Treatment of elderly patients with non-ST-elevation myocardial infarction: the nationwide POPular age registry.

OBJECTIVE: We describe the current treatment of elderly patients with non-ST-elevation myocardial infarction (NSTEMI) enrolled in a national registry. METHODS: The POPular AGE registry is a prospective, multicentre study of patients ≥ 75 years of age presenting with NSTEMI, performed in the Netherlands. Management was at the discretion of the treating physician. Cardiovascular events consisted of cardiovascular death, myocardial infarction and ischaemic stroke. Bleeding was classified according to the Bleeding Academic Research Consortium (BARC) criteria. RESULTS: A total of 646 patients were enrolled between August 2016 and May 2018. Median age was 81 (IQR 77-84) years and 58% were male. Overall, 75% underwent coronary angiography, 40% percutaneous coronary intervention, and 11% coronary artery bypass grafting, while 49.8% received pharmacological therapy only. At discharge, dual antiplatelet therapy (aspirin and P2Y12 inhibitor) was prescribed to 56.7%, and 27.4% received oral anticoagulation plus at least one antiplatelet agent. At 1­year follow-up, cardiovascular death, myocardial infarction or stroke had occurred in 13.6% and major bleeding (BARC 3 and 5) in 3.9% of patients. The risk of both cardiovascular events and major bleeding was highest during the 1st month. However, cardiovascular risk was three times as high as bleeding risk in this elderly population, both after 1 month and after 1 year. CONCLUSIONS: In this national registry of elderly patients with NSTEMI, the majority are treated according to current European Society of Cardiology guidelines. Both the cardiovascular and bleeding risk are highest during the 1st month after NSTEMI. However, the cardiovascular risk was three times as high as the bleeding risk.

Conservative versus Invasive Strategy in Elderly Patients with Non-ST-Elevation Myocardial Infarction: Insights from the International POPular Age Registry.

This registry assessed the impact of conservative and invasive strategies on major adverse clinical events (MACE) in elderly patients with non-ST-elevation myocardial infarction (NSTEMI). Patients aged ≥75 years with NSTEMI were prospectively registered from European centers and followed up for one year. Outcomes were compared between conservative and invasive groups in the overall population and a propensity score-matched (PSM) cohort. MACE included cardiovascular death, acute coronary syndrome, and stroke. The study included 1190 patients (median age 80 years, 43% female). CAG was performed in 67% (N = 798), with two-thirds undergoing revascularization. Conservatively treated patients had higher baseline risk. After propensity score matching, 319 patient pairs were successfully matched. MACE occurred more frequently in the conservative group (total population 20% vs. 12%, adjHR 0.53, 95% CI 0.37-0.77, p = 0.001), remaining significant in the PSM cohort (18% vs. 12%, adjHR 0.50, 95% CI 0.31-0.81, p = 0.004). In conclusion, an early invasive strategy was associated with benefits over conservative management in elderly patients with NSTEMI. Risk factors associated with ischemia and bleeding should guide strategy selection rather than solely relying on age.

Percutaneous coronary intervention of an iatrogenic occlusion of the circumflex coronary artery after mitral valve replacement.

Occlusion of the circumflex coronary artery by compromising sutures is a serious complication in patients undergoing mitral valve replacement. The majority of such patients have to undergo bypass surgery or redo mitral valve replacement. We report a case of an iatrogenic occlusion of the circumflex coronary artery after mitral valve replacement that was treated by percutaneous coronary intervention.

Transesophageal echocardiographic evaluation of tricuspid valve regurgitation during pacemaker and implantable cardioverter defibrillator lead extraction.

Chronically implanted ventricular pacing and defibrillator (ICD) leads can adhere to the tricuspid valve. This study examined the effect of lead extraction, and laser sheath extraction in particular, on tricuspid valve regurgitation. Lead extraction was first tried with traction using limited force followed by a laser sheath if not successful. Tricuspid valve regurgitation before and after extraction was evaluated with transesophageal echocardiography and graded from 0 (none) to 4 (severe). A change in regurgitation was considered clinically relevant if it increased with two grades or more and resulted in at least grade 3 regurgitation. Fifty ventricular leads were extracted in 43 consecutive patients, including 14 ICD leads. In 20 patients (group I) leads were removed without a (laser) sheath crossing the tricuspid valve, in 23 patients (group II) leads were extracted with lasing across the valve. The mean time from implant was 43 +/- 43 months and 99 +/- 78 months, respectively, (P = 0.007). Tricuspid regurgitation increased in five (12%) patients. In group I only in one patient the laser failed proximal of the valve and forceful traction was subsequently used, and in group II this occurred in four (17%) patients. This difference did not reach statistical significance even excluding the patient from group I (P = 0.111). The increase of tricuspid regurgitation cautions against indiscriminate extraction of superfluous leads. There is a trend that when tools like a laser sheath are necessary the chance of tricuspid valve damage increases.