Hospitalization Outcomes Among Nonagenarians Undergoing PCI after AMI

Reference: Sawant AC et al. JACC Cardiovasc Interv. 2017;10(13):1295-1303.

Several studies have suggested early revascularization to be associated with favorable outcomes in elderly patients with cardiogenic shock complicating acute myocardial infarction (CS-AMI).^1,2 Early revascularization for patients serves multiple purposes. First, early reperfusion may reduce the amount of ischemic myocardial injury. Secondly, a timely reperfusion approach may improve ventricular electrical stability.

Nonagenarians, persons who are between the ages of 90 and 99, are at higher risk for mortality following PCI.³ A study by Sawant et al pooled data of nonagenarian veterans undergoing PCI (n = 274) from the Veterans Affairs Clinical Assessment, Reporting, and Tracking for Cardiac Catheterization Laboratories (CART-CL) program to assess temporal trends, mortality outcomes (30 days and 1 year), and predictors of mortality.⁴

According to an editorial by Holmes,⁵ the consecutive and comprehensive nature of the Veterans Affairs system improves the structure of this study because, “...[the Veterans Affairs system] deals with perhaps more of a ‘captive’ population with more distinct characteristics by virtue of their typically being veterans.”

Patients in this cohort had a lower body mass index compared with younger patients, representing the frailty of this patient population. Nonagenarians were also less likely to have diabetes but were more likely to have a history of hypertension, cerebrovascular disease, and chronic kidney disease. Additionally, nonagenarians were more likely to present with cardiogenic shock (2.6% vs 0.5%; p < 0.001) and have a higher incidence of renal failure compared with younger patients (31.8% vs 10.3%; p < 0.001).

Overall complication rates post-PCI were low, with no in-laboratory events of MI, death, stroke, or coronary perforation. Compared with younger patients, there were significantly more incidences of no reflow (2.9% vs 1%; p = 0.02) and acute cardiogenic shock (0.73% vs. 0.12%; p = 0.04) post-PCI.

Unadjusted post-procedural and all-cause mortality at 30 days and 1 year were 1.4% and 4.2% among all veterans undergoing PCI. Crude 30-day and 1-year mortality was significantly higher in nonagenarians than younger patients (10.6% vs 1.4%; p < 0.0001 vs 16.3% vs 4.2%; p < 0.0001, respectively). Prior cardiogenic shock was associated with a greater incidence of death at 30 days (13.8% vs 0.4%, p<0.001). There was worse 30-day (odds ratio [OR]: 2.14; 95% confidence interval [CI]: 1.42 to 3.22) and 1-year mortality (OR: 1.82; 95% CI: 1.27 to 2.62) among nonagenarians after risk adjustment, demonstrating the effects of these patients’ higher age-related comorbidities on outcomes.

References:

1. Lim HS, Farouque O, Andrianopoulos N, et al. Survival of elderly patients undergoing percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock. JACC Cardiovasc Interv. 2009;2(2):146-152.
2. Rogers PA, Daye J, Huang H, et al. Revascularization improves mortality in elderly patients with acute myocardial infarction complicated by cardiogenic shock. Int J Cardiol. 2014;172(1):239-241.
3. Lee MS, Zimmer R, Pessegueiro A, Jurewitz D, Tobis J. Outcomes of nonagenarians who undergo percutaneous coronary intervention with drug-eluting stents. Catheter Cardiovasc Interv. 2008;71(4):526-530.
4. Sawant AC, Josey K, Plomondon ME, et al. Temporal Trends, Complications, and Predictors of Outcomes Among Nonagenarians Undergoing Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. JACC Cardiovasc Interv. 2017;10(13):1295-1303.
5. Holmes DR Jr. Four Score and 10 Years. JACC Cardiovasc Interv. 2017;10(13):1304-1306.

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