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PCI in Older Adults With STEMI and Cardiogenic Shock
Study Questions:
What is the use of percutaneous coronary intervention (PCI) in older adults with ST-segment elevation myocardial infarction (STEMI) and cardiogenic shock and its influence on in-hospital mortality?
Methods:
The investigators used a large publicly available all-payer inpatient healthcare database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). To compare older adults with STEMI and cardiogenic shock by treatment with PCI, the authors performed a logistic regression to examine the association of hospital mortality with treatment by PCI (vs. non-PCI) within each of the five quintiles of the PS.
Results:
Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was eight (interquartile range, 6-10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%; p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of PS (Mantel-Haenszel odds ratio, 0.48; 95% confidence interval [CI], 0.45-0.51). This reduction in hospital mortality risk was seen across the four different US Census Bureau regions (adjusted odds ratio, Northeast: 0.41; 95% CI, 0.36-0.47; Midwest: 0.49; 95% CI, 0.42-0.57; South: 0.51; 95% CI, 0.46-0.56; West: 0.46; 95% CI, 0.41-0.53).
Conclusions:
The authors concluded that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality.
Perspective:
This study reports that older adults who were not treated with PCI had worse comorbidity burden, shorter hospital length of stay, and higher crude mortality rates after STEMI and cardiogenic shock than those treated with PCI and using PS methods. Treatment with PCI appears to be associated with significant improvement in hospital mortality in older patients. Based on these and other data, early revascularization should not be denied to older adults in the absence of absolute contraindications such as active bleeding, severe neurocognitive decline, and very limited life expectancy with end-stage disease processes. Additional studies are indicated to optimize early revascularization strategies for older adults with STEMI and cardiogenic shock.
Keywords: Acute Coronary Syndrome, Geriatrics, Heart Failure, Hospital Mortality, Inpatients, Length of Stay, Myocardial Infarction, Percutaneous Coronary Intervention, Propensity Score, Secondary Prevention, Shock, Cardiogenic
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