Invasive Strategy With Intended Percutaneous Coronary Intervention Versus Conservative Treatment in Older People With
Sascha Macherey-Meyer1, David Dilley2, Sebastian Heyne1
1Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine University of Cologne Cologne Germany.
Insights
Primary percutaneous coronary intervention (PCI) significantly improves survival in patients aged 80 and older with ST-segment-elevation myocardial infarction. This meta-analysis highlights potential ageism and advocates for wider PCI use in this elderly population.
Area of Science:
- Cardiology
- Geriatric Medicine
- Interventional Cardiology
Background:
- Elderly patients (≥80 years) are underrepresented in major ST-segment-elevation myocardial infarction (STEMI) trials.
- Landmark trials often exclude older adults, limiting evidence for optimal STEMI treatment in this demographic.
Purpose of the Study:
- To assess the efficacy of primary percutaneous coronary intervention (PCI) versus conservative treatment in patients aged 80 and older with STEMI.
- To evaluate the impact of an invasive PCI strategy on survival outcomes in the elderly STEMI population.
Main Methods:
- A comprehensive literature search was conducted to identify relevant studies.
- Meta-analysis of thirteen studies involving 102,158 older adults (≥80 years) with STEMI.
- Primary outcome: overall survival; Secondary outcomes: 30-day and 1-year mortality.
Main Results:
- PCI was associated with significantly higher overall survival (76.5% vs. 67.2%) compared to conservative treatment.
- PCI significantly reduced 30-day (OR, 0.39) and 1-year mortality (OR, 0.34) in older adults with STEMI.
- Confounding factors may influence these survival benefits, necessitating careful interpretation.
Conclusions:
- Primary PCI offers significant short- and long-term survival advantages for elderly patients (≥80 years) with STEMI.
- The findings suggest potential underuse and ageism in STEMI treatment decisions for older adults.
- PCI should not be automatically withheld from elderly patients based solely on age.
Background:
Patients ≥80 years old were underrepresented or excluded from landmark trials demonstrating the superiority of primary percutaneous coronary intervention (PCI) in ST-segment-elevation myocardial infarction. The current meta-analysis assessed the effects of an invasive strategy with intended PCI compared with conservative treatment in older people (≥80 years) with ST-segment-elevation myocardial infarction.
Methods:
A structured literature search was performed. The primary outcome was overall survival. Secondary outcome analyses included but were not limited to 30-day and 1-year mortality.
Results:
Thirteen studies reporting on 102 158 older adults were included. Of these, 31 629 (31%) were assigned to PCI and 70 529 (69%) were treated conservatively. The overall survival was 76.5% in PCI and 67.2% in conservative treatment at the time of longest available follow-up (odds ratio [OR], 2.18 [95% CI, 1.79-2.66], P<0.001, I2=88%, favoring PCI). The follow-up period ranged from 30 days to 26.5 months. The 30-day. (OR, 0.39 [95% CI, 0.31-0.50], P<0.001, I2=0%) and 1-year mortality (OR, 0·34 [95% CI, 0.25-0.46], P<0.001, I2=0%), were lower in the PCI group.
Conclusions:
This meta-analysis indicates a potential underuse of PCI in older adults with ST-segment-elevation myocardial infarction. PCI was advantageous in short- and long-term survival, but these results were affected by confounding. Nonetheless, every second patient not referred for invasive treatment survived at least 1 year. These findings have hypothesis generating implications, but they indicate ageism and emphasize that PCI should not be automatically withheld in older patients.
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