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Changing practice patterns in the management of acute myocardial infarction complicated by cardiogenic shock: elderly
1University of Alberta, Edmonton. vlad@tachy.uah.ualberta.ca
Insights
Aggressive management of acute myocardial infarction (AMI) with cardiogenic shock, including invasive procedures, improved survival across age groups. However, the very elderly (over 75) showed less benefit, highlighting the need for tailored strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Myocardial Infarction Management
Background:
- Cardiogenic shock is a severe complication of acute myocardial infarction (AMI).
- Aggressive management with emergent revascularization improves survival in AMI patients with cardiogenic shock.
- Age is a known independent predictor of survival in this patient population.
Purpose of the Study:
- To retrospectively analyze changes in practice patterns for managing AMI with cardiogenic shock.
- To determine the impact of these practice changes on patient survival, stratified by age.
- To assess the effectiveness of invasive treatment strategies in different age groups.
Main Methods:
- Retrospective analysis of 115 patients with cardiogenic shock complicating AMI from 1989-1995.
- Data extraction from medical records, including coronary angiograms for 72 patients.
- Stratification of patients by age groups: ≤65, 66-75, and >75 years.
Main Results:
- Increased use of cardiac catheterization, interventional procedures, and intra-aortic balloon pump (IABP) support over time.
- Fewer elderly patients (>75 years) received invasive procedures.
- In-hospital survival improved significantly from 4% (1989-90) to 44% (1993-95) (P=0.001).
- Survival improved in younger patients (≤65 years) from 10% to 59% (P=0.032).
- Only 20% of patients >75 years survived in the final period.
- Coronary angiography, intervention, and IABP support were associated with improved survival (P<0.0001).
- Multivariate analysis identified younger age, lower heart rate, and coronary intervention as independent predictors of survival.
Conclusions:
- Invasive treatment strategies for AMI with cardiogenic shock have increased and are linked to improved survival.
- Survival benefits were observed across age groups, with less pronounced improvement in the very elderly (>75 years).
- Patients undergoing coronary intervention have distinct baseline characteristics.
- Randomized trials are needed to define optimal strategies, especially for elderly patients.
Background:
Cardiogenic shock continues to be an ominous complication of acute myocardial infarction (AMI). Evidence from retrospective analyses, registries and observational studies suggests that aggressive management using emergent revascularization strategies can bring about significant improvement in survival in this setting. Several studies have identified age as an independent predictor of survival.
Objective:
To study retrospectively the possible changes in practice patterns in the management of patients with AMI complicated by cardiogenic shock in a tertiary care referral centre, and to determine what effect these changes may have had on survival of the patients, stratified by age.
Methods:
From 1989 to 1995, 115 patients fulfilled the study criteria of cardiogenic shock based on pump failure and of presenting within 48 h of onset of shock. Prespecified data were extracted from medical records. All available coronary angiograms (n = 72) were analyzed by two experienced angiographers and consensus of findings was obtained.
Results:
The study revealed a significant increase in the use of cardiac catheterization, interventional procedures and intra-aortic balloon pump (IABP) support in patients in the age groups 65 years or less, 66 to 75 years, and older than 75 years in 1989 to 1990, through 1991 to 1992, to 1993 to 1995. Significantly fewer patients aged older than 75 years received cardiac catheterization, coronary intervention and IABP support throughout the study period and even in the final period analyzed. In-hospital survival improved from 4% in 1989-90 to 33% in 1991-92, and 44% in 1993-95 (P = 0.001). Patients aged 65 years or less improved from 10% in 1989-90 to 59% in 1993-95 (P = 0.032). Only 20% of patients aged older than 75 years survived in the 1993-95 period. By univariate analysis, use of coronary angiography (catheterization 46% versus no catheterization 5%; P < 0.0001), coronary intervention procedures (percutaneous transluminal coronary angioplasty or coronary artery bypass grafting) (intervention 48% versus no intervention 9%; P < 0.0001) and IABP support (IABP 41% versus no IABP 18%; P = 0.0096) were all associated with improved in-hospital survival. Use of thrombolytic therapy showed possible survival benefit only in patients aged older than 75 years (thrombolysis 33% versus no thrombolysis 5%; P = 0.10). Patients who underwent coronary intervention were younger (P = 0.002), had a lower incidence of previous myocardial infarction (P = 0.0002), lower heart rate (P = 0.04), higher peak creatine phosphokinase (P = 0.04) and fewer vessels with at least 70% stenosis (P < 0.0001). On multivariate analysis only lower age, lower heart rate and presence of coronary intervention procedures were found to have an independent effect on survival.
Conclusions:
Use of invasive treatment strategies has increased significantly since 1989-90 in the management of patients with AMI complicated by cardiogenic shock. This increase has been associated with improved in-hospital survival in all age groups except possibly the very elderly. Patients undergoing coronary interventional procedures are significantly different in baseline clinical characteristics from patients not undergoing these procedures. These observations underscore the need for randomized trials to define the optimal treatment strategies in these patients. Efficacy of invasive treatment strategies in elderly patients aged older than 75 years-deserves special attention.