As old patients, who were treated by percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), are regularly excluded or underrepresented in randomized trials, data on treatment and outcomes of this patient group at high risk have to be collected by registries. The study population of the German Bremen STEMI Registry was divided into the age groups G1: <75 years (n = 4,108, young), G2: 75 to 85 years (n = 1,032, old), and G3: >85 years (n = 216, very old) and was evaluated for clinical management and course. PCI failure (Thrombolysis In Myocardial Infarction flow 0 or 1 after PCI) was observed more often with increasing age. Patients >85 years without successful PCI had a very high inhospital mortality (40.0% without PCI success vs 18.1% with PCI success, p <0.05). Despite a reduced rate of periinterventional treatment with glycoprotein IIb/IIIa inhibitors in elderly patients of G2 and G3, inhospital bleedings (Thrombolysis In Myocardial Infarction/Bleeding Academic Research Consortium ≥2) occurred more frequently in these patients (G1: 5.4% vs G2: 11.0% vs G3: 19.6%, p <0.0001). Mortality rates during inhospital and long-term course increased with increasing age. In a multivariate analysis successful PCI was associated with improved outcomes in all age groups; even in very old patients successful PCI was associated with a significantly lower inhospital mortality rate (odds ratio 0.26, 95% confidence interval 0.08 to 0.81) and a trend toward a lower 1-year mortality. In conclusion, the present “real-world” data demonstrate an elevated rate of PCI failure, bleeding complications, and mortality in elderly patients treated by primary PCI for STEMI. However, a beneficial effect of successful PCI on mortality was observed in all age groups, even in very old patients, indicating the crucial role of revascularization therapy.
The general population is aging and elderly subjects comprise the fastest growing segment of the population worldwide. Advanced age is associated with an increased incidence of myocardial infarction and the presence of several cardiovascular co-morbidities. A few studies showed disappointing outcomes and high age-related mortality rates after primary percutaneous coronary interventions (PCIs), whereas others presented superior clinical outcomes as reviewed previously. Elderly patients are often underrepresented or even excluded in randomized clinical trials evaluating primary PCI for ST-segment elevation myocardial infarction (STEMI); thus, only limited data on elderly patients with STEMI compared with younger ones exist. In the present study, clinical course of different age groups of patients with STEMI was investigated in the Bremen STEMI Registry (BSR). The residents of the metropolitan area of Bremen with the diagnosis of STEMI are admitted to the Bremen heart center and are documented in the BSR (“all-comers” study). Therefore, the BSR provides data for a unique comprehensive epidemiological analysis on a well-defined clinical entity.
Methods
The BSR is a prospective monocentric registry of patients admitted with STEMI at the Bremen heart center. The Bremen heart center exclusively serves a 24-hour PCI service for a large region in northwest Germany with a population of approximately more than 1 million residents from Bremen and the north western part of Lower Saxony. Because all STEMIs from the Bremen heart center are documented in the BSR it claims to give a complete statistical overview about the patients with STEMI in this region. The BSR was established in 2006 and is still running. Documentation is done through datasheets completed by the responsible interventional cardiologist and/or through patient records after a physician has confirmed the exact clinical diagnosis. Follow-up examination is performed after 1 year by a telephone interview. Further details regarding the BSR have been published previously.
STEMI was defined according to current guidelines as persistent angina pectoris for ≥20 minutes in conjunction with either (1) an ST-segment elevation at the J point of ≥0.25 mV in men aged <40 years or ≥0.2 mV in men aged >40 years or ≥0.15 mV in women in the precordial leads V2 to V3, and ≥0.1 mV in all other leads; or (2) the presence of a new left bundle branch block. Major adverse cardiac and cerebrovascular events (MACCE) were defined as recurrent nonfatal myocardial infarction, nonfatal stroke, and all-cause mortality. Bleedings were defined as grade ≥2 after the Thrombolysis in Myocardial Infarction (TIMI) bleeding criteria and/or the Bleeding Academic Research Consortium (BARC) classification. These bleeding definitions have been shown to be good predictors for mortality previously. PCI failure was defined as TIMI flow grade 0 or 1 after primary PCI, whereas successful PCI was defined as postinterventional TIMI flow grade 2 or 3. Glomerular filtration rate was calculated by the Modification of Diet in Renal Disease formula as defined by Levey et al.
Patients were separated by cut off into 3 age-related groups defined as: G1: <75 years (young), G2: 75 to 85 years (old), G3: >85 years (very old). Previous studies on age effects in patients with STEMI chose similar age groups. Baseline characteristics were given as mean values ± SD for continuous variables and absolute numbers and percentages for categorical variables. Onset-to-door and door-to-balloon delays were given in median (quartiles). A nonparametric distribution of age was assumed by the Kolmogorov–Smirnov test. Therefore, statistical significance was analyzed using the chi-square test for categorical variables. For comparison of continuous variables, Kruskal–Wallis and Mann–Whitney U tests were used. Multivariate analysis was performed to analyze factors influencing survival in the different age groups. Therefore, a binary logistic regression was used including the following variables: bleedings (TIMI/BARC ≥2), creatinine level >2 mg/dl, Killip’s class >II, PCI success (TIMI flow 2/3), diabetes mellitus, coronary multivessel disease (>2 vessels affected), and maximum level of creatine kinase >3,000 U/L. The latter parameter was chosen to adjust for STEMIs with large myocardial damage, the value >3,000 U/L has been used in other trials and identifies patients with substantially higher levels than the mean value of all patients in the BSR (1,970 U/L). p Values <0.05 were considered as statistically significant. Analyses were performed using SPSS Statistics (version 22, 2014; IBM Corp, Armonk, NY).
Results
From January 1, 2006 to July 15, 2013, a total of 5,356 patients with STEMI (mean 670 ± 128 patients/year) were included in the BSR. According to age, patients were assigned to group G1 (<75 years) with 4,108 patients (76.7%), group G2 (75 to 85 years) with 1,032 patients (19.3%), and group G3 (>85 years) with 216 patients (4.0%; Table 1 ).
| Variable | Total (n = 5356) | Age group (years) | p-value | |||
|---|---|---|---|---|---|---|
| < 75 (n = 4108) | 75 – 85 (n = 1032) | > 85 (n = 216) | G1 vs. G2 vs. G3 | G2 vs. G3 | ||
| Age [years] | 63.6 ±13.3 | 58 ±10.3 | 79 ±3.1 | 89 ±2.6 | ||
| 16 -97 | 16-74 | 75-85 | 86-97 | |||
| Women | 1484 (28%) | 871 (21.2%) | 480 (46.5%) | 133 (61.6%) | < 0.0001 | < 0.0001 |
| Hypertension [>140/90mmHg] | 3355 (62.6%) | 2453 (59.7%) | 745 (72.2%) | 157 (72.7%) | < 0.0001 | 0.662 |
| Diabetes mellitus | 1027 (19.2%) | 726 (17.7%) | 259 (25.1%) | 42 (19.4%) | < 0.0001 | 0.079 |
| Body mass index ≥ 30 kg/m 2 | 1991 (37.2%) | 1622 (39.5%) | 320 (31.0%) | 49 (22.7%) | < 0.0001 | 0.007 |
| Current smoker | 2387 (44.6%) | 2233 (54.4%) | 143 (13.9%) | 11 (5.1%) | < 0.0001 | < 0.0001 |
| Glomerular filtration rate [ml/min] | 57.2 ±14.9 | 58.3 ±7.1 | 54.5 ±28.9 | 50.5 ±12.6 | < 0.0001 | 0.002 |
| Prior myocardial infarcion | 556 (10.4%) | 408 (9.9%) | 125 (12.1%) | 23 (10.7%) | 0.734 | 0.220 |
| Prior stroke | 199 (3.7%) | 129 (3.1%) | 59 (5.7%) | 11 (5.2%) | 0.021 | 0.532 |
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