Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

Abdulla A. Damluji, Karen Bandeen-Roche, Carol Berkower, Cynthia M. Boyd, Mohammed S. Al-Damluji, Mauricio G Cohen, Daniel E. Forman, Rahul Chaudhary, Gary Gerstenblith, Jeremy D. Walston, Jon R. Resar, Mauro Moscucci

Research output: Contribution to journalArticle

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Abstract

Background: Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. Objectives: The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. Methods: We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Results: Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53). Conclusions: This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

Original languageEnglish (US)
Pages (from-to)1890-1900
Number of pages11
JournalJournal of the American College of Cardiology
Volume73
Issue number15
DOIs
StatePublished - Apr 23 2019

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Cardiogenic Shock
Percutaneous Coronary Intervention
Hospital Mortality
Propensity Score
Confidence Intervals
Shock
Mortality
Odds Ratio
Health Services Research
Censuses
ST Elevation Myocardial Infarction
Inpatients
Databases
Delivery of Health Care

Keywords

  • cardiogenic shock
  • mortality
  • older adults
  • percutaneous coronary intervention
  • ST-segment elevation myocardial infarction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. / Damluji, Abdulla A.; Bandeen-Roche, Karen; Berkower, Carol; Boyd, Cynthia M.; Al-Damluji, Mohammed S.; Cohen, Mauricio G; Forman, Daniel E.; Chaudhary, Rahul; Gerstenblith, Gary; Walston, Jeremy D.; Resar, Jon R.; Moscucci, Mauro.

In: Journal of the American College of Cardiology, Vol. 73, No. 15, 23.04.2019, p. 1890-1900.

Research output: Contribution to journalArticle

Damluji, AA, Bandeen-Roche, K, Berkower, C, Boyd, CM, Al-Damluji, MS, Cohen, MG, Forman, DE, Chaudhary, R, Gerstenblith, G, Walston, JD, Resar, JR & Moscucci, M 2019, 'Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock', Journal of the American College of Cardiology, vol. 73, no. 15, pp. 1890-1900. https://doi.org/10.1016/j.jacc.2019.01.055
Damluji, Abdulla A. ; Bandeen-Roche, Karen ; Berkower, Carol ; Boyd, Cynthia M. ; Al-Damluji, Mohammed S. ; Cohen, Mauricio G ; Forman, Daniel E. ; Chaudhary, Rahul ; Gerstenblith, Gary ; Walston, Jeremy D. ; Resar, Jon R. ; Moscucci, Mauro. / Percutaneous Coronary Intervention in Older Patients With ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. In: Journal of the American College of Cardiology. 2019 ; Vol. 73, No. 15. pp. 1890-1900.
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abstract = "Background: Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. Objectives: The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. Methods: We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Results: Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35{\%}) were adults age ≥75 years. Of these, 53{\%} were women and 83{\%} were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42{\%} vs. 2013: 29{\%}). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27{\%} vs. 2013: 56{\%}, p < 0.001), with declining in-hospital mortality rates (1999: 64{\%} vs. 2013: 46{\%}; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95{\%} confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95{\%} CI: 0.36 to 0.47; Midwest: 0.49; 95{\%} CI: 0.42 to 0.57; South: 0.51; 95{\%} CI: 0.46 to 0.56; West: 0.46; 95{\%} CI: 0.41 to 0.53). Conclusions: This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.",
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AU - Damluji, Abdulla A.

AU - Bandeen-Roche, Karen

AU - Berkower, Carol

AU - Boyd, Cynthia M.

AU - Al-Damluji, Mohammed S.

AU - Cohen, Mauricio G

AU - Forman, Daniel E.

AU - Chaudhary, Rahul

AU - Gerstenblith, Gary

AU - Walston, Jeremy D.

AU - Resar, Jon R.

AU - Moscucci, Mauro

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N2 - Background: Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. Objectives: The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. Methods: We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Results: Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53). Conclusions: This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

AB - Background: Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock. Objectives: The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. Methods: We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Results: Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53). Conclusions: This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.

KW - cardiogenic shock

KW - mortality

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KW - ST-segment elevation myocardial infarction

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