Trends and Impact of Door-to-Balloon Time on Clinical Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction.

Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. The impact of timely reperfusion on clinical outcomes in patients aged 75-84 and ≥85 years is uncertain. We analysed 2,972 consecutive STEMI patients who underwent primary percutaneous coronary intervention from the Melbourne Interventional Group Registry (2005-2014). Patients aged <75 years were included in the younger group, those aged 75-84 years were in the elderly group and those ≥85 years were in the very elderly group. The primary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). 2,307 (77.6%) patients were <75 years (mean age 59 ± 9 years), 495 (16.7%) were 75-84 years and 170 (5.7%) were ≥85 years. There has been a significant decrease in DTBT over 10 years in younger and elderly patients (p-for-trend <0.01 and 0.03) with a trend in the very elderly (p-for-trend 0.08). Compared to younger and elderly patients, the very elderly had higher 12-month mortality (3.6% vs 10.7% vs. 29.4%; p = 0.001) and MACE (10.8% vs 20.6% vs 33.5%; p = 0.001). DTBT ≤90 minutes was associated with improved outcomes on univariate analysis but was not an independent predictor of improved 12-month mortality (OR 0.84, 95% CI 0.54-1.31) or MACE (OR 0.89, 95% CI 0.67-1.16). In conclusion, over a 10-year period, there was an improvement in DTBT in patients aged <75 years and 75-84 years however DTBT ≤90 minutes was not an independent predictor of 12-month outcomes. Thus assessing whether patients aged ≥85 years are suitable for invasive management does not necessarily translate to worse clinical outcomes.

Impact of door-to-balloon time on long-term mortality in high- and low-risk patients with ST-elevation myocardial infarction.

BACKGROUND: Door-to-balloon time (DTBT) less than 90min remains the benchmark of timely reperfusion in ST-elevation myocardial infarction (STEMI). The relative long-term benefit of timely reperfusion in STEMI patients with differing risk profiles is less certain. Thus, we aimed to assess the impact of DTBT on long-term mortality in high- and low-risk STEMI patients. METHOD: We analysed baseline clinical and procedural characteristics of 2539 consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry from 2004 to 2012. Patients were classified high risk (HR-STEMI) if they presented with cardiogenic shock, out-of-hospital cardiac arrest (OHCA) or Killip class ≥2; or low-risk (LR-STEMI) if there were no high-risk features. We then stratified high- and low-risk patients by DTBT (≤90min vs. >90min) and assessed long-term mortality. RESULT: Of the 2539 patients, 395 (16%) met the high-risk criteria. A DTBT ≤90min was achieved in 43% of HR-STEMI patients and in 55% of LR-STEMI patients. Patients in the HR-STEMI compared to LR-STEMI cohort had higher in-hospital (31% vs. 1%, p<0.01) and long-term mortality (37% vs. 7%, p<0.01). A DTBT ≤90min was associated with significant improvements in short- and long-term mortality in both groups. A DTBT ≤90min was an independent multivariate predictor of long-term survival in LR-STEMI (hazard ratio [HR] 0.5, 95% confidence interval [CI] 0.3-0.9, p=0.02) but not in HR-STEMI (HR 0.7, 95% CI 0.5-1.1, p=0.11). CONCLUSION: A DTBT ≤90min was associated with improved short- and long-term outcomes in high- and low-risk STEMI patients. However, it was only an independent predictor of long-term survival in LR-STEMI patients.

Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction.

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.

Low molecular weight advanced glycation end products predict mortality in asymptomatic patients receiving chronic haemodialysis.

BACKGROUND: Advanced glycation end products (AGEs) have biological properties that may contribute to the premature cardiovascular mortality of haemodialysis patients. This study examines the hypothesis that low molecular weight forms of fluorescent AGEs (LMW fluorescence) predict mortality in haemodialysis patients. METHODS: The LMW fluorescence was measured in 85 patients treated with chronic haemodialysis and prospectively followed for 4 years. The primary outcome of all-cause mortality was assessed using Cox proportional hazards regression model. RESULTS: At the end of the follow-up period 37 (44%) patients died. The median LMW fluorescence level was 24.2 arbitrary units (range: 10.6-148.1 AU) and the receiver operator characteristic (ROC) curve cut-off for mortality was 37.0 AU. The LMW fluorescence predicted death both as a binary variable at the ROC cut-off, and as a continuous log-transformed variable when adjusted for age, albumin and C-reactive protein (CRP). Adjusted for age, albumin and CRP, the hazard ratio for mortality was 3.05 (1.41-6.60, P = 0.005) for LMW fluorescence as a binary variable and 2.71 per log unit (1.37-5.38, P = 0.004) as a continuous log-transformed variable. CONCLUSION: The low molecular weight forms of AGEs predict mortality in patients receiving chronic haemodialysis, and may be important in the mechanisms leading to atherosclerosis and inflammation in such patients.

Magnetocardiogram recordings in a nonshielded environment--reproducibility and ischemia detection.

BACKGROUND: Magnetocardiography (MCG) is a noninvasive technology that measures the magnetic field of the heart by superconducting quantum interference devices (SQUID) sensors. The novelty of the present system is that the sensors can be operated without electromagnetic shielding of the examination room, thus allowing the system to be easily installed in the emergency department or chest pain unit. Studies in shielded rooms, found that this imaging modality may have better sensitivity as compared to ECG in detecting ischemia. We aimed (1) to assess the reproducibility, intra-observer, and interobserver interpretation variability and (2) to assess the MCG maps in the presence of coronary narrowings. METHODS AND RESULTS: All measurements were performed in a nonshielded room. For the first part of the study, two MCG maps were recorded in 24 otherwise healthy volunteers (age 20-44 years, median 24, 16 male) in an interval ranging from 2 to 48 hours. The maps were interpreted using the CardioMag software for contour maps, averaged MCG time traces, and waveform morphology of repolarization by two observers blinded to each other. The parameters tested had low disagreement between repeated measurements. The correlations of the intra-observer and interobserver interpretation were excellent. Secondly, MCG maps were obtained in 29 patients referred for angiography due to suspected coronary artery disease. Nineteen of them had coronary narrowings defined as more than 50%. In this group, 16 (84.2%) had abnormal MCG maps as compared to only 5 (26.3%) who had abnormal ECGs (P < 0.01). CONCLUSIONS: MCG maps can be successfully obtained in a nonshielded room and allow feasible, accurate, and reproducible measurements with little intra-observer and interobserver variability. Ischemic changes in the heart's magnetic field may occur before electrical changes. Our pilot data suggests that this imaging modality may potentially offer better sensitivity as compared to rest ECG in detecting ischemia in a cohort of patients who had coronary narrowings identified by angiography.

Percutaneous intervention for renovascular disease: rationale and patient selection.

PURPOSE OF REVIEW: The anatomic diagnosis of renovascular disease is increasing in frequency due to the advent of sophisticated non-invasive imaging modalities such as MRA (Magnetic Resonance Angiography) and renal angiography at the time of cardiac catheterization. Despite this fact, the investigation and appropriate management of renovascular disease has remained a controversial topic. This review addresses the clinical syndromes associated with renal artery stenosis (RAS) and the published data guiding appropriate patient selection for revascularization. RECENT FINDINGS: There is a growing literature in support of renal revascularization as an aid in improving anti-hypertensive control, preserving renal function, and easing the management of congestive heart failure. Meanwhile, technological advances have allowed intervention in an expanding pool of eligible patients. One such technology is the atheroembolic protection device, which may soon allow renal salvage in patients with significant baseline renal impairment that were previously denied intervention for fear of worsening renal function. SUMMARY: The data reviewed herein helps to identify patients that will benefit from renal revascularization. Large-scale, randomized data further defining the role of renal revascularization and optimal patient selection is still needed.