Clinical Investigation
Acute Ischemic Heart Disease
Impact of age on treatment and outcomes in ST-elevation myocardial infarction

https://doi.org/10.1016/j.ahj.2010.12.018Get rights and content

Objectives

We hypothesized that older patients in a regional ST-elevation myocardial infarction (STEMI) transfer program would attain comparable treatment to younger patients.

Background

Older patients have been either excluded or underrepresented in STEMI clinical trials. Observational studies suggest that these patients are less likely to receive adjunctive pharmacologies and reperfusion therapy—thrombolysis or percutaneous coronary intervention (PCI)—and therapy is frequently delayed.

Methods

We identified a consecutive series of 2,262 STEMI patients (March 2003–December 2008) who either presented or were transferred to Abbott Northwestern Hospital for PCI (<65 years [n = 1285], 65-74 years [n = 436], 75-84 years [n = 381], and ≥85 years [n = 160]). Main outcome measures included time-to-reperfusion therapy, adjunctive medications received, and all-cause mortality.

Results

Overall time-to-reperfusion therapy was similar across age strata—94 minutes (<65 years), 101 minutes (65-74 years), 106 minutes (75-84 years), and 103 minutes (≥85 years). No difference in adjunctive antiplatelet or anticoagulant medications was seen at hospital admission, and only slight differences in standard post–myocardial infarction medication use were seen by age at hospital discharge. Age was an independent predictor of in-hospital and yearly mortality up to 5 years (1-year mortality 3.4% [<65 years], 9.2% [65-74 years], 15.2% [75-84 years], and 28.9% [≥85 years]; P < .0001).

Conclusions

Older patients receive similar care to younger patients when treated in a regional STEMI transfer program. Although all-cause mortality in the elderly is increased, the absolute rates are lower than previously established. Our data suggest primary PCI (including transfer) can be applied to all appropriate STEMI patients, regardless of age.

Section snippets

Minneapolis Heart Institute Level 1 MI program

Details and outcomes of the Minneapolis Heart Institute Level 1 STEMI Program have been previously published.15, 23 After an initial pilot period in early 2003, a regional STEMI program using a standardized protocol was developed for transfer of STEMI patients for primary PCI. Patients presenting to community hospitals within 60 miles of Abbott Northwestern Hospital (Zone 1) receive aspirin, β-blocker, heparin (unfractionated heparin is used per protocol, whereas <1% of patients were already on

Results

We identified 2,262 patients who were treated for STEMI during a 5-year interval (March 2003 through December 2008). The distribution of patients was weighted to younger individuals: age greater than 65 years (n = 1,285; range, 17-64 years), age 65 to 74 years (n = 436), age 75 to 84 years (n = 381), age 85 years or greater (n = 160; range, 85-99 years). However, 24% (n = 541) of patients were 75 years or older.

Demographic, baseline clinical, and angiographic factors varied by age stratum (

Discussion

There are limited data regarding MI outcomes in older patients, particularly in the setting of PCI for STEMI. Numerous randomized clinical trials have compared a strategy of PCI to fibrinolysis for patients with STEMI, but older patients have been excluded from most of these trials.9 Three relatively small randomized clinical trials appear to support PCI over fibrinolysis, but the results are inconclusive.16, 17, 18 Observational registries also suggest a benefit of PCI over fibrinolysis in

Disclosures

Grant support: Minneapolis Heart Institute Foundation.

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