Caractéristiques et mortalité intrahospitalières des patients âgés, admis pour syndrome coronaire aigu avec sus décalage du segment ST et traités par angioplastie primaire dans un centre tertiaire en Algerie

Ashraf T., Khan M.N., Afaque S.M., Aamir K.F., Kumar M., Saghir T., Rasool S.I., Rizvi S.N., Sial J.A., Nadeem A., Khan A.A., Karim M.

In the present study, we analysed the incidence of no-reflow phenomenon, its clinical and procedural predictors, and associated in-hospital outcomes for the patients undergoing primary percutaneous coronary intervention (PCI).No-reflow phenomenon after primary PCI is a procedural complication associated with adverse post-procedure outcomes.Data for this study were extracted from global registry, NCDR®, the site of National Institute of Cardiovascular Disease (NICVD), Karachi from July 2017 to March 2018. The demographic, clinical, and procedural characteristics, and in-hospital outcomes were analysed for the patients with and without no-reflow after primary PCI.Of total of 3255 patients, no-reflow phenomenon was found in 132 (4.1%) patients and it was associated with significantly higher in-hospitality mortality (6.8% vs. 2.9%; p = 0.01), cerebrovascular accident (1.5% vs. 0%; p < 0.001), post procedure bleeding (2.3% vs. 0.5%; p = 0.009), and cardiogenic shock (3.8% vs. 1.2%; p = 0.011). The multivariate analysis showed advanced age [odds ratio = 1.63, 95% confidence interval 1.09-2.44, p = 0.018], diabetes [1.66, 1.14-2.42, p = 0.009], prior history of CABG [8.70, 1.45-52.04, p = 0.018], low pre-procedure TIMI flow grade [2.04, 1.3-3.21, p = 0.002], longer length of target lesion [1.51, 1.06-2.16, p = 0.023], and 10 fold raised troponin I [1.55, 1.08-2.23, p = 0.018] were the independent predictors of no-reflow.In this selected group of patients, the no-reflow phenomenon after primary percutaneous coronary intervention is not that uncommon. It is associated with an increased risk of adverse post-procedure hospital course including mortality. Pathophysiology of the no-reflow phenomenon is complex and opaque, however, it can be predicted based on certain clinical and procedural characteristics.

Uemura S., Okamoto H., Nakai M., Nishimura K., Miyamoto Y., Yasuda S., Tanaka N., Kohsaka S., Kadota K., Saito Y., Tsutsui H., Komuro I., Ikari Y., Ogawa H., Nakamura M.

Primary percutaneous coronary intervention (pPCI) is strongly recommended by guidelines for patients presenting with acute myocardial infarction (AMI), but its applications in elderly patients are less clear.Methods and Results:The JROAD-DPC is a Japanese nationwide registry for patients with cardiovascular diseases combined with an administrative claim-based database. Among 2,369,165 records from 2012 to 2015, data for 115,407 AMI patients were extracted for this study. Elderly patients (≥75 years) comprised 45,645 subjects (39.6%), and received pPCI less frequently (62.2%) than younger patients (79.2%, P

Fajar J.K., Heriansyah T., Rohman M.S.

To investigate the no reflow risk factors after percutaneous coronary intervention in ST elevation myocardial infarction patients.Sample size, mean±standard deviation (SD) or frequencies (percent) of normal and no reflow groups were extracted from each study.Of 27 retrospective and prospective studies, we found that increasing risks of no reflow were associated with advanced age, male, family history of coronary artery disease, smoking, diabetes mellitus, hypertension, delayed reperfusion, killip class ≥2, elevated blood glucose, increased creatinine, elevated creatine kinase (CK), higher heart rate, decreased left ventricular ejection fraction (LVEF), collateral flow ≤1, longer lesion length, multivessel disease, reference luminal diameter, initial thrombolysis in myocardial infarction (TIMI) flow, and high thrombus burden. Moreover, initial TIMI flow ≤1 and high thrombus burden had the greater impact on no reflow (OR95%CI=3.83 [2.77-5.29], p

Pek P.P., Zheng H., Ho A.F., Wah W., Tan H.C., Foo L.L., Ong M.E.

Background With an ageing population, there is a need to understand the relative risk/benefit of interventions for elderly ST segment elevation myocardial infarction (STEMI) patients. The primary aim of this study was to compare epidemiology, treatments and outcomes between young and elderly STEMI patients. Our secondary aim was to determine the cut-off age when the benefits of primary percutaneous coronary intervention (PCI) were less pronounced.Methods Data were collected by the Singapore Myocardial Infarction Registry. Patients were categorised into young (age <65 years) and elderly STEMI (age ≥65 years) patients.Results We analysed 14 006 STEMI cases collected between January 2007 and December 2014; 33.9% were elderly STEMI patients. Elderly STEMI patients had longer median door to balloon (73 vs 64 min, P<0.001) time and were less likely to receive PCI (proportion difference=−23.6%, 95% CI −25.3 to −22.0). In the absence of PCI, elderly STEMI patients had a higher mortality within 30 days (elderly: HR 1.65, 95% CI 1.36 to 1.99, P<0.001; young: HR 1.10, 95% CI 0.79 to 1.54, P=0.573) and 1 year (elderly: HR 1.83, 95% CI 1.57 to 2.14, P<0.001; young: HR 1.41, 95% CI 1.09 to 1.83, P=0.009) of admission. The 1 year survival benefit of PCI started to decline after the age of 65 years.Conclusion Elderly STEMI patients were less likely to receive PCI and had longer door to balloon times. Survival benefit of PCI decreased after the age of 65 years, with the decline most evident from age 85 years onwards. The risks of PCI need to be weighed carefully against its benefits, especially in very elderly patients.

Ibanez B., James S., Agewall S., Antunes M.J., Bucciarelli-Ducci C., Bueno H., Caforio A.L., Crea F., Goudevenos J.A., Halvorsen S., Hindricks G., Kastrati A., Lenzen M.J., Prescott E., Roffi M., et. al.

2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)

de Waha S., Patel M.R., Granger C.B., Ohman E.M., Maehara A., Eitel I., Ben-Yehuda O., Jenkins P., Thiele H., Stone G.W.

Microvascular obstruction (MVO) is the underlying cause for the no-reflow phenomenon in ST-segment elevation myocardial infarction (STEMI). The association between MVO assessed by cardiac magnetic resonance imaging (CMR) and prognosis has not been convincingly demonstrated. We sought to determine the relationship between MVO assessed early after primary percutaneous coronary intervention (PCI) in STEMI and all-cause mortality, hospitalization for heart failure (HF), and reinfarction.We performed a pooled analysis using individual patient data from seven randomized primary PCI trials in which MVO was assessed within 7 days after reperfusion by CMR using late gadolinium enhancement imaging (n = 1688). Clinical follow-up was performed for at least 6 months after the index event. Median time to CMR after STEMI was 3 days [interquartile range (IQR) 2-4], and median duration of clinical follow-up was 365 days (IQR 188-374). Microvascular obstruction was present in 960 (56.9%) of patients, and median MVO (percent left ventricular myocardial mass) was 0.47% (IQR 0.00-2.54). A graded response was present between the extent of MVO (per 1.0% absolute increase) and subsequent mortality [Cox adjusted hazard ratio (HR) 1.14, 95% confidence interval (CI) 1.09-1.19, P < 0.0001] and hospitalization for HF (Cox adjusted HR 1.08, 95% CI 1.05-1.12, P < 0.0001). Microvascular obstruction remained significantly associated with all-cause mortality even after further adjustment for infarct size (Cox adjusted HR 1.09, 95% CI 1.01-1.17, P = 0.03). MVO was not significantly related to subsequent reinfarction (P = 0.29).The presence and extent of MVO measured by CMR after primary PCI in STEMI are strongly associated with mortality and hospitalization for HF within 1 year.

Jomaa W., Hamdi S., Ben Ali I., Azaiez M.A., El Hraiech A., Ben Hamda K., Maatouk F.

Little is known about the risk profile and in-hospital prognosis of elderly patients presenting for ST-elevation myocardial infarction (STEMI) in Tunisia. We sought to determine in-hospital prognosis of elderly patients with STEMI in a Tunisian center.The study was carried out on a retrospective registry enrolling 1403 patients presenting with STEMI in a Tunisian center between January 1998 and January 2013. Patients ≥75 years old were considered elderly. Risk factors and in-hospital prognosis were compared between elderly and younger patients, and then predictive factors of in-hospital death were determined in elderly patients.Out of the overall population, 211 (15%) were part of the elderly group. Compared to younger patients, elderly patients were more likely to have arterial hypertension but less likely to be smokers and obese. Thrombolysis was significantly less utilized in the elderly group (22.3% vs. 36.6% in the younger group, p

Fach A., Bünger S., Zabrocki R., Schmucker J., Conradi P., Garstka D., Fiehn E., Hambrecht R., Wienbergen H.

As old patients, who were treated by percutaneous coronary interventions (PCI) for ST-segment elevation myocardial infarction (STEMI), are regularly excluded or underrepresented in randomized trials, data on treatment and outcomes of this patient group at high risk have to be collected by registries. The study population of the German Bremen STEMI Registry was divided into the age groups G1: 85 years (n = 216, very old) and was evaluated for clinical management and course. PCI failure (Thrombolysis In Myocardial Infarction flow 0 or 1 after PCI) was observed more often with increasing age. Patients >85 years without successful PCI had a very high inhospital mortality (40.0% without PCI success vs 18.1% with PCI success, p

Addad F., Gouider J., Boughzela E., Kamoun S., Boujenah R., Haouala H., Gamra H., Maatouk F., Ben Khalfallah A., Kachboura S., Baccar H., Ben Halima N., Guesmi A., Sayahi K., Sdiri W., et. al.

FAST-MI Tunisian registry was initiated by the Tunisian Society of Cardiology and Cardio-vascular Surgery to assess characteristics, management, and hospital outcomes in patients with ST-elevation myocardial infarction (STEMI).We prospectively collected data from 203 consecutive patients (mean age 60.3 years, 79.8 % male) with STEMI who were treated in 15 public hospitals (representing 68.2 % of Tunisian public centres treating STEMI patients) during a 3-month period at the end of 2014. The most common risk factor was tobacco (64.9 %), hypertension (38.6 %), diabetes (36.9 %) and dyslipidemia (24.6 %).Among these patients, 66 % received reperfusion therapy, 35 % with primary percutaneous coronary interventions (PAMI), 31 % with thrombolysis (28.6 % of them by pre-hospital thrombolysis). The median time from symptom onset to thrombolysis was 185 and 358 min for PAMI, respectively. The in-hospital mortality was 7.0 %. Patients enrolled in interventional centers (n=156) were more likely to receive any reperfusion therapy (19.8 % vs 44.6 %; p

Lee K.H., Ahn Y., Kim S.S., Rhew S.H., Jeong Y.W., Jang S.Y., Cho J.Y., Jeong H.C., Park K., Yoon N.S., Sim D.S., Yoon H.J., Kim K.H., Hong Y.J., Park H.W., et. al.

Puymirat E., Aissaoui N., Simon T., Bataille V., Drouet E., Mulak G., Ferrières J., Danchin N.

The FAST-MI 2010 registry collected information on characteristics and management of patients hospitalized for acute myocardial infraction during a one-month period in 213 centers across France, at the end of 2010. Among the 3079 patients included, 31% were aged 75 years or over (25% of those with ST-elevation myocardial infarction, and 38% of those with non-ST-elevation myocardial infarction). The clinical profile and risk factors differ in elderly patients, but chest pain remains the most common presenting symptom, although a substantial percentage of patients also present with signs of heart failure. Elderly individuals receive less recommended medications, including reperfusion therapy for STEMI, with the largest difference observed beyond 85 years of age. In-hospital mortality increases with age, particularly after 85 years, but has decreased compared with previous French surveys.

Claessen B.E., Kikkert W.J., Engstrom A.E., Hoebers L.P., Damman P., Vis M.M., Koch K.T., Baan J., Meuwissen M., J van der Schaaf R., de Winter R.J., Tijssen J.G., Piek J.J., Henriques J.P.

Objective The general population is gradually ageing in the western world. Therefore, the number of octogenarians undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is increasing. We aim to provide insight into temporal trends in the annual proportions of octogenarians among STEMI patients undergoing primary PCI and their clinical characteristics and outcomes over an 11-year observational period.Design Single-centre observational study.Patients Between 1997 and 2007, 4506 STEMI patients were treated with primary PCI at the authors9 institution. Patients aged over 80 years were identified.Main outcome measures Temporal trends in the annual proportion of octogenarian STEMI patients and their baseline characteristics, 30-day and 1-year mortality were analysed.Results A total of 379 octogenarians (8.4% of the total population) was treated with primary PCI between 1997 and 2007. Over time, the annual proportion of octogenarians gradually increased from four of 113 (3.5%) in 1997 to 51 of 579 (8.8%) in 2007 (p for trend <0.01). In the total cohort of 379 patients, 30-day mortality was 21% (81 patients) and 1-year mortality was 28% (107 patients). There was no improvement in survival among octogenarian STEMI patients over the 11-year study period.Conclusion The annual proportion of octogenarian STEMI patients increased significantly over the 11-year study period. Mortality among these high-risk patients was high and did not improve during the study period. Unfortunately, little is known about the optimal treatment of the elderly as they are underrepresented in many randomised clinical trials. Further studies into the optimal STEMI management strategy for the elderly are warranted.

Kirma C., Izgi A., Dundar C., Tanalp A.C., Oduncu V., Aung S.M., Sonmez K., Mutlu B., Ozdemir N., Erentug V.

The aim of the study was to identify clinical factors, angiographic findings, and procedural features that predict no-reflow phenomenon (Thrombolysis In Myocardial Infarction (TIMI) flow grade < or =2) in patients with acute myocardial infarction (AMI) who undergo primary percutaneous coronary intervention (PCI).A series of 382 consecutive patients with AMI underwent primary PCI within 12 h of symptom onset. Patients with ischemic symptoms continuing for more than 12 h were also included. Clinical, angiographic and procedural data were collected for each subject. Ninety-three (24.3%) of the patients developed no-reflow phenomenon, and their findings were compared with those of the reflow group. Univariate analysis showed that advanced age (>60 years), delayed reperfusion (> or =4 h), low (< or =1) TIMI flow prior to PCI, cut-off type total occlusion, high thrombus burden on baseline angiography, long target lesion (>13.5 mm) and large vessel diameter all correlated with no-reflow (p

de Boer M., Ottervanger J., van’t Hof A.W., Hoorntje J.C., Suryapranata H., Zijlstra F.

This study sought to determine the short- and long-term outcome of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) in patients older than 75 years of age.The benefit of reperfusion therapy in elderly patients with AMI is uncertain, although elderly people account for a large proportion of deaths.We randomly assigned a total of 87 patients with an AMI who were older than 75 years to treatment with angioplasty or intravenous (IV) streptokinase. Clinical outcome was measured by taking the end points of death and the combination of death, reinfarction or stroke during follow-up.The primary end point, a composite of death, reinfarction or stroke, at 30 days had occurred in 4 (9%) patients in the angioplasty group as compared with 12 (29%) in the thrombolysis group (p = 0.01, relative risk [RR]: 4.3, 95% confidence interval [CI]: 1.2 to 20.0). At one year the corresponding figures were 6 (13%) and 18 (44%), respectively (p = 0.001, RR: 5.2, 95% CI: 1.7 to 18.1).In this series of patients with AMI who were older than 75 years, primary coronary angioplasty had a significant clinical benefit when compared with IV streptokinase therapy.

Lee P.Y.

Elderly persons and women were underrepresented in randomized controlled trials (RCTs) prior to 1990. Since then, efforts have been made to correct these biases, but their effect is unclear.To determine whether the percentage of elderly persons and women in published clinical trials of acute coronary syndromes has increased and how this enrollment compared with disease prevalence.The MEDLINE and Cochrane databases were searched for English-language articles from January 1966 to March 2000 regarding myocardial infarction, unstable angina, or acute coronary syndromes. Additional data sources included meta-analyses, review articles, and cardiology textbooks. Estimates of community-based myocardial infarction rates came from the National Registry of Myocardial Infarction and the Worcester Heart Study.Published RCTs of acute coronary syndrome patients were included and trials enrolling 50 patients or fewer, those without clinical end points, papers published in a language other than English, and unpublished manuscripts were excluded. Of 7645 studies identified, 593 RCTs were selected for review.The RCTs were abstracted by 2 of the authors for year of publication, source of support (ie, funding), pharmacotherapy, study phase, number of study sites, trial location, number of patients, mean age of the study population, and any age exclusion criteria for enrollment.The number of published RCTs with explicit age exclusions has declined from 58% during 1966-1990 to 40% during 1991-2000. Trial enrollment of patients aged 75 years or older increased from 2% for studies published during 1966-1990 to 9% during 1991-2000, but remains well below their representation among all patients with myocardial infarction (37%) in the United States. Enrollment of women has risen from 20% for studies published between 1966-1990 to 25% during 1991-2000, but remains well below their proportion of all patients with myocardial infarction (43%) in the United States.Attempts at making cardiovascular RCTs more inclusive appear to have had limited success; thus, women and elderly persons remain underrepresented in published trial literature relative to their disease prevalence. Because safety and efficacy can vary as a function of sex and age, these enrollment biases undermine efforts to provide evidence-based care to all cardiac patients.