Coronary artery disease
Angiographic and clinical characteristics associated with increased in-hospital mortality in elderly patients with acute myocardial infarction undergoing percutaneous intervention (a pooled analysis of the primary angioplasty in myocardial infarction trials)

https://doi.org/10.1016/S0002-9149(00)00824-9Get rights and content

Abstract

Advanced age is associated with increased mortality in acute myocardial infarction (AMI) but the mechanism remains unclear. We performed a pooled analysis of 3,032 patients from the Primary Angioplasty in Myocardial Infarction (PAMI)-2, Stent-PAMI, and PAMI-No Surgery On Site trials to determine which clinical, hemodynamic, and angiographic characteristics in the elderly were associated with in-hospital death. There were 452 patients aged ≥75 years and 2,580 patients aged <75 years. Older patients had a lower number of risk factors for coronary artery disease but more comorbidities. Acute catheterization demonstrated more 3-vessel disease, higher left ventricular (LV) end-diastolic pressure, lower LV ejection fraction, and higher initial rates of Thrombolysis In Myocardial Infarction (TIMI) trial 2 or 3 flow. Elderly patients were equally likely to undergo percutaneous intervention but had a lower procedural success rate and lower rates of final TIMI 3 flow, and older patients were more likely to have post-AMI complications. In-hospital mortality was 10.2% and 1.8%, respectively (p = 0.001). Cardiac and noncardiac mortality was higher in elderly patients, and no significant differences in causes of death were identified. Multivariate analysis revealed that the strongest predictors of death were age ≥75 years, lower LV ejection fraction, lower final TIMI flow, higher Killip class, need for an intra-aortic balloon pump (IABP), and post-AMI stroke/transient ischemic attack, or significant arrhythmia. Despite avoiding thrombolysis, elderly patients remain at increased risk of bleeding, stroke, and other post-AMI complications, and death. Cardiac risk factor analysis and acute catheterization offer prognostic information but do not completely explain the mechanism of increased in-hospital mortality in the elderly.

Section snippets

Methods

The information was obtained from review of the databases from 3 primary angioplasty trials (PAMI-2,18 Stent PAMI,19 and PAMI No Surgery On Site20) maintained at the PAMI Coordinating Center at William Beaumont Hospital, Royal Oak, Michigan. These trials involved 1,100 patients (recruited between June 1990 and April 1992), 1,458 patients (recruited between September 1993 and January 1995), and 474 patients (recruited between August 1996 and June 1998) for a total of 3,032 patients. All trials

Results

There were 2,580 patients (85%) aged <75 years and 452 (15%) aged ≥75 years. Older patients were smaller and more likely to be women and had a higher Killip class at presentation (Table I). Cardiac risk factors and comorbidities more prevalent among older patients included hypertension, diabetes mellitus, history of congestive heart failure, prior AMI, history of peripheral vascular disease, and history of a cerebral vascular accident. Those more common in younger patients included

Discussion

As life expectancy continues to increase, cardiologists can expect to encounter a significant increase in the number of patients with AMI who are ≥75 years old. In the era before reperfusion, elderly patients had 1-month and 1-year mortality rates of 30% and 75%, respectively.21, 22 Our study attempts to use information obtained at acute cardiac catheterization to identify the mechanism(s) of this increased risk and to define predictors that may help the clinician identify a high-risk subset of

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