Gender-related differences in elderly patients with myocardial infarction in a European Centre.

BACKGROUND: Weighing the benefit of revascularization procedures against the risk of adverse events is particularly challenging in elderly patients suffering acute myocardial infarction (AMI). Based on a general gender gap in coronary interventions, the restraint in invasive procedures may be particularly high in elderly women. We therefore investigated gender-related differences in the frequency of coronary interventions as well as gender- and age-specific outcomes after coronary interventions in patients with AMI. DESIGN: We included 906 AMI patients in the final analysis. Among patients ≥ 80 years (n = 453), the intention to intervention (lysis and/or coronary angiography) for women was significantly lower compared to men (65·7% vs. 80·8%; P < 0·001), whereas in patients < 80 years (n = 453), the rate was similar between both genders (94·8% vs. 95·1%, P = 0·89). However, the assessment of potential risk factors for adverse events did not explain the gender gap. When assessing the benefit of any coronary intervention (stenting and/or lysis and/or coronary artery bypass graft), elderly women benefited at least as much with a hazard ratio (HR) for cardiovascular mortality of 0·56 (95% confidence interval [CI] 0·37-0·84, P = 0·005) compared to a HR of 0·96 (95% CI 0·76-1·23, P = 0·766) in elderly men. CONCLUSION: We observed a lower intention to coronary intervention in elderly women compared with men. However, the distribution of risk factors in elderly women and men who did not undergo coronary intervention was similar and therefore seemed not to be causal for the gender gap although the benefit of any coronary interventions was even higher in elderly women.

Platelet count predicts cardiovascular mortality in very elderly patients with myocardial infarction.

BACKGROUND: The prognosis of elderly patients with acute myocardial infarction (AMI) is poor, and information on specific risk factors remains scarce. The aim of our study was to assess the influence of platelet count on cardiovascular mortality in very elderly patients with acute myocardial infarction (≥ 85 years of age). METHODS: We identified 208 elderly AMI patients and compared the platelet count with 208 matched young AMI patients (≤ 65 years) and 208 matched intermediate age AMI patients (66-84 years) who derived from the same cohort. RESULTS: During a median follow-up of 4·7 years, 25% of patients (n = 156) died of cardiovascular causes (97 very elderly, 46 intermediate age and 13 young age patients). We detected a mean platelet count of 227G/l (SD ± 83) in very elderly AMI patients, of 236G/l (SD ± 78) in the intermediate AMI group and of 254G/l (SD ± 79) in 208 young AMI patients (ANOVA P = 0·002). We revealed a significant interaction between age and platelet count with regard to cardiovascular mortality (p for interaction = 0·014). Platelet count displayed a significant risk transformation from an independent risk factor for cardiovascular mortality in very elderly AMI patients (adj. hazard ratio (HR) per 1-SD increase 1·25;95%CI 1·02-1·54;P = 0·028), via displaying no association with mortality in the intermediate age group (P = 0·10), to a strong inverse association in young patients (adj. HR 0·36;95%CI 0·18-0·68;P = 0·002). CONCLUSION: Our study demonstrates an independent association between elevated platelet count and long-term cardiovascular mortality in the growing and vulnerable group of very elderly AMI patients. Nevertheless, the pathophysiologic mechanisms underlying this age-dependent effect have to be further clarified.

Long-term prognosis of de novo atrial fibrillation during acute myocardial infarction: the impact of anti-thrombotic treatment strategies.

AIMS: While the prognosis of patients presenting with de novo atrial fibrillation (AF) during the acute phase of myocardial infarction has been controversially discussed, it seems intuitive that affected individuals have an increased risk for both thrombo-embolic events and mortality. However, profound data on long-term outcome of this highly vulnerable patient population are not available in current literature. Therefore, we aimed to investigate the impact of de novo AF and associated anti-thrombotic treatment strategies on the patient outcome from a long-term perspective. METHODS AND RESULTS: Patients presenting with acute myocardial infarction, treated at the Medical University of Vienna, were enrolled within a clinical registry and screened for the development of de novo AF. After discharge, participants were followed prospectively over a median time of 8.6 years. Primary study endpoint was defined as cardiovascular mortality. Out of 1372 enrolled individuals 149 (10.9%) developed de novo AF during the acute phase of acute myocardial infarction. After a median follow-up time of 8.6 years, a total of 418 (30.5%) died due to cardiovascular causes, including 93 (62.4%) in the de novo AF subgroup. We found that de novo AF was significantly associated with long-term cardiovascular mortality with an adjusted HR of 1.45 (95% CI 1.19-2.57; P < 0.001). While patients with de novo AF were less likely to receive a triple anti-thrombotic therapy as compared to patients with pre-existing AF at time of discharge, this therapeutic approach showed a strong and inverse association with mortality in de novo AF, with an adj. HR of 0.86 (95% CI 0.45-0.92; P = 0.012). CONCLUSION: De novo AF was independently associated with a poor prognosis with a 67% increased risk of long-term cardiovascular mortality. Intensified anti-thrombotic treatment in this high-risk patient population might be considered.

Blood urea nitrogen has additive value beyond estimated glomerular filtration rate for prediction of long-term mortality in patients with acute myocardial infarction.

OBJECTIVES: Blood urea nitrogen (BUN) has been shown to independently predict short- and intermediate-term outcomes in patients with acute myocardial infarction (AMI). We aimed to assess the additive predictive value of BUN beyond estimated glomerular filtration rate (eGFR) in AMI patients with an 8.6-year follow-up. METHODS: This retrospective, observational single-centre study included 1332 consecutive AMI patients (median age 64 years, 58.4% male). BUN, creatinine and eGFR were determined at hospital admission. RESULTS: During a median follow-up of 8.6 years (interquartile range [IQR] 4.0-11.6), 408 patients (30.6%) experienced the study endpoint of cardiovascular mortality. BUN (median 17.0 mg/dL [IQR 13.5-22.7]) was a significant predictor of cardiovascular mortality in univariate Cox regression (hazard ratio (HR) per 1 standard deviation increase 2.10, 95% confidence interval [CI] 1.94-2.28, p < .001). This association remained significant after multivariable adjustment for demographics, clinical variables and eGFR (adjusted HR 1.52 [CI 1.16-2.00, p = .003]). The association between BUN and outcome was more pronounced in patients with eGFR >60 mL/min/1.73m2 (HR 2.81 [CI 2.20-3.58, p < .001]). The discriminatory abilities (Harrell's C-statistic) for BUN, eGFR and creatinine were 0.75, 0.76 and 0.67, respectively. The addition of BUN to eGFR significantly improved the C-statistic (0.78, p for comparison = 0.017), net reclassification (23.7%, p < .001) and integrated discrimination (2.9%, p < .001). CONCLUSIONS: Circulating BUN on admission is an independent predictor of long-term cardiovascular mortality in AMI patients and adds predictive power beyond eGFR. BUN reflects not only kidney function, but also acute haemodynamic and neurohumoral alterations during AMI, and may help to identify high-risk patients.

Cardiac arrest as an age-dependent prognosticator for long-term mortality after acute myocardial infarction: the potential impact of infarction size.

BACKGROUND:: The development of cardiac arrhythmias resulting in cardiac arrest represents a severe complication in patients with acute myocardial infarction. While the worsening of the prognosis in this vulnerable patient collective is well known, less attention has been paid to its age-specific relevance from a long-term perspective. METHODS:: Based on a clinical acute myocardial infarction registry we analysed 832 patients with acute myocardial infarction within the current analysis. Patients were stratified into equal groups ( n=208 per group) according to age in less than 45 years, 45-64 years, 65-84 years and 85 years and older via propensity score matching. Multivariate Cox regression analysis was used to assess the age-dependent influence of cardiac arrest on mortality. RESULTS:: The total number of cardiac arrests differed significantly between age groups, demonstrating the highest incidence in the youngest population with 18.8% ( n=39), and a significantly lower incidence by increasing age (-11.6%; P=0.01). After a mean follow-up time of 8 years, a total of 264 patients (31.7%) died due to cardiovascular causes. While cardiac arrest was a strong and independent predictor for mortality within the total study population with an adjusted hazard ratio of 3.21 (95% confidence interval 2.23-4.61; P<0.001), there was no significant association with mortality independently in very young patients (<45 years; adjusted hazard ratio of 1.73, 95% confidence interval 0.55-5.53; P=0.35). CONCLUSION:: We found that arrhythmias resulting in cardiac arrest are more common in very young acute myocardial infarction patients (<45 years) compared to their older counterparts, and were able to demonstrate that the prognostic value of cardiac arrest on long-term mortality in patients with acute myocardial infarction is clearly age dependent.

De-Ritis Ratio Improves Long-Term Risk Prediction after Acute Myocardial Infarction.

BACKGROUND: Recent evidence suggested levels of aspartate aminotransferase (AST), alanine transaminase (ALT), and AST/ALT ratio (De-Ritis ratio) were associated with a worse outcome after acute myocardial infarction (AMI). However, their value for predicting long-term prognosis remained unknown. Therefore, we investigated the prognostic potential of transaminases on patient outcome after AMI from a long-term perspective. METHODS: Data of a large AMI registry including 1355 consecutive patients were analyzed. The Cox regression hazard analysis was used to assess the impact of transaminases and the De-Ritis ratio on long-term mortality. RESULTS: The median De-Ritis ratio for the entire study population was 1.5 (interquartile range [IQR]: 1.0⁻2.6). After a median follow-up time of 8.6 years, we found that AST (crude hazard ratio (HR) of 1.19 per 1-SD [95% confidence interval (CI): 1 .09⁻1.32; p < 0.001]) and De-Ritis ratio (crude HR of 1.31 per 1-SD [95% CI: 1.18⁻1.44; p < 0.001]), but not ALT (p = 0.827), were significantly associated with long-term mortality after AMI. After adjustment for confounders independently, the De-Ritis ratio remained a strong and independent predictor for long-term mortality in the multivariate model with an adjusted HR of 1.23 per 1-SD (95% CI: 1.07⁻1.42; p = 0.004). Moreover, the De-Ritis ratio added prognostic value beyond N-terminal pro-B-Type Natriuretic Peptide, Troponin T, and Creatine Kinase. CONCLUSION: The De-Ritis ratio is a strong and independent predictor for long-term mortality after AMI. As a readily available biomarker in clinical routine, it might be used to identify patients at risk for fatal cardiovascular events and help to optimize secondary prevention strategies after AMI.

Long-term outcome and risk prediction in patients suffering acute myocardial infarction complicated by post-infarction cardiac rupture.

BACKGROUND: Post-infarction cardiac rupture (CR) such as ventricular septal rupture (VSR), free wall rupture (FWR), atrial septal rupture (ASR) or papillary muscle rupture (PMR) is a rare but dreaded complication in patients with acute myocardial infarction (AMI) associated with a very poor prognosis with reported mortality rates between 60 and 100%. Therefore suitable risk stratification for secondary prevention seems crucial, but data on long-term survival und risk prediction in this especially vulnerable patient collective remains scarce. METHODS: Out of 11,641 patients presenting with AMI a total of 28 individuals suffering post-infarction CR were identified and stratified in "acute survivors of CR" (n=10) and "non-survivors of CR" (n=18). Cox regression hazard analysis was used to assess prognosticators on long-term survival. RESULTS: Ten patients (35.7%) survived the initial event. After a median follow-up time of 9years 2 (20%) of the survivors died, both due to cardiovascular causes. Younger age (p=0.023) and higher systolic blood pressure at admission (p=0.018) turned out to be significant predictors of long-term survival. Systolic blood pressure 48h after CR proved to be a strong and independent predictor for survival with an adjusted hazard ratio per one standard deviation of 0.89 (95% CI: 0.72-0.99; 0.048). CONCLUSION: Hemodynamic stabilization and severity of cardiogenic shock were detected as clinically most common among patients suffering post-infarction CR and proved to be of major importance for survival. If survival of the initial event was achieved, satisfying long-term mortality could be reached.

Butyrylcholinesterase predicts cardiac mortality in young patients with acute coronary syndrome.

BACKGROUND: The incidence of acute coronary syndrome (ACS) in young people (≤65 years) is continuously rising. While prognostic factors in ACS are well-investigated less attention has been paid to their age-dependent prognostic value and their particular relevance in younger patients. The aim of our study was to assess the age-dependent prognostic impact of butyrylcholinesterase (BChE). METHODS: Retrospective cohort study including 624 patients with ACS. Patients were stratified by age into equal groups (n = 208) corresponding to "young patients" (45-64 years), "middle-aged patients" (65-84 years) and "old patients" (85-100 years). Cox regression hazard analysis was used to assess the influence of BChE on survival. RESULTS: After a mean follow-up time of 4.0 (interquartile range [IQR] 2.0-6.4) years, 154 patients (24.7%) died due to a cardiac cause. In the overall cohort, BChE was indirectly associated with cardiac mortality-free survival (adjusted hazard ratio (HR): 0.70 (95% confidence interval [CI] 0.53-0.93, p = 0.01). The primary-analysis of BChE by age strata showed the strongest effect in the age group 45-64 years with an adjusted HR per 1-SD of 0.28 (95% CI 0.12-0.64, p = 0.003), a weaker association with mortality in middle aged (65-84 years: adjusted HR per 1-SD 0.66 [95% CI: 0.41-1.06], p = 0.087), and no association in older patients (85-100 years: adjusted HR per 1-SD 0.89 [95% CI: 0.58-1.38], p = 0.613). CONCLUSION: BChE is a strong predictor for cardiac mortality specifically in younger patients with ACS aged between 45 and 64 years. No significant association of BChE with cardiac-mortality was detected in other age classes.

History of previous bleeding and C-reactive protein improve assessment of bleeding risk in elderly patients (≥ 80 years) with myocardial infarction.

We aimed to assess whether the CRUSADE risk score represents a robust instrument for stratification of bleeding risk in elderly myocardial infarction (MI) patients (≥ 80 years) and further aimed to identify age-specific predictors of major bleeding events. Binary logistic regression models were applied to assess the effect of variables on the occurrence of bleeding events during hospital stay. Receiver operating characteristic (ROC) analysis was used to evaluate the discriminatory power. Out of 387 patients in the final study cohort, 74 patients (19.1 %) experienced a major bleeding event according to the definition of the International Society on Thrombosis and Haemostasis. The CRUSADE risk score demonstrated only a weak discriminatory power to predict bleeding in this group of patients (area under the ROC curve: 0.57 [0.51-0.65]; p=0.05). In the multivariate regression analysis, history of bleeding with an adjusted hazard ratio (HR) of 3.21 (95 % confidence interval: 1.29-8.03, p=0.01) and C-reactive protein with an adjusted HR per increase of 10 mg/l of 1.05 (1.01-1.10) were independent predictors of major bleeding. Integration of both variables into the CRUSADE score demonstrated a significantly improved performance for bleeding as indicated by a significant increase in the ROC analysis (area under the curve: 0.64 vs 0.57; for comparison p< 0.045), net reclassification index (35.6 %; p=0.006) and integrated discrimination increment (0.0242; p=0.02). In conclusion, bleeding history and C-reactive protein significantly improve the modest predictive power of the CRUSADE risk score in elderly patients with MI. These results point towards a specific risk profile for bleeding events in this high-risk group of patients.