Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its infl...

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Published in:Journal of the American College of Cardiology Vol. 73; no. 15; p. 1890
Main Authors: Damluji, Abdulla A, Bandeen-Roche, Karen, Berkower, Carol, Boyd, Cynthia M, Al-Damluji, Mohammed S, Cohen, Mauricio G, Forman, Daniel E, Chaudhary, Rahul, Gerstenblith, Gary, Walston, Jeremy D, Resar, Jon R, Moscucci, Mauro
Format: Journal Article
Language:English
Published: United States 23.04.2019
Subjects:
Aged
Aged, 80 and over
Cohort Studies
Databases, Factual
Female
Follow-Up Studies
Geriatric Assessment
Hospital Mortality
Humans
Male
Patient Safety
Percutaneous Coronary Intervention - methods
Percutaneous Coronary Intervention - mortality
Propensity Score
Retrospective Studies
Risk Assessment
Shock, Cardiogenic - diagnostic imaging
Shock, Cardiogenic - mortality
Shock, Cardiogenic - surgery
ST Elevation Myocardial Infarction - diagnostic imaging
ST Elevation Myocardial Infarction - mortality
ST Elevation Myocardial Infarction - surgery
Survival Analysis
Time Factors
Treatment Outcome
mortality
older adults
percutaneous coronary intervention
cardiogenic shock
ST-segment elevation myocardial infarction
ISSN:1558-3597, 1558-3597
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Summary:Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53). This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.
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ISSN:1558-3597
1558-3597
DOI:10.1016/j.jacc.2019.01.055