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Time Trends in Mechanical Complications After STEMI
Study Questions:
What are the time trends in the incidence, management, and fatality rates of mechanical complications (MCs), and its influence on short-term mortality in older patients with ST-segment elevation myocardial infarction (STEMI)?
Methods:
The study investigators analyzed trends in the incidence and outcomes of MC in 1,393 consecutive patients between 1988 and 2008, by Mantel-Haenszel linear association test. The population consisted of all patients ≥75 years of age admitted to the Coronary Care Unit of Hospital General Universitario Gregorio Marañón in Madrid, Spain, with a definitive diagnosis of first STEMI. MC was defined as any spontaneous rupture of the myocardium following acute MI. This comprises three types, according to the area where the myocardial rupture happens: free-wall rupture, ventricular septal rupture, and papillary muscle rupture. A logistic regression analysis for mortality was performed to assess the time trend in risk-adjusted mortality including age, risk factors, prior cardiovascular disease, delay to admission, and time period as covariates.
Results:
Overall in-hospital mortality decreased from 34.3% to 13.4% (relative risk reduction, 61%; p < 0.001). Although the absolute mortality due to MC decreased from 9.6% to 3.3% (p < 0.001), the proportion of deaths due to MC among all deaths did not change (28.1% to 24.5%; p = 0.53). The incidence of MC decreased from 11.1% to 4.3% (relative risk reduction, 61%) with no change in their hospital fatality rate over time (from 87.1% to 82.4%; p = 0.66). The proportion of patients undergoing surgical repair decreased from 45.2% to 17.6% (p = 0.04), with no differences in postoperative survival (from 28.6% to 33.3%; p = 0.74).
Conclusions:
The authors concluded that although the incidence of MC has decreased substantially since the initiation of reperfusion therapy in elderly STEMI patients, this reduction was not accompanied by an improvement in fatality rates, with or without surgery.
Perspective:
This study reports that parallel to the initiation and increased use of reperfusion therapy in the elderly, there was a dramatic reduction in hospital mortality and in the incidence of MCs in these patients, which was numerically more important for free-wall rupture, the most frequent MC. However, there was no improvement over time in the survival of patients who developed a MC, who still had a very poor prognosis. These and other data suggest that when MCs develop, prognosis is poor, and additional research is needed to improve the outcome of MCs in elderly patients with STEMI.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS
Keywords: Acute Coronary Syndrome, Anterior Wall Myocardial Infarction, Cardiac Surgical Procedures, Geriatrics, Heart Failure, Heart Rupture, Hospital Mortality, Myocardial Infarction, Papillary Muscles, Reperfusion, Risk Factors, Rupture, Spontaneous, Ventricular Septal Rupture
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