Effect of Emergency Percutaneous Coronary Intervention on In-Hospital Mortality of Very Elderly (80+ Years of Age) Patients With Acute Myocardial Infarction

Dementia: a barrier to receiving percutaneous coronary intervention for elderly patients with ST-elevated myocardial infarction

OBJECTIVE

Percutaneous coronary intervention (PCI) is the first line of treatment for ST-elevated myocardial infarction (STEMI). This study evaluates the role of dementia in diagnostic cardiac catheterization (to receive PCI) in STEMI patients ≥65 years old admitted to high annual volume PCI hospitals.

METHODS

Participants were registered in Florida's comprehensive inpatient surveillance system for the years 2006-2007 with principal diagnosis of STEMI. Dementia was defined using ICD-9 codes for presenile, senile, and Alzheimer's type dementia.

RESULTS

Data from 8331 STEMI patients were used. Of these, 77.2% were catheterized, 67.2% received PCI, and 9.3% had coronary artery bypass graft (CABG). The mean age of the cohort was 76.3 years (SD 7.8 years.); with 43.3% female, 83.4% white, 4.6% black, and 12% Hispanic/other. Of the 248 (3%) patients with dementia, 42% were catheterized. After adjustment for age, gender, and race/ethnicity, patients with dementia were less likely to be catheterized (RR 0.30, 95% CI 0.30-0.50) than non-demented patients. However, among patients who were catheterized, there was no difference in the use of PCI or CABG for patients with versus without dementia (p = 0.56). Of those with dementia, being older and arriving to the hospital in the afternoon were associated with lower likelihood of being catheterized (RR 0.08, 95% CI 0.02-0.28, and RR 0.30, 95% CI 0.10-0.88, respectively). However, having hyperlipidemia increased the probability of catheterization (RR 3.60, 95% CI 1.86-6.98).

CONCLUSION

ST-elevated myocardial infarction patients with dementia were much less likely to receive diagnostic cardiac catheterization, thereby limiting the possibility for receiving optimal care including PCI or CABG.

Elective single-vessel percutaneous coronary intervention in a vegetative state patient

A 73-year-old male in a persistent vegetative state underwent percutaneous coronary intervention (PCI) for unstable angina with multiple-vessel stenosis. The maximum dose pharmaceutical therapy was ineffective in controlling his symptoms. The goal of the procedure was to alleviate the patient's severe chest pain and vomiting with minimal invasion and risk. The procedure was effective despite treating only the culprit artery. Symptoms disappeared immediately after PCI and the patient remained attack free for 12 months. With the consent of the patient's family and support of medical staff, elective single-vessel PCI can be a practical and effective treatment option for refractory angina in patients with impaired consciousness.

Absence of outcome difference in elderly patients with and without dementia after acute myocardial infarction

It is still unclear whether the presence of dementia has a negative effect on survival in elderly patients with acute myocardial infarction (AMI). Therefore, using data from the Tokai Acute Myocardial Infarction Study II (TAMIS-II), we set out to clarify the differences in in-hospital and long-term mortality between AMI patients with and without dementia. The study was a prospective study of all consecutive patients admitted to 15 acute care hospitals in the Tokai region with a diagnosis of AMI between 2001 and 2003. A total of 1837 patients (62 with dementia and 1775 without dementia) with AMI, aged 65 and over, were included in the present analysis. Patients with dementia were in general older, female, and impaired in their daily activities. They were also more likely to have a history of myocardial infarction, heart failure, cerebrovascular disease, and less likely to have a history of angina or smoking. They were less likely to have chest pain on arrival and lateral myocardial infarction. The percentage of patients with dementia who were transferred to an intensive care unit/coronary care unit or who were given percutaneous coronary intervention was lower. At discharge, the percentage of patients with dementia treated with aspirin was lower, and that of patients with dementia treated with diuretics was higher. In-hospital death rates for patients with and without dementia were 17.7% and 11.1% during hospitalization, respectively (P = 0.101). Long-term mortality after AMI was higher among patients with dementia before adjustment (24.2% versus 14.6%, P = 0.004). However, we were unable to detect differences after adjustment for potential confounders. Thus, our findings suggest that dementia has minimal effects on long-term mortality in patients with AMI.

[Differences in cardiac management and in-hospital mortality between elderly patients with and without dementia after acute myocardial infarction: findings from TAMIS data]

AIM

In the United States, a study has shown that dementia is a significant factor negatively associated with medical treatment. Because the increasing number of the elderly has resulted in cause a rise in patients with dementia or acute myocardial infarction (AMI), or both, we need to know the differences in in-hospital mortality between patients with or without dementia in patients with AMI.

METHODS

We used data from 13 acute care hospitals including in the data from the Tokai Acute Myocardial Infarction Study (TAMIS), a retrospective study of all patients admitted to these hospitals from 1995 to 1997 with a diagnosis of AMI. We abstracted the baseline and procedural characteristics from detailed chart reviews. A total of 22 patients with dementia and 1,030 with no dementia who were aged 65 and over were included in the present study, and were divided into two groups according to their diagnosis of dementia. We compared the baseline and procedure characteristics and clinical outcomes between the two groups.

RESULTS

Patients with dementia were older and more likely to have either a lower body mass index score or ADL impairment. As for medical history, patients with dementia were more likely to have a history of cerebrovascular disease, and less likely to have a history of angina or smoking. Before and after multivariable adjustment, no significant difference was found in in-hospital mortality between patients with or without dementia.

CONCLUSIONS

Our study demonstrates that AMI elderly patients with dementia were not less likely to be undertreated and did not have a higher in-hospital mortality rate than non-dementia patients.