009; 38:469-73. [PMID: 19420143 DOI: 10.1093/ageing/afp055] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Behan
- Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton, Sussex, UK.
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Park JW, Leithäuser B, Hill P, Jung F. Resting magnetocardiography predicts 3-year mortality in patients presenting with acute chest pain without ST segment elevation. Ann Noninvasive Electrocardiol 2008; 13:171-9. [PMID: 18426443 DOI: 10.1111/j.1542-474x.2008.00217.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Magnetocardiography (MCG) as a noninvasive, noncontact and risk-free diagnostic method predicts ischemic coronary artery disease (CAD) in patients with acute chest pain at admission with high accuracy. However, it remains unclear whether MCG findings can add prognostic information. METHOD A cohort of 402 consecutive patients presenting at the intensive care unit (ICU) with acute chest pain without ST segment elevation (NSTEMI) were included in a prospective registry. In order to prove the prognostic value of MCG a head-to-head comparison of the admission MCG, ECG, TnI, and ECHO tests was made. RESULTS In 43 patients (10.7%) the MCG could not be analyzed due to insufficient signal-to-noise ratio. Complete follow-up over a period of up to 3 years was obtained in 355 out of the 359 patients (98.9%). Age at admission was 67.2 +/- 10.3 years, 59.7% males. In the group of patients with an abnormal MCG at admission, 43 out of 249 patients (17.3%) died in the follow-up period, while in the group of patients with a normal MCG at admission only 4 out of 106 patients died (3.77%). The relative risk was 4.58 (95% confidence intervals: 1.68-12.42). A multivariate regression analysis revealed the highest mortality risk for patients with diabetes mellitus and an abnormal MCG at admission (RR = 18.0; 95% CI: 2.49-133.3). CONCLUSION Resting MCG at hospital admission predicts 3-year mortality in patients presenting with acute chest pain without ST segment elevation in the ECG. MCG seems to be valuable in identifying chest pain patients at highest risk.
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Affiliation(s)
- Jai-Wun Park
- Cardiology/Angiology Division, Hoyerswerda Hospital, Hoyerswerda, Germany.
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Lee MS, Zimmer R, Pessegueiro A, Jurewitz D, Tobis J. Outcomes of nonagenarians who undergo percutaneous coronary intervention with drug-eluting stents. Catheter Cardiovasc Interv 2008; 71:526-30. [DOI: 10.1002/ccd.21382] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Xue YZ, Wang LX, Liu HZ, Qi XW, Wang XH, Ren HZ. l-carnitine as an Adjunct Therapy to Percutaneous Coronary Intervention for Non-ST Elevation Myocardial Infarction. Cardiovasc Drugs Ther 2007; 21:445-8. [DOI: 10.1007/s10557-007-6056-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Núñez J, Sanchis J, Núñez E, Bodi V, Bertomeu-González V, Bosch MJ, Santas E, Fácila L, Chorro FJ, Gómez C, Consuegra L, Llàcer A. Prognostic differences between routine invasive and conservative strategies for the management of high-risk, non-ST segment acute coronary syndromes: Experience from two consecutive periods in a single center. Eur J Intern Med 2007; 18:409-16. [PMID: 17693230 DOI: 10.1016/j.ejim.2006.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 11/06/2006] [Accepted: 12/15/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal revascularization strategy for non-ST elevation acute coronary syndromes (NSTE-ACS) remains controversial, especially in a real world context. The objective of this work was to assess differences at 1 year in all-cause mortality and the composite endpoint of mortality or acute myocardial infarction (MI) between two management strategies for NSTE-ACS: a conservative strategy (CS) versus a routine invasive strategy (RIS). METHODS Of 799 consecutive patients admitted to our institution, 369 were treated with CS (from January 2001 to October 2002); 430 patients admitted with the same diagnosis were treated with RIS (from November 2002 to November 2004). A propensity score (PS) matched sample was created and included 694 patients (87% of the original population). The event rate was compared between each paired member of the PS-matched sample, one receiving RIS and the other CS, and their differences were tested by Cox proportional analysis. RESULTS No significant differences in baseline characteristics were noted between the two management cohorts. By design, the rate of in-hospital catheterization and revascularization procedures increased in RIS compared with CS. The mortality rate was lower, but not significant, in RIS (HR: 0.76, 95% CI=0.51-1.11; p=0.155). For the composite of death or MI, RIS showed a relative risk reduction of 29% (HR: 0.71, 95% CI=0.53-0.94); p=0.018) compared with CS, differences that become non-significant (p=0.680) if we adjust for differences in rate of revascularization procedures and changes in medication prescription. CONCLUSIONS RIS was associated with a 1-year lower risk of the combined endpoint of all-cause death and MI in patients with NSTE-ACS, attributable to changes in frequency of revascularization procedures and in medical treatment.
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Affiliation(s)
- Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de Valencia, Valencia, Spain
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Han JH, Lindsell CJ, Hornung RW, Lewis T, Storrow AB, Hoekstra JW, Hollander JE, Miller CD, Peacock WF, Pollack CV, Gibler WB. The elder patient with suspected acute coronary syndromes in the emergency department. Acad Emerg Med 2007; 14:732-9. [PMID: 17567963 DOI: 10.1197/j.aem.2007.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To describe the evaluation and outcomes of elder patients with suspected acute coronary syndromes (ACS) presenting to the emergency department (ED). METHODS This was a post hoc analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS) registry, which had 17,713 ED visits for suspected ACS. First visits from the United States with nonmissing patient demographics, 12-lead electrocardiogram results, and clinical history were included in the analysis. Those who used cocaine or amphetamines or left the ED against medical advice were excluded. Elder was defined as age 75 years or older. ACS was defined by 30-day revascularization, Diagnosis-related Group codes, or death within 30 days with positive cardiac biomarkers at index hospitalization. Multivariable logistic regression analyses were performed to determine the association between being elder and 1) 30-day all-cause mortality, 2) ACS, 3) diagnostic tests ordered, and 4) disposition. Multivariable logistic regression was also performed to determine which clinical variables were associated with ACS in elder and nonelder patients. RESULTS A total of 10,126 patients with suspected ACS presenting to the ED were analyzed. For patients presenting to the ED, being elder was independently associated with ACS and all-cause 30-day mortality, with adjusted odds ratios of 1.8 (95% confidence interval [CI] = 1.5 to 2.2) and 2.6 (95% CI = 1.6 to 4.3), respectively. Elder patients were more likely to be admitted to the hospital (adjusted odds ratio, 2.2; 95% CI = 1.8 to 2.6), but there were no differences in the rates of cardiac catheterization and noninvasive stress cardiac imaging. Different clinical variables were associated with ACS in elder and nonelder patients. Chest pain as chief complaint, typical chest pain, and previous history of coronary artery disease were significantly associated with ACS in nonelder patients but were not associated with ACS in elder patients. Male gender and left arm pain were associated with ACS in both elder and nonelder patients. CONCLUSIONS Elder patients who present to the ED with suspected ACS represent a population at high risk for ACS and 30-day mortality. Elders are more likely to be admitted to the hospital, but despite an increased risk for adverse events, they have similar odds of receiving a diagnostic test, such as stress cardiac imaging or cardiac catheterization, compared with nonelder patients. Different clinical variables are associated with ACS, and clinical prediction rules utilizing presenting symptoms should consider the effect modification of age.
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Affiliation(s)
- Jin H Han
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Liistro F, Ducci K, Falsini G, Bolognese L. Early invasive strategy in elderly patients with non-ST-elevation acute coronary syndromes. Eur Heart J Suppl 2005. [DOI: 10.1093/eurheartj/sui071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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