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Published on: May 28, 2019
Clinical outcomes and discharge disposition in nonagenarians with ST-elevation myocardial infarction
Janki Shukla1, Christian Schmidt2, David Larson2
1University of Cincinnati, College of Medicine, Cincinnati, OH.
Insights
Nonagenarians with ST-elevation myocardial infarction (STEMI) face higher mortality. Living situation before and after hospitalization significantly impacts outcomes, with skilled nursing facility residents experiencing worse prognosis.
Area of Science:
- Cardiology
- Geriatric Medicine
- Public Health
Background:
- Nonagenarians (≥90 years) with ST-elevation myocardial infarction (STEMI) are an underrepresented yet growing population in clinical trials.
- Understanding STEMI management in this demographic is crucial due to arbitrary exclusion criteria in past studies.
Purpose of the Study:
- To examine the outcomes of nonagenarians experiencing STEMI.
- To identify prognostic factors, specifically focusing on living status before and after hospitalization, in this elderly population.
Main Methods:
- A cohort study analyzed data from the Midwest STEMI Consortium database (March 2003-October 2020).
- Patients presenting with STEMI within 24 hours of symptom onset were included, regardless of age, shock, or cardiac arrest status.
- Data were stratified by age groups (<70, 70-79, 80-89, ≥90 years), with outcomes including discharge disposition and mortality at in-hospital, 30-day, and 1-year intervals.
Main Results:
- Among 15,039 STEMI patients, 303 (2%) were nonagenarians, with 64% being female.
- Nonagenarians had in-hospital, 30-day, and 1-year mortality rates of 17%, 20%, and 33%, respectively.
- Patients residing in a skilled nursing facility (SNF) before presentation had significantly higher in-hospital mortality (36%) compared to those living at home or in an assisted living facility (ALF) (14-15%). One-year mortality was 43% for those discharged to SNF versus 13% for those discharged home (P < .001).
Conclusions:
- Living in an SNF prior to STEMI presentation was associated with more than double the in-hospital mortality compared to living at home.
- Discharge to an SNF resulted in a threefold increase in 1-year mortality compared to discharge home.
- Pre-presentation and post-discharge living status are critical prognostic indicators in elderly STEMI patients.
Background:
Nonagenarians with ST-elevation myocardial infarction (STEMI) represent a unique and growing population and are underrepresented in clinical trials due to arbitrary exclusion criteria. Therefore, a thorough examination of STEMI in this age population may better inform management decisions.
Methods:
This is a cohort study examining the Midwest STEMI Consortium database from March 2003 through October 2020. All patients with STEMI, presenting within 24 hours of symptom onset, were enrolled -including those with advanced age, cardiogenic shock, or out-of-hospital cardiac arrest. Data are described across age groups: <70, 70-79, 80-89, and ≥90 years. Main outcome measures were discharge disposition; mortality in-hospital, 30-days, and 1-year.
Results:
Among 15,039 consecutive STEMI patients, 303 (2%) were ≥90 years, of whom 194 (64%) were females. Among nonagenarians, mortality was 17% in the hospital, 20% at 30-day, and 33% at 1-year; and those living in a skilled nursing facility (SNF) before presentation had significantly higher in-hospital mortality (36%) versus those living at home or in an assisted living facility (ALF) (14% and 15% respectively). The mortality at 1 year was 13% for patients discharged to home, 20% for those discharged with home health care or ALF, and 43% for those discharged to SNF (P < .001).
Conclusions:
In this large multicenter prospective STEMI database, nonagenarians living in SNF before presentation had more than 2-fold higher in-hospital mortality than those living at home. Furthermore, patients discharged to SNF had a 3-fold higher 1-year mortality than those discharged to home. In this older STEMI population, living status before the presentation and at hospital discharge carries important prognostic information.
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