Functional outcomes of elderly patients ≥80 years who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) are unknown. Registry data indicate that up to 55% of elderly patients with STEMI do not receive reperfusion therapy despite a suggested mortality benefit, and only limited data are available regarding outcomes in elderly patients treated with primary PCI. Therefore, prospective data from a regional STEMI transfer program were analyzed to determine major adverse cardiac events, length of stay, and discharge status of consecutive patients with STEMI ≥80 years from March 2003 to November 2006. Of the 1,323 consecutive patients with STEMI treated in this regional STEMI system from March 2003 to November 2006, 199 (15.0%) were ≥80 years old. In-hospital mortality in elderly patients was 11.6%, with a 1-year mortality rate of 25.6%. Of the 166 patients with age ≥80 who lived independently or in assisted living before hospital admission and survived, 150 (90.4%) were discharged to a similar living situation or projected to such a living situation after temporary nursing home care. The median length of hospital stay was 4 days for these patients. In conclusion, elderly patients with age ≥80 receiving PCI for STEMI in a regional STEMI program have short hospital stays and excellent functional recovery on the basis of a very high rate of return to a similar previous living situation.
Limited data exist regarding outcomes in patients with age ≥80 after percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) with basically no data regarding the functional recovery of such patients. We recently reported improvement in the use of adjunctive medication, time to treatment, and outcomes in elderly patients treated as part of a regional STEMI network. The aim of this study was to determine the functional status of elderly patients who underwent PCI for STEMI.
Methods
The Minneapolis Heart Institute at Abbott Northwestern Hospital developed a standardized, regional STEMI system (level 1 myocardial infarction program) for the rapid transfer of patients with STEMI presenting at 35 hospitals within a 210-mile radius. The program was designed to improve patient access to rapid reperfusion, thereby improving outcomes for patients presenting at non-PCI facilities. The details of the program have been previously described. All patients with ST elevation or new left branch bundle block with symptoms <24 hours are enrolled in a comprehensive prospective database including patients suffering out-of-hospital cardiac arrest, cardiogenic shock, and the elderly. Prospective data on 1,323 consecutive patients with STEMI treated from March 1, 2003 to November 25, 2006 were reviewed, including 199 patients ≥80 years old. All patients received a standardized protocol including 325 mg aspirin, 600 mg clopidogrel, and intravenous bolus of unfractionated heparin (≤4,000 U). All patients are taken directly to the cardiac catheterization laboratory for primary PCI. Use of procedural antithrombin and glycoprotein IIb/IIIa inhibitors are at the discretion of the treating interventional cardiologist.
Information was gathered prospectively with patient consent and Institutional Review Board approval. Major adverse cardiac events including (1) all-cause mortality, (2) recurrent nonfatal reinfarction or ischemia, (3) target vessel revascularization, and (4) stroke (and the composite end point of these events) were assessed in all patients in hospital, at 1 month, and at 1 year.
Patients were grouped as ≥80, 70 to 79, and <70. Although arbitrary, this allowed an assessment of the oldest patients with a direct comparison to the next most comparable group. These breakdowns are similar with those in the Get With The Guidelines Coronary Artery Disease study. To address elderly patients’ functional recovery, we reviewed patients’ lengths of hospital stay and their residence types before and after hospital treatment. Although length of stay may be a general indicator of the overall health of patients, the comparison of admission to discharge residence type indicates whether patients gained adequate functional recovery to return to their initial residence types. Length of stay and residence type were available for 199 patients age ≥80. Baseline residence types were categorized as personal home, nursing home, or assisted living facility. Discharge residence types were categorized as personal home, assisted living facility, temporary rehabilitation, or permanent nursing home. Detailed data regarding periprocedural and discharge medications were also prospectively followed.
Descriptive statistics are displayed as mean and SDs for continuous variables; number and percentage with characteristic are given for categorical variables. When continuous variables had skewed distributions, data are summarized with medians and twenty-fifth and seventy-fifth percentiles. Normally distributed continuous variables were compared through analysis of variance. Categorical variables were tested using chi-square test. The Wilcoxon rank-sum test was used to test differences among non-normally distributed continuous variables. Kaplan-Meier analysis with log-rank test was used to determine differences in mortality through 1 year. A p value <0.05 was considered statistically significant, and p values are 2 sided when appropriate. Statistical analysis and plots were done in Stata 11.2 (StataCorp, College Station, Texas) and SAS 9.3 (SAS Institution Inc., Cary, North Carolina).
Results
Baseline and angiographic characteristics of the 199 patients ≥80 years are listed in Table 1 with comparisons to patients <70 years and ages 70 to 79; 33 patients (16.6%) with age ≥80 presented with cardiogenic shock, 17 (8.5%) with out-of-hospital cardiac arrest, and the Thrombolysis In Myocardial Infarction risk score for this patient group was 6.3 ± 1.9. After PCI, 94.5% had successful reperfusion on the basis of a Thrombolysis In Myocardial Infarction flow of 2 or 3 in culprit lesions.
| Variable | Age Group (Yrs) | p for Trend | ||
|---|---|---|---|---|
| <70, n = 875 (%) | 70–79, n = 249 (%) | ≥80, n = 199 (%) | ||
| Men | 698 (79.8) | 156 (62.7) | 92 (46.2) | <0.001 |
| Diabetes mellitus | 116 (13.3) | 48 (19.3) | 29 (14.6) | 0.039 |
| Current smoker | 467 (53.4) | 43 (17.3) | 13 (6.5) | <0.001 |
| Cardiogenic shock | 64 (7.3) | 35 (14.1) | 33 (16.6) | <0.001 |
| Out-of-hospital cardiac arrest | 70 (8.0) | 23 (9.2) | 17 (8.5) | 0.047 |
| Family history of coronary artery disease | 446 (51.1) | 95 (38.2) | 57 (29.1) | <0.001 |
| Dyslipidemia ∗ | 483 (55.3) | 136 (54.6) | 87 (43.9) | 0.035 |
| Hypertension | 415 (47.4) | 166 (66.7) | 142 (71.4) | <0.001 |
| Ejection fraction, mean (SE) | 48.4 (0.4) | 46.2 (0.8) | 44.9 (0.9) | 0.001 |
| Stents (number), median (25th, 75th percentile) | 1 (1, 1) | 1 (1, 1) | 1 (0, 1) | 0.89 |
| Peak creatine kinase-MB ng/ml, median (25th, 75th percentile) | 77 (25, 180) | 52.5 (14.5, 162.5) | 66 (19, 180) | 0.038 |
| Peak creatine kinase U/L, median (25th, 75th percentile) | 847 (316, 1825.5) | 591 (196, 1452) | 644.5 (222, 1548) | 0.001 |
| Peak troponin T ng/ml, median (25th, 75th percentile) | 1.54 (0.23, 4.27) | 1.12 (0.14, 3.76) | 1.75 (0.39, 5.06) | 0.037 |
| Peak creatinine, median (25th, 75th percentile) | 1.0 (0.9, 1.2) | 1.1 (0.9, 1.4) | 1.3 (1.0, 1.7) | <0.001 |
| Killip class ≥II | 104 (11.9) | 51 (20.5) | 49 (24.6) | <0.001 |
| Culprit lesion | ||||
| Left anterior descending | 270 (30.9) | 82 (32.9) | 67 (33.7) | 0.038 |
| Right coronary artery | 322 (36.8) | 91 (36.6) | 37 (33.7) | |
| Left circumflex artery | 121 (13.8) | 27 (10.8) | 27 (13.6) | |
| Other | 32 (3.6) | 19 (7.6) | 17 (8.5) | |
| None | 130 (14.9) | 30 (12.1) | 21 (10.6) | |
| TIMI flow before PCI | 0.33 | |||
| 0 | 380 (43.6) | 91 (36.7) | 77 (38.9) | |
| 1 | 41 (4.7) | 16 (6.5) | 11 (5.6) | |
| 2 | 163 (18.7) | 50 (20.2) | 47 (23.7) | |
| 3 | 288 (33.0) | 91 (36.7) | 63 (31.8) | |
| TIMI flow after PCI | 0.027 | |||
| 0 | 9 (1.0) | 7 (2.8) | 9 (4.6) | |
| 1 | 2 (0.2) | 0 (0.0) | 1 (0.5) | |
| 2 | 12 (1.4) | 5 (2.0) | 4 (2.0) | |
| 3 | 849 (97.4) | 236 (95.2) | 184 (92.9) | |
Pre-PCI and discharge medications are listed in Table 2 . Ninety-seven percent of patients with age ≥80 received aspirin, 92.4% received clopidogrel, and 98.9% received heparin before PCI, with 44.8% receiving a glycoprotein IIb/IIIa inhibitor. Patients presenting at transfer facilities 60 to 210 miles away received half-dose thrombolytics per protocol with percentages similar to those for patients aged <70 and 70 to 79 ( Table 2 ). At discharge, approximately 96% of elderly patients who underwent PCI went home with aspirin, 91% with an additional platelet aggregation inhibitor, 86% with β blocker, 72% with angiotensin-converting enzyme inhibitor, and 81% with statin. These results indicate elderly patients receive similar medications at admission (according to the standardized regional STEMI protocol) and only slightly lower rates of guideline-based medications at discharge.
| Variable | Age Group (Yrs) | p for Trend | ||
|---|---|---|---|---|
| <70, n = 875 | 70–79, n = 249 | ≥80, n = 199 | ||
| Pre-PCI medications (%) | ||||
| Aspirin | 845 (98.5) | 239 (97.6) | 192 (97.0) | 0.16 |
| Glycoprotein IIb/IIIa | 434 (52.8) | 105 (45.6) | 86 (44.8) | 0.21 |
| Clopidogrel | 785 (95.9) | 221 (94.0) | 170 (92.4) | 0.09 |
| Thrombolytics | 219 (25.5) | 65 (26.5) | 51 (25.8) | 0.98 |
| Heparin | 835 (99.4) | 232 (100) | 187 (98.9) | 0.36 |
| Discharge medications ∗ (%) | n = 691 | n = 188 | n = 138 | |
| Aspirin | 683 (98.8) | 183 (97.3) | 132 (95.7) | 0.031 |
| Platelet aggregation inhibitors | 665 (96.2) | 177 (94.2) | 126 (91.3) | 0.060 |
| β Blocker | 654 (94.7) | 174 (92.6) | 119 (86.2) | 0.005 |
| Angiotensin-converting enzyme inhibitor | 574 (83.1) | 147 (78.2) | 100 (72.5) | 0.019 |
| Statin | 630 (91.2) | 158 (84.0) | 112 (81.2) | <0.001 |
∗ Includes only patients with complete data who survived through discharge and received PCI.
As demonstrated in Kaplan-Meier survival curves for all patients in Figure 1 , age was a powerful predictor of mortality. As listed in Table 3 , 23 of the 199 patients with age ≥80 (11.6%) died in hospital; in-hospital mortality was highly associated with cardiogenic shock (16/23 [69.6%] vs 26/176 [14.8%]; odds ratio: 13.19 [95% confidence level: 4.94, 35.17]; p <0.001). Thirty-day and 1-year mortalities in elderly patients were 15.1% (30/199) and 25.6% (51/199). Of the out-of-hospital deaths, 15 (53.6%) were noncardiac-related (including sepsis [n = 3], pulmonary disease [n = 3], cancer [n = 2], renal failure [n = 2], miscellaneous [n = 5] including gastrointestinal bleed caused by a ruptured ulcer, a motor vehicle accident, and a noncardiac postsurgical complication). Although mortality and stroke rates were higher for patients with age ≥80, major adverse cardiac events and hospital readmissions were no different ( Table 3 ).
| Variable | Age Group (Yrs) | p for Trend | ||
|---|---|---|---|---|
| <70, n = 875 (%) | 70–79, n = 249 (%) | ≥80, n = 199 (%) | ||
| In-hospital death | 18 (2.1) | 18 (7.2) | 23 (11.6) | <0.001 |
| Death at 30 days | 20 (2.3) | 19 (7.6) | 30 (15.1) | <0.001 |
| Death at 1 yr | 32 (3.7) | 32 (12.9) | 51 (25.6) | <0.001 |
| Stroke at 30 days | 6 (0.7) | 6 (2.4) | 6 (3.2) | 0.011 |
| Stroke at 1 yr | 10 (1.1) | 6 (2.4) | 12 (6.0) | <0.001 |
| Cardiac admission at 30 days | 30 (3.4) | 4 (1.6) | 4 (2.0) | 0.23 |
| Cardiac admission at 1 yr | 79 (9.0) | 20 (8.0) | 5 (2.5) | 0.009 |
| MACE ∗ at 30 days | 24 (2.7) | 13 (5.2) | 11 (5.5) | 0.054 |
| MACE ∗ at 1 yr | 73 (8.3) | 23 (9.2) | 20 (10.1) | 0.71 |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
