JACC: Elderly patients can benefit from selective use of revascularization

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The one-year survival of elderly patients with acute MI complicated by cardiogenic shock (CS) undergoing PCI using contemporary techniques was comparable with survival of younger patients, according to a study published in the February issue of JACC: Cardiovascular Interventions.

"Elderly patients who are admitted to the hospital with massive heart attacks may still benefit from emergency coronary artery balloon angioplasty and stenting, despite their advanced age," said the study's senior author David Clark, MBBS, interventional cardiologist at Austin Hospital in Melbourne, Australia. "Although mortality occurs in roughly half of patients in these high-risk situations, without this aggressive treatment, the prospect of survival is very poor."

Researchers analyzed baseline characteristics (e.g., smoking status, blood pressure, previous MI, renal function and symptom onset) and clinical outcomes, including death and emergence of other complications, in 143 consecutive patients, age 75 years and older, from the Melbourne Interventional Group registry between 2004 and 2007.

They found that elderly patients (45) were more likely to be female and have hypertension, previous MI, renal failure and multi-vessel coronary artery disease. Data indicated no significant differences for in-hospital, 30-day and one-year mortality in the elderly versus the younger groups.

While outcomes data show that early revascularization can improve survival among elderly patients, other clinical factors-proper patient selection, the "physiological age" and prior condition of the patient (e.g., prior functional status, co-morbidities, such as dementia and frailty) and a cost-benefit analysis of therapies-need to be considered by cardiologists, the authors wrote.

"A patient's age in and of itself should not be used to deny someone more aggressive, invasive care with angioplasty for cardiogenic shock," said Judith S. Hochman, MD, professor of cardiology and director of the Cardiovascular Clinical Research Center at New York University School of Medicine in New York City.

"Having said that, we need to better understand and standardize criteria to improve selection of older patients who are likely to benefit," Hochman said. "For example, as shown in this study, better kidney function clearly is a useful indicator that a patient will do well. What we don't want is to subject patients to uncomfortable, unnecessary procedures if they will not derive a benefit in terms of quality of life or life prolongation."

The elderly in particular are at increased risk for other complications, the authors wrote. They added that further investigation of the selective use of early revascularization among this patient population is needed.