Eliano P. Navarese
Utilization of PCI in older patients with STEMI and cardiogenic shock increased from 27% in 1999 to 56% in 2013, which was paralleled by a significant reduction in mortality over time, according to a study published in the Journal of the American College of Cardiology.
Abdulla A. Damluji, MD, MPH, interventional cardiologist at Sinai Hospital of Baltimore, assistant professor at Johns Hopkins University and the Pepper Scholar at The Johns Hopkins University School of Medicine, and colleagues analyzed data from 111,901 patients aged 75 years and older with STEMI and cardiogenic shock included in the National Inpatient Sample from 1999 to 2013. The mean age at baseline was 82 years and 54% were women. Patients presented with a mean of 7.7 chronic conditions, including diabetes, hypertension, obesity and valvular heart disease.
The primary outcome of interest was death during index hospitalization, which decreased from 64% in 1999 to 46% in 2013; P < .001).
The number of older patients diagnosed with STEMI and cardiogenic shock decreased from 42% in 1999 to 29% in 2013, while the use of PCI in older patients increased P < .001) Older patients who underwent PCI had a decreased risk for in-hospital mortality in propensity score matching (Mantel-Haenszel OR = 0.48; 95% CI, 0.45-0.51).
These reduction in mortality risk was seen in all parts of the United States, including the Northeast (OR = 0.41; 95% CI, 0.36-0.47), Midwest (OR = 0.49; 95% CI, 0.42-0.57), south (OR = 0.51; 95% CI, 0.46-0.56) and west (OR = 0.46; 95% CI, 0.41-0.53).
“We believe that this study fills important gaps in addressing the influence of invasive care for older adults with multimorbidity,” Damluji and colleagues wrote. “From a public health perspective, early revascularization should not be denied for older adults in the absence of absolute contraindications (ie, active bleeding, severe neurocognitive decline and very limited life expectancy with end-stage disease processes).”
Cardiogenic shock remains a “devastating complication” and is the most frequent cause of in-hospital mortality following STEMI, Eliano P. Navarese, MD, PhD, interventional cardiologist and scientific director at Mater Dei Hospital in Bari, Italy, and adjunct professor at University of Alberta in Edmonton, Canada, and colleagues wrote in a related editorial. More than 10% of patients aged older than 75 years with STEMI present with cardiogenic shock, according to estimates.
“... [T]he findings by Damluji et al indirectly trigger additional considerations on the emerging role of large observational studies in elderly patients,” Navarese and colleagues wrote in the editorial. “Geriatric cardiology is a field where many older patients are excluded from [randomized controlled trials] because of their higher risk profile and the presence of geriatric intricacies (eg, multimorbidity, physical dysfunction, cognitive dysfunction, polypharmacy and frailty). Further, such research efforts can prove to be informative from the epidemiology of aging standpoint as the population continues to age.” – by Darlene Dobkowski
Disclosures: Damluji and Navarese report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Please see the editorial for all other editorialists’ relevant financial disclosures.