Clinical investigations: interventional cardiology
Impact of ST-segment resolution after primary angioplasty on outcomes after myocardial infarction in elderly patients: an analysis from the CADILLAC trial

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Abstract

Background

Age is a strong independent predictor of outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). Whether lower rates of reperfusion success contribute to the poor prognosis in elderly patients is unknown.

Methods

A formal ST-segment analysis substudy was performed in 695 patients undergoing primary PCI for AMI in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Reperfusion success (determined by the magnitude of ST-segment elevation resolution [STR] after PCI) was evaluated in 4 age groups: <50 years (n = 163), ≥50 to <60 years (n = 187), ≥60 to <70 years (n = 194), and ≥70 years (n = 151).

Results

There were no differences in the age groups for angiographic procedural success >91% in all, P = .6), postprocedural Thrombolysis in Myocardial Infarction grade 3 flow >94%, P = .8), and the proportions of patients with complete, partial, or absent STR (P >.8). However, rates of 30-day mortality (0.6%, 1.1%, 3.6%, 6.0%, respectively) and major adverse cardiac events (MACE; 2.5%, 4.8%, 6.2% 9.3%, respectively) increased with age. Rates of mortality and MACE were also inversely related to the magnitude of STR. Absent STR (hazard ratio, 3.00; 95% CI, 1.37–6.58; P = .006) and age (hazard ratio, 1.34; 95% CI, 1.01–1.77; P = .04) were independent predictors of 30-day MACE by using multivariable modeling.

Conclusions

Lack of effective myocardial reperfusion is not a contributory mechanism responsible for the high morbidity and mortality rates observed in elderly patients. Nevertheless, advanced age and absent STR are both independent predictors of adverse outcomes after primary PCI, emphasizing the importance of successful reperfusion in the elderly population.

Section snippets

Methods

The details of the CADILLAC trial protocol have been published previously.18 In brief, 2082 patients were enrolled in 76 centers in 9 countries between November 1997 and September 1999. The inclusion criteria were age >18 years (with no upper limit), presence of at least 30 minutes but <12 hours of symptoms consistent with AMI, and presence of ST-segment elevation in at least 2 contiguous leads or new left bundle-branch block. Patients with other electrocardiographic patterns were enrolled when

Results

A total of 695 patients with AMI and serial interpretable ST-segment analyses within the appropriate time frame were included in the STR substudy. The clinical characteristics of the study population stratified by age are summarized in Table I. Patients in the older age groups were more likely to be women, had a higher prevalence of hypertension and diabetes mellitus, and were less likely to be current smokers. Increasing age was also associated with a greater likelihood of congestive heart

Discussion

This study suggests that increasing age is not associated with lower rates of STR after primary PCI for AMI. Thus, adverse outcomes in elderly patients are unrelated to the primary PCI procedure itself, and lack of myocardial reperfusion is not the predominant mechanism responsible for the increasing morbidity and mortality rates. This thus strengthens the argument that advanced age is not a contraindication for primary PCI and may be the preferred management approach to AMI. In addition,

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    Citation Excerpt :

    In our study we found that patients’ age, infarct duration, localization and epicardial blood flow after PPCI were important associates of myocardium damage reflected by STR. Previous studies of STR after PPCI for patients with STEMI did not find statistically significant association between patients’ age and STR [4,11,12]. Yet, one of the associates of incomplete STR in our study was higher patients’ age.

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Guest Editor for this manuscript was Frank Aquirre, MD, Prairie Cardiovascular Consultants, Ltd, Springfield, Ill.

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