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Published on: June 12, 2021
Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic
Abdulla A Damluji1, Karen Bandeen-Roche2, Carol Berkower3
1Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland; Division of Cardiology, Johns Hopkins University, Baltimore, Maryland.
Insights
Percutaneous coronary intervention (PCI) significantly reduces in-hospital mortality for older adults (≥75 years) experiencing ST-elevation myocardial infarction (STEMI) with cardiogenic shock. Age should not preclude this life-saving treatment.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Older adults (≥75 years) face higher mortality risks following ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock.
- This demographic presents unique challenges in managing acute cardiac events due to age-related physiological changes and comorbidities.
Purpose of the Study:
- To investigate the utilization and impact of percutaneous coronary intervention (PCI) on in-hospital mortality in elderly patients with STEMI and cardiogenic shock.
- To assess trends in PCI use and outcomes for older adults experiencing STEMI and shock between 1999 and 2013.
Main Methods:
- Analysis of a large, all-payer inpatient healthcare database (1999-2013).
- In-hospital mortality was the primary outcome.
- Propensity score matching was employed to evaluate the influence of PCI on mortality across different patient subgroups and geographic regions.
Main Results:
- PCI utilization in older adults with STEMI and shock increased from 27% in 1999 to 56% in 2013.
- In-hospital mortality rates for this group decreased significantly from 64% to 46% during the study period.
- PCI was associated with a substantially lower risk of in-hospital mortality (OR: 0.48; 95% CI: 0.45-0.51) across propensity score quintiles and all U.S. regions.
Conclusions:
- Increasing PCI use in older adults with STEMI and cardiogenic shock correlates with significant mortality reduction.
- Age alone should not be a contraindication for early revascularization with PCI in STEMI patients with cardiogenic shock, provided no absolute contraindications exist.
Background:
Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.
Objectives:
The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.
Methods:
We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).
Results:
Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).
Conclusions:
This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.
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