Long-term survival of elderly patients undergoing percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock.

BACKGROUND: The long-term benefit of early percutaneous coronary intervention (PCI) for cardiogenic shock (CS) in elderly patients remains unclear. We sought to assess the long-term survival of elderly patients (age ≥ 75 years) with myocardial infarction (MI) complicated by CS undergoing PCI. METHODS: We analyzed baseline characteristics, early outcomes, and long-term survival in 421 consecutive patients presenting with MI and CS who underwent PCI from the Melbourne Interventional Group registry from 2004 to 2011. Mean follow-up of patients who survived to hospital discharge was 3.0 ± 1.8 years. RESULTS: Of the 421 consecutive patients, 122 patients were elderly (≥ 75 years) and 299 patients were younger (< 75 years). The elderly cohort had significantly more females, peripheral and cerebrovascular disease, renal impairment, heart failure (HF) and prior MI (all p < 0.05). Procedural success was lower in the elderly (83% vs. 92%, p < 0.01). Long-term mortality was significantly higher in the elderly (p < 0.01), driven by high in-hospital mortality (48% vs. 36%, p < 0.05). However, in a landmark analysis of hospital survivors in the elderly group, long-term mortality rates stabilized, approximating younger patients with CS (p = 0.22). Unsuccessful procedure, renal impairment, HF and diabetes mellitus were independent predictors of long-term mortality. However, age ≥ 75 was not a significant predictor (HR 1.2; 95% CI 0.9-1.7; p = 0.2). CONCLUSIONS: Elderly patients with MI and CS have lower procedural success and higher in-hospital mortality compared to younger patients. However, comparable long-term survival can be achieved, especially in patients who survive to hospital discharge with the selective use of early revascularization.

Impact of renal function in patients with multi-vessel coronary disease on long-term mortality following coronary artery bypass grafting compared with percutaneous coronary intervention.

BACKGROUND: Comorbidities, such as diabetes, affect revascularization strategy for coronary disease. We sought to determine if the degree of renal impairment affected long-term mortality after percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) in patients with multi-vessel coronary disease (MVD). METHODS AND RESULTS: 8970 patients with MVD undergoing revascularization between 2004 and 2008, in two multi-center parallel PCI and CABG Australian registries were assigned to three groups based on their estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2 (n=1678:839), 30-59 mL/min/1.73 m2 (n=452:226) and <30 mL/min/1.73 m2 (n=74:37). We used 2:1 propensity matching to compare 3306 patients undergoing primary CABG versus PCI. Shock, myocardial infarction (MI)<24 h, previous CABG, valve surgery or PCI were exclusions. Long-term mortality (mean 3.1 years) was compared with Cox-proportional hazard-adjusted modeling. Observed long-term mortality rates (CABG vs. PCI) were 4.5% vs. 4.3% p=0.84, 12.8% vs. 17.3% p=0.12, and 23.0% vs. 40.5% p=0.05 in the three strata, respectively. In patients with eGFR≥60 mL/min/1.73 m2, long-term mortality between PCI and CABG (HR 0.99, 95% CI 0.65-1.49, p=0.95) was similar. However, amongst patients with eGFR 30-59 mL/min/1.73 m2, there was a significant mortality hazard with PCI (HR 2.00, 95% CI 1.32-3.04, p=0.001). In patients with eGFR<30 mL/min/1.73 m2, there was a trend for hazard with PCI (HR 1.66, 95% CI 0.80-3.46, p=0.17). CONCLUSION: Long-term mortality in MVD patients with preserved renal function was very low and similar between PCI and CABG. However there was a long-term mortality hazard associated with PCI amongst patients with moderate renal impairment.

Survival in patients with myocardial infarction complicated by out-of-hospital cardiac arrest undergoing emergency percutaneous coronary intervention.

OBJECTIVES: We sought to evaluate the clinical outcomes of patients with myocardial infarction (MI) complicated by out-of-hospital cardiac arrest (OHCA) undergoing percutaneous coronary intervention (PCI). BACKGROUND: Controversy remains regarding the benefit of early PCI in patients with MI complicated by OHCA. METHODS: We analyzed the outcomes of 88 consecutive patients presenting with MI complicated by OHCA compared to 5101 patients with MI without OHCA who underwent PCI from the Melbourne Interventional Group registry between 2004 and 2009. RESULTS: Patients with OHCA had a higher proportion of ST-elevation MI presentations (90.9% vs. 50%, p<0.01) and were more likely to be to be in cardiogenic shock (38.6% vs. 4.6%, p<0.01). Procedural success was similar in the two groups (95.5% OHCA vs. 96.5% non-OHCA MI cohort, p=0.65). In-hospital, 30-day, and 1-year survival in the OHCA cohort versus the non-OHCA MI cohort were 62.5% vs. 97.2% (p<0.01), 61.4% vs. 96.5% (p<0.01), and 60.2% vs. 94.2% (p<0.01), respectively. Within the OHCA cohort, presentation with cardiogenic shock (OR 7.2, 95% CI: 2.7-18.8; p<0.01) was strongly associated with in-hospital mortality. Importantly, 1-year survival of patients discharged alive from hospital was similar between the two groups (96% vs. 97% p=0.8). CONCLUSION: Patients with MI complicated by OHCA remain a high-risk group associated with high mortality. However, high procedural success rates similar to non-OHCA patients can be attained. Survival rates better than previously reported were observed with an emergent PCI approach, with 1-year survival comparable to a non-OHCA cohort if patients survive to hospital discharge.

Contemporary outcomes in women undergoing percutaneous coronary intervention for acute coronary syndromes.

BACKGROUND: Uncertainty remains as to whether females benefit as much as males from percutaneous coronary intervention (PCI) in the setting of an acute coronary syndrome (ACS). METHODS: We compared 802 women with 2151 men presenting with ACS, undergoing PCI from April 2004 to October 2006 from the Melbourne Interventional Group registry. Clinical characteristics, in-hospital, 30-day and 1-year outcomes were compared. RESULTS: Women were older (69.6 ± 11.6 vs. 62.17 ± 12.3 years, p<0.001), and had more diabetes (27.1% vs. 19.6%, p<0.001) and hypertension (70.3% vs. 53.9%, p<0.001) than men. Women were less likely to present with ST-elevation myocardial infarction (30.5% vs. 37.9%, p<0.001). Bleeding (3.6% vs. 0.8%, p<0.001) was higher among women. Thirty-day mortality (4.7 vs. 2.4%, p<0.001) and MACE (10.1 vs. 6.4%, p<0.001) were higher in women. Gender was an independent predictor of overall MACE at 30 days (OR 1.45, 95% CI 1.04-2.02, p=0.03) but not death. At 12 months, there were no significant differences in mortality (6.4% vs. 4.8%, p=0.09), myocardial infarction (5.5% vs. 5.0%, p=0.64), target vessel revascularization (7.9% vs. 7.0%, p=0.42) and MACE (16.3% vs. 14%, p=0.13) between women and men. CONCLUSIONS: There is an early hazard amongst women undergoing PCI for ACS, but not at 12 months. These data suggest that gender should not affect the decision to offer PCI but further gender specific studies are warranted.

Is there an obesity paradox after percutaneous coronary intervention in the contemporary era? An analysis from a multicenter Australian registry.

OBJECTIVES: We sought to determine whether an obesity paradox exists in the contemporary era of percutaneous coronary intervention (PCI) and to explore potential clinical factors that might contribute. BACKGROUND: Previous studies have suggested that overweight and obese patients might have better outcomes after PCI than patients with a normal or low body mass index (BMI); however this "obesity paradox" remains poorly understood. METHODS: We evaluated 4,762 patients undergoing PCI between April 1, 2004 and September 30, 2007, enrolled in the MIG (Melbourne Intervention Group) registry. Patients were classified as underweight, normal, overweight, class I obese, and class II to III obese, BMI <20, 20 to 25, 25.1 to 30, 30.1 to 35, and >35 kg/m(2), respectively. We compared in-hospital, 30-day, and 12-month outcomes. RESULTS: As BMI increased from <20 to >35 kg/m(2), there was a statistically significant, linear reduction in 12-month major adverse cardiac events (MACE) (21.4% to 11.9%, p = 0.008) and mortality (7.6% to 2.0%, p < 0.001). Obesity was, with multivariate analysis, an independent predictor of reduced 12-month MACE and showed a trend for reduced 12-month mortality. At 12 months, obese patients had higher use of aspirin, clopidogrel, beta-blockers, renin-angiotensin system blockers and statins. CONCLUSIONS: Compared with normal-weight individuals, overweight and obese patients had lower in-hospital and 12-month MACE and mortality rates after PCI. Moreover, obese patients had a higher rate of guideline-based medication use at 12 months, which might in part explain the obesity paradox seen after PCI.

Survival of elderly patients undergoing percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock.

OBJECTIVES: We sought to assess clinical outcomes of elderly patients (age >or=75 years) undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) complicated by cardiogenic shock (CS) in a contemporary multicenter PCI registry. BACKGROUND: Although benefits of early PCI have been shown in younger groups, few studies have reported on clinical outcomes in elderly shock patients using current PCI techniques. METHODS: We analyzed baseline characteristics and procedural and clinical outcomes in 143 consecutive patients presenting with MI and CS who underwent PCI from the Melbourne Interventional Group registry between 2004 and 2007. RESULTS: Of the 143 patients, 31.5% (n = 45) were elderly and 68.5% were younger (age <75 years). Elderly patients were more likely to be female (46.7% vs. 22.4%, p < 0.01) and have hypertension (77.8% vs. 46.4%, p < 0.01), previous MI (31.1% vs. 15.5%, p = 0.03), renal failure (24.4% vs. 11.3%, p < 0.05) and multivessel coronary artery disease (93.1% vs. 68.3%, p < 0.01). Stent (86.7% vs. 94.8%, p = 0.09), glycoprotein IIb/IIIa inhibitor (68.9% vs. 65.3%, p = 0.67), and intra-aortic balloon pump (57.8% vs. 58.2%, p = 0.97) use were similar in both groups. In-hospital, 30-day, and 1-year mortality in the elderly group versus the younger group were 42.2% vs. 33.7% (p = 0.32), 43.2% vs. 36.1% (p = 0.42), and 52.6% vs. 46.8% (p = 0.56), respectively. CONCLUSIONS: In this study, the 1-year survival of elderly patients with acute MI complicated by CS undergoing PCI was comparable to younger patients. These data suggest that in elderly patients presenting with CS, benefit is possible with selective use of early revascularization and merits further investigation.

Outcomes after percutaneous coronary intervention of ostial lesions in the era of drug-eluting stents.

BACKGROUND: Ostial lesions are a difficult subset associated with suboptimal outcomes after percutaneous coronary intervention (PCI). The aim of this study was to analyze outcomes of ostial lesions in contemporary Australian interventional practice. METHODS: The study population comprised 1,713 consecutive patients who underwent PCI for proximal lesions of the left anterior descending, left circumflex, and right coronary arteries, who were prospectively enrolled in the Melbourne Interventional Group Registry (February 2004-December 2006). We compared the in-hospital, 30-day, and 1-year outcomes of the 109 patients undergoing PCI for ostial, with the 1,604 patients with proximal nonostial lesions. Left main and bifurcation lesions were excluded. RESULTS: Patients in the ostial group were older (mean age 68.8 +/- 11 vs. 64.9 +/- 12 years; P = 0.001), and there was a greater proportion of women (38.5% vs. 28.0%; P = 0.021). Other clinical characteristics were similar. The nonostial group were more likely receive a stent (94.6% vs. 87.2%; P = 0.005) but drug-eluting stents (DES) were deployed more often in the ostial group (47.9% vs. 66.1%; P < 0.0001). There was lower procedural success, with no significant difference in in-hospital death, bleeding or emergency PCI, but unplanned in-hospital coronary artery bypass grafting was more frequent in the ostial group (4.8% vs. 1.0%; P = 0.007). There was no difference in 30-day major adverse cardiac events. However, 12-month death (8.8% vs. 4%, log rank P = 0.032) and MACE (24.2% vs. 13.8%, log rank P = 0.005) were higher in the ostial group than the nonostial group with trends to increased incidence of myocardial infarction (6.6% vs. 4.7%, P = NS), and target vessel revascularization (13.2% vs. 7.9%, P = NS). CONCLUSION: In contemporary, Australian interventional practice, PCI for ostial lesions is associated with a high incidence of adverse outcome at one year despite the introduction of DES.