PCI Reduces In-Hospital Mortality in Nonagenarians with STEMI

 

In patients older than 90 years who experience ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) is associated with lower in-hospital mortality, according to a research letter published online January 30, 2013, ahead of print in the Journal of the American College of Cardiology. Per the report, PCI use in this patient population has also more than doubled since 2004.

Investigators led by Mahendra K. Mandawat, MD, of Charlie Norwood VA Medical Center (Augusta, GA), conducted a cross-sectional analysis of patients discharged between 2004 and 2008 in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS). The researchers collected data from 33,644 STEMI admissions of patients who were at least 90 years old.

The overall usage rate of PCI was 16.9%, with higher rates in men, those with mild comorbidity, and patients seen at large, urban, and teaching hospitals (P < 0.0001 for each comparison). In addition, the rate of PCI use in the overall patient group more than doubled during the study period (table 1).

Table 1. PCI Use by Year^a

^a P < 0.0001 for each comparison (PCI vs. no PCI).

The overall in-hospital mortality rate was 24.6% with a number-needed-to-treat of 8.77. Mortality was lower among patients receiving PCI (15.1% vs. 26.5%; P < 0.001), and in a comparison of overall mortality between early (2004/2005) and late (2007/2008) time periods, mortality decreased over time (from 25.5% to 24.1%; P < 0.001). On multivariate analysis, PCI continued to be associated with lower mortality (OR 0.47; 95% CI 0.44-0.51) even after adjustment for demographic data, comorbidity, and hospital characteristics.

PCI “might benefit a large proportion of nonagenarians who present with a STEMI, although further study is needed,” Dr. Mandawat and colleagues conclude. “Risk stratification and long-term outcomes of PCI versus non-PCI therapy in the setting of STEMIs are important areas of future research.”

Advances Needed in Understanding Frailty

In a telephone interview with TCTMD, Dr. Mandawat said he expected PCI to reduce mortality, but was “surprised at the extent of benefit.” 

The results should be practice-changing, he continued, adding that since there are no prior randomized trials in this patient group and no official guidelines for treatment, decisions have been left to individual practitioners. “What we’re seeing is that there’s a huge risk reduction even in this population. . . . I would assume that [the findings] will eventually make their way into guidelines and people will adopt [PCI in nonagenarians] a lot more,” Dr. Mandawat commented. 

However, Ajay J. Kirtane, MD, SM, of Columbia University Medical Center (New York, NY), said it is hard to draw conclusions from the analysis. “Especially in this patient population, if you compare those that got the intervention with those who did not get the intervention, it is such a confounding comparison,” he said. “They are [often] so frail and debilitated . . . you’d expect that the people who got taken to the lab in the vast majority of cases are going to be inherently healthier than those who didn’t.” 

Still, intervention decisions are becoming increasingly important as the population ages, Dr. Kirtane observed, noting that “there are definitely people who have survived past 90 and have good qualities of life. So I think that the fact that there are people who are doing PCI in these patients speaks to the fact that we should definitely not age discriminate.”   

Dr. Mandawat added that all patients in the study were divided by comorbidity, and “we see the benefits even after adjustment for comorbidities.” 

DES Use Likely Did Not Impact Results

Looking at the study time period, Dr. Kirtane also commented on the likelihood of stent type having any impact on outcomes. “I would not be surprised to hear that the majority of [very elderly] patients are being treated with a bare metal stent,” he said, adding that the XIMA trial, which studied restenosis in octogenarians implanted with both BMS and DES, is the “only trial that we can use to inform our decision.” 

Even so, there is not much additional information that can be gleaned from XIMA, Dr. Kirtane commented. “A patient has to survive beyond at least a year to determine the full-effectiveness of a DES,” he said, adding that the incidence of noncardiac mortality was high in the study because of higher patient comorbidity.   

Dr. Mandawat and colleagues did not collect data on stent type, but he acknowledged that the transition from BMS to DES likely occurred in the middle of the study period. Even so, “in the early period of 2004, 2005, and 2006, there is clearly benefit,” he reported.   

The most important task going forward is similar to what needs to happen in the field of TAVR, according to Dr. Kirtane. “It’s important to be able to try and get better at determining patients’ overall frailty status and their overall likelihood of recovery,” he concluded, adding that it is difficult in STEMI patients because of the time aspect. “On the other hand, for some of these patients, especially those with larger infarcts that are potentially salvageable, they have a lot to gain by going to the cath lab.” 

Study Details

The average patient age was 92.64 years and most (71.3%) were female. Of the patients, 19.3% had mild comorbidities, 70.5% had moderate comorbidities, and 10.2% had severe comorbidities.

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Source:
Mandawat A, Mandawat A, Mandawat MK. Percutaneous coronary intervention after ST-segment elevation myocardial infarction in nonagenarians: Use rates and in-hospital mortality. J Am Coll Cardiol. 2013;Epub ahead of print.

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