Predictors of long-term outcome of percutaneous coronary intervention in octogenarians with acute coronary syndrome

AbstractThe majority of patients with acute coronary syndrome (ACS) are elderly. Limited evidence makes decision-making on the use of percutaneous coronary intervention (PCI) mainly empirical. Old age is one risk factor, but other factors than age may have an impact on mortality as well. Therefore, we investigated predictors of long-term all-cause mortality among octogenarians who have undergone PCI due to ACS. A total of 182 patients ≥ 80 years who underwent PCI during 2006–2007 at Sahlgrenska University Hospital were studied consecutively from recorded clinical data. All-cause five-year mortality of follow-up was 46.2%. Mean age was 83.7 ± 2.8, 62% were male, 76% were in sinus rhythm, and 42% had left ventricular ejection fraction < 45%. Indications for PCI were STEMI (52%), NSTEMI (36%) and unstable angina (11%). Multivariate analysis in two steps identified atrial fibrillation, moderate tricuspid valve regurgitation, moderate mitral valve regurgitation, dependency in ADL and eGFR ≤ 30 ml/min at the first step and moderate mitral valve regurgitation, atrial fibrillation and eGFR ≤ 30 ml/min at the last step, as independent predictors of all-cause mortality. Kaplan Meier analysis of positive parameters from both steps of multivariate analysis showed high significant difference in survival between patients having these parameters and those who were free from these parameters, with worst prognosis in patients with accumulation of these parameters. Accordingly, we have, in an octogenarian patient cohort who suffered from ACS, undergone PCI in daily clinical practice, identified five prognostic predictors for all-cause death after five years' follow-up

Prognostic prediction and treatment of cardiac diseases in elderly

Aim: The overall aim of this thesis was to study the prognostic prediction and its association with treatment strategies in the elderly patients presenting with acute coronary syndrome (ACS) and left ventricular systolic heart failure (HF). Methods: A total 353 octogenarians with ACS, 182 patients treated with percutaneous coronary intervention (PCI) and 171 treated without PCI, were consecutively included and retrospectively studied for prognostic predictors of long-term all-cause mortality. Moreover, 140 patients >70 years were prospectively studied for prognostic predictors for major adverse cardiovascular events (MACE) in patients with ACS referred for coronary angiography. In case of heart failure, 182 octogenarians with left ventricular systolic HF were consecutively included and retrospectively studied for impact of different dose levels of guideline recommended neurohormonal blockades, beta-blockers (BBs) and angiotensin converting enzyme inhibitors (ACEIs)/ angiotensin receptor blockers (ARBs), on long-term mortality. Results: In ACS-cohorts: Cox-regression analysis of octogenarian patients with ACS treated with PCI showed following factors as independent predictors of 5-year all-cause mortality: atrial fi brillation, mitral regurgitation (MR), tricuspid regurgitation (TR), estimated glomerular fi ltration rate (eGFR) <30 ml/min and dependency in activities of daily living. Furthermore, in the overall cohort of octogenarians with ACS, both PCI-treated and non-PCI-treated, PCI was associated with lower 5-year all-cause mortality. At least mild grade MR was associated with higher 5-year all-cause mortality and PCI was associated with improved prognosis even in patients with MR compared with patients with MR treated without PCI. Finally, in a prospective cohort of ACS patients >70 years referred for coronary angiography, during an average follow-up of 39+11 months, 41% of the patients had one or more MACE and 24% developed post-ACS heart failure. The study cohort had as good quality of life as an age-matched reference population from Swedish normative SF-36 database in both physical health subscales (physical functioning, role physical, bodily pain and general health) and mental health subscales (Vitality, social functioning, role emotional and mental health). The all-cause mortality rate was 10%. In heart failure cohort: In octogenarians with left ventricular systolic HF treated with highest tolerable doses of neurohormonal blockades, target dose of ACEIs/ARBs were associated with improved 5-year survival rate, despite that this was achievable in only about half of the patients. No signifi cant differences in survival were found between the different doses of BBs; however the heart rate was comparable between the different dose groups. Conclusion: In elderly patients with ACS, PCI was associated with improved long-term survival despite high age. Several prognostic predictors including MR were identifi ed. Moreover, in the modern era of reperfusion therapy, despite improved quality of life and low mortality rate MACE occurred frequently in elderly patients after ACS indicating further need of tailored care. In octogenarian patients with systolic HF, target dose of ACEIs/ ARBs was associated with reduced fi ve-year all-cause mortality, but this dose survival relationship did not fi nd in case of the beta-blockers

Improved short and long term survival associated with percutaneous coronary intervention in the elderly patients with acute coronary syndrome

Abstract Background Percutaneous coronary intervention (PCI) are increasingly used in daily clinical practice in elderly patients with acute coronary syndrome (ACS) despite limited evidence. The purpose of this study was to assess the impact of PCI on short and long term survivals in a large cohort of elderly patients with ACS from a “real world”. Methods We enrolled 491 patients aged ≥70 years admitted to our institution with ACS from 2006 to 2012. Effect of PCI on short and long term survival was evaluated in both overall and a propensity score-matched cohort. Results The mean age of the overall cohort is 83 ± 6 years. Among them, 285 were treated with PCI, whereas 206 were not. Patients treated with PCI were younger (82 ± 5 vs. 85 ± 6), more males (67% vs. 46%), with lower heart rate (77 ± 22 vs. 84 ± 21), higher eGFR (58 ± 20 vs. 47 ± 23), and less with heart failure (29% vs. 15%) (all p < 0.001). In both overall and propensity-matched population, improved survival was associated with PCI-treatment at 1 and 3 years (p < 0.001 for all comparisons). Furthermore, by using multivariate Cox proportional-hazards regression model following factors were identified as independent predictors of 3-year all-cause mortality: age (HR 1.08, 95% CI 1.00–1.16), heart rate (HR 1.02, 95% CI 1.01–1.03), eGFR (HR 3.07, 95% CI 1.63–5.77), malignancy (HR 2.03, 95% CI 1.27–4.57), prior CABG (HR 2.033, 95% CI 1.27–4.57), medication with statin (HR 0.40, 95% CI 0.19–0.86) in PCI group, whereas age (HR 1.08, 95% CI 1.03–1.13), heart rate (HR 1.01, 95% CI 1.01–1.02), hypertension (HR 1.87, 95% CI 1.01–3.49) and using of ACEI/ARB (HR 0.46, 95% CI 0.28–0.76) in non-PCI group. Conclusions In elderly ACS patients, PCI-treatment was associated with improved 1 and 3-year survival and PCI-treated patients had different prognostic profile compared to those without PCI treatment