Early PCI Makes Inroads in Elderly With STEMI, Shock

Patrice Wendling

May 02, 2019

Results of a national database analysis show substantial survival benefits of early percutaneous coronary intervention (PCI) among patients 75 years and older with ST-segment-elevation myocardial infarction (STEMI) complicated by cardiogenic shock.

Independent of the propensity methods used, PCI was associated with a 41% relative reduction and a 21% absolute reduction in the risk for in-hospital mortality compared with no PCI, the authors report.

Additionally, interventionalists appear less reluctant to treat these high-risk patients, with a consistent increase in PCI use observed after the pivotal 1999 SHOCK trial.

Patients 75 years and older account for about a third of all patients with STEMI and more than 10% will develop cardiogenic shock — a condition with up to a 79% mortality rate.

"From a public health perspective, early revascularization should not be denied for older adults in the absence of absolute contraindications (i.e., active bleeding, severe neurocognitive decline, and very limited life expectancy with end-stage disease processes)," write Abdulla A. Damluji, MD, MPH, Johns Hopkins University, Baltimore, and colleagues.

After the SHOCK trial, guidelines on the management of STEMI did not exclude older adults with cardiogenic shock from early revascularization. However, national estimates on the use of PCI during hospital admission in this population have not been determined, the authors note.

The study was published in the April 23 issue of the Journal of the American College of Cardiology.

Breaching the Age Barrier

Using the National Inpatient Sample, the investigators estimated that 111,901 patients 75 years and older were admitted in the United States with STEMI and cardiogenic shock from 1999 to 2013. They had an average age of 82 years and eight chronic conditions. Disease burden was significantly lower in patients treated with than without PCI (Charlson comorbidity indexm 2.6 vs 2.9).

The results show admissions for STEMI and cardiogenic shock among these older patients fell from 42% to 29% over the study period and was paralleled by a substantial reduction in crude unadjusted in-hospital mortality rates (64% vs 46%; P < .001).

In propensity score analysis, PCI was associated with lower mortality risk compared with no PCI (unweighted Mantel-Haenszel odds ratio [OR], 0.48; 95% CI, 0.45 - 0.51).

The survival benefit was consistent across all quintiles of propensity score and when the propensity score was treated as a continuous variable (OR, 0.47; 95% CI, 0.44 - 0.50), the authors report.

During hospitalization, 8.4% of patients had a bleeding event, which was associated with higher unadjusted mortality in the PCI group (34% vs 29% with no bleeding; P < .001).

Additional sensitivity analyses performed to include bleeding in the model showed that PCI remained significantly associated with survival within each quintile of the propensity score. Similar survival benefits with PCI were present after the exclusion of patients who died in the first 48 hours or first week, and across all four regions of the United States.

"The findings of this large-scale report agree with previous nonadministrative-based registries…that consistently support the benefit of revascularization versus no revascularization among older adults presenting with STEMI and CS [cardiogenic shock] with varying degree of mulitmorbidity," Eliano  P. Navarese, MD, PhD, SIRIO MEDICINE Research Network, Bari, Italy, and the University of Alberta, Edmonton, Canada, and colleagues, write in an accompanying editorial.

An important aspect of the study is that it accounts for bleeding risk in multivariate adjustment and that bleeding risk was a driver of increased mortality, they note. Because of the retrospective claims-based nature of the dataset, however, the authors lacked granular information on coronary anatomy, which can play a role in the development of and recovery from CS. A coding bias also might have occurred because of the lack of event adjudication and variance in criteria used to define CS.

The editorialists note that many randomized controlled trials (RCTs) of PCI in STEMI share a lack of generalizability because of the exclusion of elderly patients.

The present study "supports the need for more robust RCTs in CS, particularly to study mechanical support devices that are currently widely used without adequate RCT data," Navarese and colleague write. "Robust real-world data are indeed warranted to provide evidence supporting more informed best practice for the growing elderly population in the United States."

The study was funded in part by a research grant from the Jane and Stanley F. Rodbell family in support of geriatric cardiology research at Sinai Hospital of Baltimore . Damluji has received research funding from the Johns Hopkins University Claude D. Pepper Older Americans Independence Center, funded by the National Institute on Aging.

The editorialists have reported no relevant conflicts of interest.

J Am Coll Cardiol. 2019;73:1890-1900 and 1901-1904. Abstract, Editorial

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