Coronary Artery Disease
Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2016.04.010Get rights and content

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.

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Methods

The cohort studied included consecutive patients aged ≥85 years who presented with STEMI to Austin Health from November 2011 to July 2015. Austin Health is a large metropolitan tertiary hospital affiliated with the University of Melbourne; it services a population of approximately 1.25 million people.

Scrutiny of coding data identified patients aged ≥85 years with a diagnosis of STEMI (International Classification of Disease [ICD] 10 code I21.3). A manual chart review was performed to confirm

Results

A total of 115 patients aged ≥85 years were assigned the ICD 10 code I21.3 for STEMI. Of these patients, 2 (1.7%) were excluded as they were transferred from the emergency department to another institution. A further 12 patients (10.6%) were excluded as their electrocardiogram and/or clinical history did not meet criteria for an STEMI. Of the remaining 101 patients included in our analysis, 56 (55%) were managed conservatively and 45 (45%) received invasive management. Follow-up data were

Discussion

In this cohort of patients aged ≥85 years who were treated at the discretion of their physicians, those managed invasively were younger with greater functional and cognitive status and had a lower combined Charlson age-comorbidity index score. Markers of increased risk including age, anterior STEMI, and cognitive impairment were independently associated with a decision for conservative management. Patients selected for invasive management exhibited improved survival rates in-hospital and during

Disclosures

The authors have no conflicts of interest to disclose.

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Drs. Matias Yudi and Nicholas Jones contributed equally to this manuscript.

Dr. Yudi is supported by a combined National Health and Medical Research Council (NHMRC) and National Heart Foundation Postgraduate Scholarship (Australia).

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