[Impact of age on treatment and outcomes after acute myocardial infarction, particularly in very elderly patients]. / Impacto da idade no tratamento e resultados após enfarte agudo do miocárdio em particular nos muito idosos.

INTRODUCTION: The elderly population admitted for acute myocardial infarction is increasing. This group is not well studied in international trials and is probably treated with a more conservative approach. OBJECTIVES: To evaluate the presentation and treatment of myocardial infarction according to age, particularly in very elderly patients. METHODS: We studied 1242 consecutive patients admitted with acute myocardial infarction, assessing in-hospital, 30-day and one-year mortality during follow-up for each age-group. Patients were divided into four groups according to age: <45 years (7.6%); 45-64 years (43.3%); 65-74 years (23.4%); and ≥75 years (25.7%). RESULTS: Elderly patients had a worse risk profile (except for smoking), more previous history of coronary disease and a worse profile on admission, with the exception of lipid profile, which was more favorable. With regard to treatment of the elderly, although less optimized than in other age-groups, it was significantly better compared to other registries, including for percutaneous coronary angioplasty. Both complications and mortality were worse in the older groups. In elderly patients (≥75 years), adjusted risk of mortality was 4.9-6.3 times higher (p<0.001) than patients in the reference age-group (45-64 years). In these patients, the independent predictors of death were left ventricular function and renal function, use of beta-blockers being a predictor of survival. CONCLUSIONS: Elderly patients represent a substantial proportion of the population admitted with myocardial infarction, and receive less evidenced-based therapy. Age is an independent predictor of short- and medium-term mortality.

Impact of obesity on results after primary angioplasty in patients with ST segment elevation acute myocardial infarction.

INTRODUCTION: Obesity is an important risk factor for the development of diabetes, hypertension, coronary disease, left ventricular dysfunction, stroke and cardiac arrhythmias. Paradoxically, previous studies in patients undergoing elective coronary angioplasty showed a reduction in hospital and long-term mortality in obese patients. The relation with body mass index (BMI) has been less studied in the context of primary angioplasty. OBJECTIVES: To evaluate the impact of obesity on the results of ST-segment elevation acute myocardial infarction treated by primary angioplasty. METHODS: This was a study of 464 consecutive patients with ST-segment elevation acute myocardial infarction undergoing primary angioplasty, 78% male, mean age 61 +/- 13 years. We assessed in-hospital, 30-day and one-year mortality according to BMI. Patients were divided into three groups according to BMI: normal--18-24.9 kg/m2 (n = 171); overweight--25-29.9 kg/m2 (n = 204); and obese-- > 30 kg/m2 (n = 89). RESULTS: Obese patients were younger (ANOVA, p < 0.001) and more frequently male (p = 0.014), with more hypertension (p = 0.001) and dyslipidemia (p = 0.006). There were no differences in the prevalence of diabetes, previous cardiac history, heart failure on admission, anterior location, multivessel disease, peak total CK or medication prescribed, except that obese patients received more beta-blockers (p = 0.049). In-hospital mortality was 9.9% for patients with normal BMI, 3.4% for overweight patients and 6.7% for obese patients (p = 0.038). Mortality at 30 days was 11 4.4% and 7.8% (p = 0.032) and at one year 12.9%, 4.9% and 9% (p = 0.023), respectively. On univariate analysis, overweight was the only BMI category with a protective effect; however, after multivariate logistic regression analysis, adjusted for confounding variables, none of the BMI categories could independently predict outcome. CONCLUSIONS: Overweight patients had a better prognosis after primary angioplasty for ST-segment elevation acute myocardial infarction compared with other BMI categories, but this was dependent on other potentially confounding variables.

Prognostic impact of bundle branch block after acute coronary syndrome. Does it matter if it is left of right?

BACKGROUND: In previous guidelines, acute coronary syndromes (ACS) with new or presumably new left bundle branch block (LBBB) were an indication for reperfusion treatment, preferably with primary angioplasty. Recent guidelines also included the presence of right bundle branch block (RBBB) in this recommendation. It was our objective to evaluate in a population of patients with ACS the differential impact of RBBB and LBBB in prognosis. METHODS: Consecutive patients included prospectively in a single-centre registry of ACS were included in the study. Patients were analyzed according to baseline ECG characteristics (normal QRS, LBBB or RBBB). Primary outcome was all-cause mortality at one-year follow-up. We used Cox-proportional hazards models to assess the predictive value for the primary outcome. RESULTS: A total of 3990 patients were included in, with a mean age of 64 (13) years, 72% males, 3.4% with LBBB and 4.3% with RBBB. Patients with BBB were older, with more previous history of myocardial infarction and coronary revascularization and higher prevalence of cardiovascular risk factors (except smoking). Medical treatment was similar but they were less often submitted to angioplasty. In univariate analysis, BBB patients had worst outcome (Log-rank, p < 0.001), but similar in LBBB and RBBB (Log-rank, p = 0.597). In multivariate analysis, only RBBB (HR 1.66, 95%CI 1.14-2.40, p = 0.007) is an independent predictor of all-cause mortality. CONCLUSIONS: Patients with BBB have worst outcome after an ACS, particularly with RBBB. For that reason, we should pay special attention and treat these patients as aggressively as patients with normal QRS duration or LBBB.

Adherence to guidelines in the treatment of acute coronary syndromes: progress over time.

BACKGROUND: Treatment of acute coronary syndromes (ACS) has changed considerably in the last few years, as reflected in various proposals for guidelines by the ACC/AHA/ESC based on clinical evidence. We analyzed the clinical implementation of these recommendations in our patient population between 2002 and 2005. METHODS: This was a retrospective study of 368 patients admitted in 2002 and 420 patients admitted in 2005 for ACS (with and without ST-segment elevation). We analyzed clinical characteristics and treatment strategies. RESULTS: There were no differences in terms of age, gender ratio, risk factors for coronary artery disease, or previous myocardial revascularization. There was a decrease in the number of patients with previous myocardial infarction and renal insufficiency on admission, and an increase in patients with ST-segment elevation on admission. Treatment with clopidogrel (6% vs. 87%), beta-blockers (54% vs. 79%), angiotensin-converting enzyme inhibitors (72% vs. 84%) and statins (78% vs. 91%) increased (all with p < 0.001). On the other hand, there was a slight decrease in the use of aspirin (98% vs. 95%, p = 0.039) (with greater use of clopidogrel) and ticlopidine was no longer used (46% vs. 0%, p < 0.001). Use of glycoprotein IIb/IIIa receptor antagonists did not change significantly (66% vs. 67%, p = NS). Percutaneous coronary interventions increased (53% vs. 67% p < 0.001). There was no difference in in-hospital mortality (8.2% vs. 6.4%) or 30-day mortality (9.0% vs. 8.6%), but mortality was lower at one-year follow-up (17.1% vs. 11.7%, p = 0.039). Statins and beta-blockers are independent predictors of mortality during follow-up, with a protective effect. CONCLUSIONS: Between 2002 and 2005, treatment of ACS improved significantly according to existing guidelines, leading to improvement in medium-term mortality.

What is the role of beta-blockers in a contemporary treatment cohort of patients with acute coronary syndrome? A propensity-score matching analysis.

INTRODUCTION: The evidence for beta-blocker use in patients after acute coronary syndrome (ACS), particularly in those with left ventricular (LV) dysfunction, dates from the late 1990s. We aimed to assess the role of beta-blockers in a contemporary population of patients with ACS. METHODS: Propensity-score matching (1:2) was performed for the use of beta-blockers in a population of consecutive patients admitted to our department with ACS. After matching, 1520 patients were analyzed. Cox regression analysis was used to assess the impact of beta-blocker use on the primary outcome (one-year all-cause mortality). RESULTS: Patients who did not receive beta-blockers were less aggressively treated with other pharmacological and invasive interventions and had higher one-year mortality (20.3% vs. 7.5%). Beta-blocker use was an independent predictor of mortality, with a significant relative risk reduction of 56%. The other independent predictors were age, diabetes, LV dysfunction, heart rate, systolic blood pressure and creatinine on admission. The impact of beta-blockers was significant for all classes of LV function, including patients with normal or mildly reduced ejection fraction. CONCLUSIONS: In a contemporary ACS population, we confirmed the benefits of beta-blocker use after ACS, including in patients with normal or mildly to moderately impaired LV function.

A systematic invasive strategy in non-ST elevation acute coronary syndromes: is age a limiting factor?

INTRODUCTION: A systematic invasive therapeutic strategy for acute coronary syndromes (ACS) is currently accepted as safe and effective and evidence is growing for its superiority compared to a conservative attitude. Elderly patients, given their greater susceptibility, are frequently excluded from this approach, and this may limit the potential benefits. OBJECTIVE: To evaluate the influence of age on the characteristics and clinical evolution of patients with ACS treated by an invasive strategy and to determine whether this in itself limits its adoption. METHODS: We retrospectively studied 203 patients admitted for ACS (consecutive and non-selected). considered of medium to high risk after evaluation and treated with glycoprotein IIb/IIIa receptor inhibitors. Of these, 45 patients were aged > or =75 years and they constituted the Elderly group, the remainder constituting the Non-elderly group. Their baseline characteristics, treatment and clinical evolution were analyzed and compared. RESULTS: The Elderly group had more women, although the difference was not statistically significant. Of the other characteristics studied, family history of coronary disease and smoking presented significant differences, both being less frequent among the elderly. There was a non-significant tendency to perform less catheterization in the elderly, the two groups being similar regarding the revascularization therapy chosen. Overall, hemorrhagic complications were more frequent in the Elderly group, but the difference regarding significant hemorrhages did not reach statistical significance. In-hospital mortality was higher in the elderly, but diminished and did not reach statistical significance when only patients in whom catheterization was performed were considered. CONCLUSION: In this population the elderly had more non-significant hemorrhagic complications but their higher in-hospital mortality was not associated with the adoption of an invasive approach. We therefore suggest that age by itself does not limit the adoption of a systematic invasive strategy.

Prognostic value of neutrophil response in the era of acute myocardial infarction mechanical reperfusion.

BACKGROUND: In ST-segment elevation myocardial infarction (STEMI) patients treated with primary angioplasty, neutrophil response and its prognostic significance are not entirely understood. METHODS: We retrospectively studied 305 consecutive and non-selected STEMI patients. They were divided into three groups according to the maximum neutrophil percentage in the first 48 hours. We compared baseline demographic characteristics, coronary disease risk factors, cardiac history, clinical presentation, therapeutics administered and clinical evolution. We then assessed survival in the three groups and determined predictors of 30-day mortality. Group 1 (G1) had a mean age of 57 +/- 14 years and showed mean neutrophilia of 73.3%, Group 2 (G2) 61 +/- 13 years and 79.9%, and Group 3 (G3) 66 +/- 13 years and 84.2%. We compared outcomes and 30-day mortality between the groups. RESULTS: Mean age rose with increased neutrophil response. There were no statistically significant baseline differences between the groups except for more smokers in Groups 1 and 2, and more patients presenting with Killip class > or = 2 and fewer with uncomplicated evolution in Group 3. During 30-day follow-up there were 19 deaths (G1=1, G2=3 and G3=15). In univariate analysis mortality predictors were age > or = 75 years, anterior STEMI, maximum creatinine kinase > or = 2500 UI/L, culprit lesion in proximal anterior descending artery, incomplete revascularization, Killip > or = 2 at presentation, and being in G3. After multivariate regression analysis independent predictors were age > or = 75 years, incomplete revascularization and being in G3. CONCLUSION: In myocardial infarction patients undergoing mechanical revascularization, an intense neutrophil response (routinely, easily and inexpensively assessed) is related to worse short-term prognosis.

Is it possible to simplify risk stratification scores for patients with ST-segment elevation myocardial infarction undergoing primary angioplasty?

INTRODUCTION: There are several risk scores for stratification of patients with ST-segment elevation myocardial infarction (STEMI), the most widely used of which are the TIMI and GRACE scores. However, these are complex and require several variables. The aim of this study was to obtain a reduced model with fewer variables and similar predictive and discriminative ability. METHODS: We studied 607 patients (age 62 years, SD=13; 76% male) who were admitted with STEMI and underwent successful primary angioplasty. Our endpoints were all-cause in-hospital and 30-day mortality. Considering all variables from the TIMI and GRACE risk scores, multivariate logistic regression models were fitted to the data to identify the variables that best predicted death. RESULTS: Compared to the TIMI score, the GRACE score had better predictive and discriminative performance for in-hospital mortality, with similar results for 30-day mortality. After data modeling, the variables with highest predictive ability were age, serum creatinine, heart failure and the occurrence of cardiac arrest. The new predictive model was compared with the GRACE risk score, after internal validation using 10-fold cross validation. A similar discriminative performance was obtained and some improvement was achieved in estimates of probabilities of death (increased for patients who died and decreased for those who did not). CONCLUSION: It is possible to simplify risk stratification scores for STEMI and primary angioplasty using only four variables (age, serum creatinine, heart failure and cardiac arrest). This simplified model maintained a good predictive and discriminative performance for short-term mortality.

Impact of body mass index in the results after primary angioplasty in patients with ST segment elevation acute myocardial infarction.

INTRODUCTION: Obese patients submitted to elective coronary angioplasty have a paradoxical reduction in hospital and long-term mortality. In primary angioplasty setting, the relation with Body Mass Index (BMI) is less studied. OBJECTIVES: To evaluate the impact of obesity in the results after ST-segment elevation acute myocardial infarction treated by primary angioplasty. METHODS: Study of 539 consecutive patients with ST-segment elevation acute myocardial infarction (STEMI) submitted to primary angioplasty. We evaluated in-hospital, 30-day and one-year all-cause mortality according to BMI: 'normal', <25 kg/m(2); 'overweight', 25-29.9 kg/m(2) and 'obese', ≥ 30 kg/m(2). RESULTS: Obese patients were younger, had more hypertension and hyperlipidemia. There were no differences in previous cardiac history and hospital data. In-hospital mortality was 8.0% for patients with normal BMI, 4.4% for overweight patients and 5.9% for obese patients (P=0.296). At 30 days, 9.6%, 5.2% and 6.9% (P=0.212) and at first year, 11.2%, 5.2% and 6.9% (P=0.064), respectively. Overweight was the only group with decreased risk (OR: 0.44, 95% CI: 0.21-0.90, P=0.015), even after adjustment for confounding variables (OR: 0.37, 95% CI: 0.15-0.95, P=0.038). CONCLUSIONS: Overweight patients had a better prognosis after primary angioplasty for STEMI compared with other BMI groups.

Admission heart rate as a predictor of mortality in patients with acute coronary syndromes.

INTRODUCTION: Heart rate (HR) is a prognostic factor in stable angina. However, in the context of acute coronary syndromes (ACS), it is less studied. AIMS: To evaluate the influence of admission HR as a prognostic factor in patients with ACS. METHODS: We evaluated in-hospital, 30-day and one-year mortality in patients with ACS, according to admission HR. RESULTS: We analysed 1126 patients, 69% males, mean age 64 years, 59% with ST-segment elevation acute myocardial infarction and 15% on medication with a beta-blocker. On admission, 14% presented signs of heart failure. In 10%, left ventricular ejection fraction was < 35%. In-hospital mortality was 7.1%, 30-day mortality 9.1% and one-year mortality 10.7%. The best cut-off of HR to predict mortality was 80 bpm (sensitivity 64-66% and specificity 54-55%). By multivariate analysis, a heart rate ≥ 80 bpm was an independent predictor of all-cause mortality (HR 1.50, 95% CI: 1.01-2.23, P = 0.047). CONCLUSIONS: In a population with ACS, a higher admission HR is an independent predictor of short- and medium-term prognosis, which is also independent of left ventricular function.

Does admission NT-proBNP increase the prognostic accuracy of GRACE risk score in the prediction of short-term mortality after acute coronary syndromes?

BACKGROUND: NT-proBNP has prognostic implications in heart failure. In acute coronary syndromes (ACS) setting, the prognostic significance of NT-proBNP is being sought. We studied short-term prognostic impact of admission NT-proBNP in patients admitted for ACS and in association with GRACE risk score (GRS). METHODS AND RESULTS: We studied 1035 patients admitted with ACS. Patients were divided in quartiles according to NT-proBNP levels on admission: Q1 <180 pg/ml; Q2 180-691 pg/ml; Q3 696-2664 pg/ml; Q4 2698-35 000 pg/ml. Groups were compared in terms of short-term all-cause mortality. Patients with higher NT-proBNP had worst GRS on admission. They also received less aggressive treatment. In-hospital mortality was 0.8%, 3.0%, 5.8% and 12.8% (P<0.001) and 30-day mortality 1.6%, 4.6%, 6.5% and 16.7% (P<0.001) respectively. In multivariate logistic regression analysis, NT-proBNP is an independent predictor of in-hospital (OR 2.35; 95% CI: 1.12-4.93, P=0.022) and 30-day mortality (OR 2.20; 95% CI: 1.17-4.12, P=0.014). However, NT-proBNP does not add any incremental benefit to GRS for prediction of outcome by ROC curve analysis. CONCLUSIONS: NT-proBNP is an independent predictor of in-hospital and 30-day mortality after ACS, independently of left ventricular function, but does not increase the prognostic accuracy of GRS.