Treatment and prognosis of elderly patients with non-ST-elevation myocardial infarction

Background/Introduction

Elderly constitute a large though specific group of patients presenting with non-ST elevation myocardial infarction (NSTEMI), as they are at higher risk of adverse cardiovascular events, as well as treatment-related complications. However as they underrepresented in clinical trials, the optimal management strategy for older patients with NSTEMI remains unclear.

Purpose

The aim of this registry was to capture the medical and invasive treatment of elderly NSTEMI patients, find predictors for major adverse cardiovascular events (MACE) and estimate the impact of invasive management and revascularisation.

Methods

The POPular AGE registry is a prospective, observational multicentre study of patients ≥75 years of age presenting with NSTEMI at multiple sites in the Netherlands, United Kingdom and Austria. Management was at the discretion of the treating physician. MACE consisted of cardiovascular death, acute coronary syndrome (ACS) and stroke. Net adverse clinical events (NACE) was defined as composite of all-cause death, ACS, definite stent thrombosis, stroke, or major bleeding (Bleeding Academic Research Consortium [BARC] bleeding 3 or 5). The population was stratified into an invasively treated group defined as patients who underwent coronary angiography (CAG); and a conservatively-treated group with patients who received medical treatment only. The duration of follow-up was one year. Clinical variables were assessed for their predictive value for MACE and bleeding by means of a Cox proportional hazard regression.

Results

The total study population consisted of 1190 elderly patients with NSTEMI (median age 80 years [IQR 77–84], 43% female). Invasive treatment with CAG was performed in 67% of the population, of which 49% underwent PCI and 14% coronary artery bypass grafting (CABG). At discharge, the majority of patients (55%) were treated with dual antiplatelet therapy (DAPT). MACE occurred in 15% and major bleeding occurred in 5% of the total population. Age (HR 1.06, 95% CI 1.03–1.09), diabetes mellitus (HR 1.62, 95% CI 1.16–2.24), reduced LVEF (<50%) (HR 1.51, 95% CI 1.03–2.20), Killip class (HR 1.58, 95% CI 1.07–2.33) and electrocardiogram (ECG) changes at admission (HR 1.67, 95% CI 1.20–2.31) were predictors for MACE. MACE occurred more frequently in conservatively-treated than invasively-treated patients (20% vs. 12%, HR 0.52, 95% CI 0.38–0.70, p<0.001). Revascularization with PCI or CABG was associated with lower risk of MACE (PCI; HR 0.47, 95% CI 0.30–0.75, p=0.001 and CABG; HR 0.31, 95% CI 0.13– 0.73, p=0.008).

Conclusions

In this prospective registry of NSTEMI patients of ≥75 years, MACE and major bleeding were frequent. Age, diabetes mellitus, reduced LVEF, Killip class and ECG changes at admission were independent predictors for MACE. Although subject to selection bias, undergoing CAG and revascularisation, when indicated, were associated with better outcomes.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Clinical cardiology consultation at non-cardiology departments: stepchild of patient care?

BACKGROUND

Although patient care in cardiology departments may be of high quality, patients with cardiac disease in other departments tend to receive less attention from cardiologists. Driven by the shorter duration of admission nowadays and the fact that consultations are often performed in between the daily work schedules, the amount of cardiac disease as well as the impact on the daily workload can be underestimated. We determined characteristics, prevalence of cardiac disease and in-hospital mortality of patients in whom cardiology consultation was requested.

METHOD

In this prospective, observational study, individual data of all consecutive patients admitted to non-cardiology departments in whom cardiology consultation was requested were registered.

RESULTS

During the study period, 264 patients were included. Mean age was 70 years. Most patients were admitted to the internal medicine ward (37 %), followed by the surgical ward (30 %). The most common reasons for cardiology consultation were: suspected heart failure (20 %), suspected infective endocarditis (15 %), suspected rhythm abnormalities (14 %) and suspected acute coronary syndrome (13 %). In 29 % of all consultations a cardiac diagnosis was found. Hospital mortality was 9.0 %.

CONCLUSION

Patients who are admitted to a non-cardiology department and who need cardiology consultation are particularly elderly people with a high prevalence of cardiac disease and high in-hospital mortality. For these reasons cardiology consultation is an important part of clinical cardiology deserving a structured approach.

Long-term comparison of balloon angioplasty with provisional stenting versus routine stenting in patients with non-ST-elevation acute coronary syndrome

Background. In patients with unstable angina or non-ST-elevation acute coronary syndrome (NSTE-ACS) who are eligible for PCI, routine stenting is the recommended treatment strategy, based on the opinion of experts. Provisional stenting may provide a viable alternative by retaining the early benefits of stenting without its potential late hazards.Method. Patients with NSTE-ACS were randomised to provisional or routine stenting after coronary angiography. Patients were followed for up to ten years. The occurrence of major adverse cardiac events (MACE) was recorded.Results. 237 consecutive patients with NSTE-ACS were randomly assigned to routine stenting (n=116) or provisional stenting (n=121). No difference in the incidence of MACE at 30 days was observed. At six months, angiographic restenosis was lower in the routine stenting group (41 vs. 20%, p=0.02), paralleled by more MACE in the provisional stenting group at one year (40.5 vs. 27.6%, p=0.036). At complete follow-up the difference in MACE was not significant (61.2 vs. 50%, p=0.084) because of relatively more target lesion revascularisations in the routine stent group. There was no difference in the incidence of very late stent thrombosis (1.7 vs. 3.4%, p=0.439). The only independent predictor of MACE was beta-blocker use (RR 0.62 [0.431; 0.892] p=0.010).Conclusion. In selective patients with NSTE-ACS, routine stenting was more beneficial than provisional stenting for a period of up to five years, driven by a reduction in repeat revascularisation procedures. After this period, the benefit was no longer significant. Beta-blocker use was the only independent predictor of MACE throughout the complete follow-up period. (Neth Heart J 2010;18:307-13.).