Elderly Patients Treated With Percutaneous Revascularization
Elderly Patients Treated With Percutaneous Revascularization
Background: Subgroup analysis from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial indicated that patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) who were ≥75 years old did not benefit from early revascularization and may have been harmed; their mortality rate at 30 days was 75%. The applicability of this subset analysis from a select patient population enrolled in a randomized trial to the general population is unclear.
Methods: At the Mayo Clinic between 1991 and 2000, we evaluated the outcome of all patients ≥75 years old with CS caused by MI who underwent urgent percutaneous coronary intervention (PCI).
Results: The study included 61 patients with a mean age of 79.5 ± 3 years; 21% of these patients had a history of prior coronary artery bypass grafting (CABG), 41% had had a prior MI, 28% had diabetes mellitus, and 18% had a history of a cerebrovascular accident (CVA). PCI was performed 8.0 ± 7.2 hours after onset of MI. Angiographic success (<50% residual stenosis) was achieved in 91% of the lesions that were dilated. In hospital outcomes included death (44%), CABG (1.6%), and CVA (4.9%). The 30-day mortality rate was 47%. The estimated survival rate 1 year after discharge (Kaplan Meier method) was 75%.
Conclusions: These data confirm a high early mortality rate among patients ≥75 years old with MI complicated by CS, but suggest that among patients referred for angiography, outcomes may be better than previously believed when early revascularization is performed. In this population, 56% of patients survived to be discharged from the hospital, and of the hospital survivors, 75% were alive at 1 year.
Cardiogenic shock (CS) occurs in approximately 7% to 10% of patients with acute myocardial infarction (MI) and is the leading cause of inhospital death. Advanced age with markers of left ventricular dysfunction such as heart rate, blood pressure, and Killip class are powerful risk factors for the development of CS after ST-elevation and non ST-elevation acute coronary syndrome. Thrombolytic therapy alone does not appear to reduce mortality once shock has occurred. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated that emergency revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with CS caused by transmural MI resulted in a survival advantage at 6 months. Pre-specified subgroup analysis indicated that the benefit was restricted to patients <75 years old, whereas revascularization was associated with a worse outcome in the small number of elderly patients who were ≥75 years old. This observation has resulted in the widespread perception that an early invasive strategy should be avoided in elderly patients with CS. Indeed, the American College of Cardiology and American Heart Association guidelines on the management of acute MI recommend primary PCI only for patients with CS who are <75 years old. This has important implications because of the aging population and increasing incidence of elderly patients with MI at presentation. We hypothesized that the subset analysis from the SHOCK trial may not apply to the general elderly population. Therefore, the aim of this study was to evaluate the outcome of patients ≥75 years old with CS caused by MI at presentation who were treated with early PCI at the Mayo Clinic.
Background: Subgroup analysis from the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial indicated that patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) who were ≥75 years old did not benefit from early revascularization and may have been harmed; their mortality rate at 30 days was 75%. The applicability of this subset analysis from a select patient population enrolled in a randomized trial to the general population is unclear.
Methods: At the Mayo Clinic between 1991 and 2000, we evaluated the outcome of all patients ≥75 years old with CS caused by MI who underwent urgent percutaneous coronary intervention (PCI).
Results: The study included 61 patients with a mean age of 79.5 ± 3 years; 21% of these patients had a history of prior coronary artery bypass grafting (CABG), 41% had had a prior MI, 28% had diabetes mellitus, and 18% had a history of a cerebrovascular accident (CVA). PCI was performed 8.0 ± 7.2 hours after onset of MI. Angiographic success (<50% residual stenosis) was achieved in 91% of the lesions that were dilated. In hospital outcomes included death (44%), CABG (1.6%), and CVA (4.9%). The 30-day mortality rate was 47%. The estimated survival rate 1 year after discharge (Kaplan Meier method) was 75%.
Conclusions: These data confirm a high early mortality rate among patients ≥75 years old with MI complicated by CS, but suggest that among patients referred for angiography, outcomes may be better than previously believed when early revascularization is performed. In this population, 56% of patients survived to be discharged from the hospital, and of the hospital survivors, 75% were alive at 1 year.
Cardiogenic shock (CS) occurs in approximately 7% to 10% of patients with acute myocardial infarction (MI) and is the leading cause of inhospital death. Advanced age with markers of left ventricular dysfunction such as heart rate, blood pressure, and Killip class are powerful risk factors for the development of CS after ST-elevation and non ST-elevation acute coronary syndrome. Thrombolytic therapy alone does not appear to reduce mortality once shock has occurred. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated that emergency revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with CS caused by transmural MI resulted in a survival advantage at 6 months. Pre-specified subgroup analysis indicated that the benefit was restricted to patients <75 years old, whereas revascularization was associated with a worse outcome in the small number of elderly patients who were ≥75 years old. This observation has resulted in the widespread perception that an early invasive strategy should be avoided in elderly patients with CS. Indeed, the American College of Cardiology and American Heart Association guidelines on the management of acute MI recommend primary PCI only for patients with CS who are <75 years old. This has important implications because of the aging population and increasing incidence of elderly patients with MI at presentation. We hypothesized that the subset analysis from the SHOCK trial may not apply to the general elderly population. Therefore, the aim of this study was to evaluate the outcome of patients ≥75 years old with CS caused by MI at presentation who were treated with early PCI at the Mayo Clinic.
