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Amanda Jekowsky , American College of
Cardiology, 202-375-6645, ajekowsk@acc.org
February
16, 2009
Elderly Patients with Heart Attack
Complicated by Cardiogenic Shock Can Benefit from Selective
Use of Early Revascularization
Data suggest age alone should not prevent more
aggressive care
The elderly represent a growing proportion of patients presenting
with acute myocardial infarction (MI) complicated by cardiogenic
shock (CS). CS occurs when the heart fails to supply enough
blood to the organs of the body, and remains the most common
cause of death after heart attack among people 75 years of
age and older. Proper selection of older patients for invasive
management of heart disease remains a serious medical challenge,
especially as the elderly are frequently underrepresented
in or excluded from clinical trials.
In a study published in the February 2009 issue of JACC:
Cardiovascular Interventions, researchers found the one-year
survival of elderly patients (age = 75 years) with acute MI
complicated by CS undergoing percutaneous coronary intervention
(PCI) using contemporary techniques was comparable with survival
of younger patients.
“Elderly patients who are admitted to the hospital
with massive heart attacks may still benefit from emergency
coronary artery balloon angioplasty and stenting, despite
their advanced age,” says David Clark, M.B.B.S., F.R.A.C.P.,
senior author of the study and interventional cardiologist
at Austin Hospital, Melbourne, Australia. “Although
mortality occurs in roughly half of patients in these high
risk situations, without this aggressive treatment, the prospect
of survival is very poor.”
Researchers analyzed baseline characteristics (e.g., smoking
status, blood pressure, previous MI, renal function and symptom
onset) and clinical outcomes, including death and emergence
of other complications, in 143 consecutive patients from the
Melbourne Interventional Group registry between 2004 and 2007.
Elderly patients (n=45) were more likely to be female and
have hypertension, previous MI, renal failure and multi-vessel
coronary artery disease. Data indicated no significant differences
for in-hospital, 30-day and one-year mortality in the elderly
versus the younger groups.
CS is a very complicated illness to manage, often requiring
timely and very specialized care. Patients typically spend
significant time in intensive care, which often necessitates
considerable human and financial resources. So, while outcomes
data show that early revascularization can improve survival
among elderly patients, other clinical factors—proper
patient selection, the “physiological age” and
prior condition of the patient (e.g., prior functional status,
co-morbidities such as dementia and frailty) and a cost-benefit
analysis of therapies—need to be considered by cardiologists.
“A patient’s age in and of itself should not
be used to deny someone more aggressive, invasive care with
angioplasty for cardiogenic shock,” says Judith S. Hochman,
M.D., F.A.C.C., F.A.H.A., Harold Snyder Family Professor of
Cardiology and director of the Cardiovascular Clinical Research
Center, New York University School of Medicine. “Having
said that, we need to better understand and standardize criteria
to improve selection of older patients who are likely to benefit.
For example, as shown in this study, better kidney function
clearly is a useful indicator that a patient will do well.
What we don’t want is to subject patients to uncomfortable,
unnecessary procedures if they will not derive a benefit in
terms of quality of life or life prolongation.”
The elderly in particular are at increased risk for other
complications. Authors add that further investigation of the
selective use of early revascularization among this patient
population is needed.
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