The management of patients aged 90 years and older with ST-segment elevation myocardial infarction

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BACKGROUND

Ischemic heart disease (IHD) is a major cause of lethal outcomes worldwide. According to statistical data for 2018, in the Russian Federation, IHD accounted for more than half (52.6%) of the mortality from diseases of the circulatory system [1]. Myocardial infarction (MI) accounts for approximately 90% of all acute forms of IHD [2].

Currently, reperfusion treatment is recommended to reduce the risk of death in patients with ST segment elevation myocardial infarction (STEMI), which involves the use of two strategies: primary percutaneous coronary intervention (pPCI) and a pharmacoinvasive approach including sequential thrombolytic therapy (TLT) and PCI [3].

Approximately one-third of all patients with acute coronary syndrome (ACS) are older and senile [4]. According to the age classification adopted by the World Health Organization, people aged 75–90 years are classified as old, and those aged >90 years are classified as long livers. Currently, 6% of the global population are old, and by 2050, the proportion of the older population in Western countries is projected to reach 11.5%, mainly due to the rapid increase in the proportion of people aged >80 years [5]. Aging is a natural, progressive process that affects all body systems, including the cardiovascular system. With aging, structural, and functional changes occur at the cellular and subcellular levels, which spread to the entire cardiovascular system. Endothelial function is disrupted, atherosclerotic processes progress, the muscular layer of the arteries becomes atrophied and inelastic, myocardial sclerosis develops with the disruption of its systolic and diastolic functions, and metabolic disorders increase, which creates conditions for energetic and dynamic failure of the heart under stress conditions. In old age, conditioned, and unconditioned reflexes of blood circulation regulation are weakened, which is accompanied by the inertia of vascular reactions. All these processes contribute to the occurrence and progression of cardiovascular diseases (CVDs).

The abovementioned aspects of CVD development in older age groups can influence not only the course of various forms of IHD but also the approaches to their treatment. Thus, older patients with STEMI receive reperfusion therapy (TLT and/or PCI) less often [6], and the most common reasons for refusal include late admission, atypical symptoms, previously diagnosed multivessel disease, comorbidity, reduced renal function, and fragility. In addition, pPCI in these age groups was associated with an increased risk of complications during the intervention compared with that in younger patients. Older patients with STEMI are also at a higher risk of death from ischemic and nonischemic events because of the high incidence of severe comorbidities. The current lack of a special evidence base for the management of patients aged >75 years with STEMI is an important factor that contributes to the decrease in the frequency of reperfusion treatment among older patients because of their rare inclusion in large randomized controlled trials (RCTs). In addition, the pathophysiological aspects of the development and CVD course in older age groups do not enable us to interpolate the results of RCTs obtained in younger patients. From the viewpoint of the basic principles of evidence-based medicine, the most reliable and practically applicable data on optimal treatment approaches and outcomes in older patients with senility and STEMI can be obtained through prospective registries.

AIM

This study examined hospital outcomes in patients with STEMI aged >90 years depending on the management approach.

MATERIAL AND METHODS

From January 2017 to December 2020, 13,272 patients were hospitalized with ACS at the V.P. Polyakov Samara Regional Clinical Cardiological Dispensary. Of these, 4086 patients were diagnosed with STEMI (Fig. 1).

 

Figure 1. A flow-chart of the study population.

Рисунок 1. Блок-схема изучаемой популяции.

 

STEMI was established based on clinical symptoms (including persistent anginal pain) suggestive of myocardial ischemia and changes in the 12-lead electrocardiogram. Electrocardiographic criteria for acute coronary artery occlusion included new J-point ST segment elevations in two contiguous leads of 2.5 mm in men aged 40 years or 1.5 mm in women in leads V2–V3 and/or 1 mm in other leads (in the absence of left ventricular hypertrophy or left bundle branch block), as well as the appearance of a new left bundle branch block. High-sensitivity troponin I levels were measured to confirm myocardial necrosis in STEMI [5].

During the specified period, 72 patients aged >90 years were hospitalized for STEMI. The average time from the first medical contact to the delivery to the PCI center was 104 min. All patients were assessed upon admission from the standpoint of the possibility of using an invasive management approach. Consequently, coronary angiography (CA) was performed in 18 patients, and in 13 cases, it resulted in pPCI. The remaining patients were not subjected to the invasive approach (n = 54); three patients were hospitalized after ≥24 h from the onset of pain, three were diagnosed with acute renal failure, one had gastrointestinal bleeding, one was diagnosed with thrombocytopenia, six had contraindications to intervention because of the severity of their general condition, and another 40 patients signed a refusal to undergo CA.

Thus, the patients were divided into two groups depending on their management approach in the hospital. Group 1 included patients who underwent pPCI (n = 13), with a mean age of 90.6 (90–91) years, and 8 (61.5%) patients were female. Group 2 included patients who were treated conservatively, including those who underwent CG without subsequent PCI (n = 5). Group 2 included 59 patients, with a mean age of 91.9 (91–96) years, and 41 were women (69.5%). Outcomes were assessed during hospitalization.

Statistical analysis was performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, USA). When calculating descriptive statistics, quantitative variables were assessed for compliance with a normal distribution using the Shapiro–Wilk or Kolmogorov–Smirnov test. Continuous variables with a distribution close to normal were presented as the mean (M) ± standard deviation (σ); if the distribution of the variable differed from the normal distribution, the median and quartiles (Me [Q1; Q3]) were given. Fisher’s exact test was used to compare frequencies between the groups. The cutoff threshold for the level of significance when testing statistical hypotheses was chosen to be p < 0.05.

RESULTS

The baseline clinical characteristics of patients with STEMI are presented in Table 1. The invasive group was younger than the conservative group (mean age, 90.6 vs 91.9 years, p = 0.003). No significant differences were found between the groups in other parameters.

 

Table 1. Clinical characteristics of STEMI patients aged 90 years and older

Таблица 1. Клиническая характеристика пациентов с ИМпST 90 лет и старше

	Group 1	Group 2	р
Female, n	8 (61,5%)	41 (69,5%)	0,74
Age, years	90,6 [90-91]	91,9 [91-96]	0,003
RMI (recurrent myocardial infarction)	3 (23,1%)	21 (35,6%)	0,52
CHF (chronic heart failure)	4 (30,8%)	23 (38,9%)	0,76
History of stroke	3 (23,1%)	8 (13,6%)	0,41
PVD (peripheral vascular disease)	1 (7,7%)	8 (13,6%)	1,00
Chronic kidney disease (CKD) (stages 4 and 5)	4 (30,8%)	13 (22,0%)	0,49
Smoking	0	0	-
Diabetes mellitus	2 (15,4%)	8 (13,6%)	1,00
AH (arterial hypertension)	13 (100%)	56 (94,9%)	1,00
AF (atrial fibrillation)	4 (30,8%)	15 (25,4%)	0,73

Note: The difference in indicators is statistically significant at p < 0.05.

 

CG was performed mainly through radial access (94.4%). The characteristics of the coronary anatomy are presented in Table 2. Three-vessel coronary artery lesions were the most common (61%) (Fig. 2).

 

Table 2. Anatomical lesions of coronary arteries in patients with STEMI aged 90 years and older

Таблица 2. Анатомическое поражение коронарных артерий у пациентов с ИМпST в возрасте 90 лет и старше

AIVB (anterior interventricular branch)	12 (66,6%)
RCA (right coronary artery)	13 (72,2%)
CA (circumflex artery)	6 (33,3%)
LCA trunk (left coronary artery trunk)	1 (5,6%)
IMA (intermediary artery)	1 (5,6%)
DA (diagonal artery)	1 (5,6%)
OMA (obtuse marginal artery)	1 (5,6%)

 

Figure 2. The prevalence of coronary lesion in STEMI patients over 90 years of age.

Рисунок 2. Распространенность поражения коронарного русла у пациентов с ИМпST старше 90 лет.

 

Optimal drug therapy was prescribed to all patients included in the study. To reduce the risk of death, recurrent MI, and ischemic events, in the absence of contraindications, dual antiplatelet therapy with acetylsalicylic acid and P2Y12 receptor blockers was prescribed. To reduce the risk of MI complications and improve prognosis, beta blockers were prescribed. Renin–angiotensin–aldosterone system blockers were prescribed to prevent left ventricular dysfunction, heart failure, and death. In the absence of contraindications, lipid-lowering therapy with a hydroxymethylglutaryl-coenzyme A reductase inhibitor during hospitalization was used to reduce the total risk of ischemic events. The need to take nitrates, diuretics, mineralocorticoid receptor antagonists, and calcium channel blockers was based on clinical characteristics (Fig. 3).

 

Figure 3. The drug therapy during hospitalization and at discharge.

Рисунок 3. Медикаментозная терапия пациентов в стационаре и при выписке.

 

Regarding the incidence of pulmonary edema and cardiogenic shock, both groups were comparable, with no statistically significant differences detected. In-hospital mortality among patients with STEMI aged 90 years was higher in the conservative strategy group than in the invasive group, namely, 45.8% versus 7.7% (OR 10.12; 95% CI [1.24–82.96]) (Table 3).

 

Table 3. In-hospital outcomes among patients with STEMI ≥90 years

Таблица 3. Исходы пациентов старше 90 лет с ИМпST

	Group 1	Group 2	р	OR, 95% CI
Pulmonary edema	2 (15,3%)	9 (15,4%)	1,00	0,99 (0,19-5,24)
Cardiogenic shock	1 (7,7%)	16 (27,1%)	0,17	4,47 (0,54-31,17)
Hospital mortality	1 (7,7%)	27 (45,8%)	0,01	10,12 (1,24-82,96)

Note: The difference in indicators is statistically significant at p < 0.05.

 

DISCUSSION

According to the recommendations of the Russian Society of Cardiology (2020), the treatment for patients with STEMI is based on the elimination of acute occlusion and restoration of the patency of the coronary arteries. All patients, regardless of age, should be considered candidates for reperfusion therapy [2]. The European guidelines for the management of patients with STEMI (2017) indicate the absence of age restrictions for reperfusion therapy, particularly pPCI [3]. However, in real clinical practice, the invasive approach is chosen less frequently in older patients than in younger ones [7]. As a rule, this occurs because of the presence of numerous comorbidities and an often questionable prognosis in patients aged 75 years. In addition, the lack of RCTs conducted among patients in this age cohort reduces the commitment of doctors to the selection of an invasive approach for patient management.

The choice of the management approach for older patients with STEMI has long been of interest to researchers worldwide. One of the first studies (2002), including 87 patients aged >75 years, diagnosed with STEMI, showed the benefits of pPCI in reducing mortality, reinfarctions, and recurrent strokes compared with streptokinase TLT (OR 4.3; 95% CI 1.2–20.0; p = 0.01) [8].

The TRIANA multicenter, randomized, open-label study included 266 patients with STEMI aged >75 years who were hospitalized within 6 h of pain onset. Patients were divided into groups depending on whether they received pPCI (n = 132, 74 female patients, mean age 81.2 ± 4.6 years) or TLT (n = 134, 76 female patients, mean age 81 ± 4.3 years). The study did not reveal statistically significant differences in the occurrence of the combined primary endpoint (30-day death, recurrence of infarction or stroke) in the pPCI and TLT groups (OR 0.69; 95% CI 0.38–1.23; p = 0.21) [9]. In contrast, a pooled analysis including the Zwolle (2002), SENIORPAMI (2010), and TRIANA (2010) studies showed the benefits of pPCI compared with TLT in reducing lethal outcomes, recurrent infarction, and stroke in older patients with STEMI (OR 0.64; 95% CI 0.45–0.91) [9].

The EUROTRANSFER registry included 1650 patients with STEMI and a history of pPCI, who were divided into four groups according to age (<65, 65–74, 75–84, and >85 years). This study established the characteristics of treatment and outcomes in patients with STEMI with respect to age. In the group aged >85 years, an increase in the incidence of multivessel disease and a decrease in the incidence of PCI were noted. The incidence of death, recurrent infarctions, and all adverse cardiovascular outcomes increased with age (3.8% for the population aged <65 years versus 20.4% for those aged >85 years, p < 0.0001). In addition, age was an independent predictor of 30-day mortality [10].

The ISACS-TC registry identified factors associated with lower CG rates in older patients. Based on an analysis of 1315 patients with STEMI (mean age, 79.6 (76–82) years, 47.9% female patients), PCI was performed significantly less often in those aged >75 years compared with younger patients (62.1% vs 78.9 %, p < 0.001). Refusal of invasive treatment in patients aged >75 years was associated with existing risk factors, severity of symptoms, and late hospitalization. Predictors of failure to perform CA were female sex, presence of concomitant diseases, and late hospitalization [11].

The results of this study indicate the advantage of the invasive approach in the management of patients with STEMI aged >90 years, which is consistent with the results of some of the studies presented above [9, 10]. However, to date, there is no consensus on the advantage of an invasive treatment strategy in older patients and long livers. Therefore, a prospective randomized multicenter study that will provide verifiable information on the choice of the optimal approach to the management of this category of patients is considered appropriate.

CONCLUSIONS

According to the results of this study, PCI should be considered the main management strategy in patients with STEMI aged >90 years. Further prospective studies based on the principles of evidence-based medicine are required.

The study limitations are the retrospective design and enrollment of patients from a single medical center.

Conflict of interest. The authors declare no conflict of interest.

About the authors

Polina D. Duplyakova

Samara State Medical University; Samara Regional Clinical Cardiology Dispensary named after V.P. Polyakov

Author for correspondence.
Email: polina_duplyakova@yahoo.com
ORCID iD: 0000-0003-2773-1682

Postgraduate Student of the Department of Cardiology and Cardiovascular Surgery; Cardiologist

Russian Federation, Samara; Samara

Tatyana V. Pavlova

Samara State Medical University; Samara Regional Clinical Cardiology Dispensary named after V.P. Polyakov

Email: t.v.pavlova@samsmu.ru
ORCID iD: 0000-0003-3301-1577

PhD, Professor of the Department of Cardiology and Cardiovascular Surgery of the Institute of Postgraduate Education; Head of Clinical Research Department

Russian Federation, Samara; Samara

Sergey M. Khokhlunov

Samara State Medical University

Email: s.m.khokhlunov@samsmu.ru
ORCID iD: 0000-0001-6000-620X

PhD, Professor, Head of the Department of Cardiology and Cardiovascular Surgery of the Institute of Postgraduate Education

Russian Federation, Samara

Dmitry V. Duplyakov

Samara State Medical University; Samara Regional Clinical Cardiology Dispensary named after V.P. Polyakov

Email: duplyakov@yahoo.com
ORCID iD: 0000-0002-6453-2976

PhD, Professor, Head of the Department of Propaedeutic Therapy; Deputy Chief Physician for Medical Affairs

Russian Federation, Samara; Samara

References

Supplementary files