ABSTRACT
Importance: To our knowledge, no randomized clinical trial has compared the invasive and conservative strategies in frail, older patients with non-ST-segment elevation acute myocardial infarction (NSTEMI). Objective: To compare outcomes of invasive and conservative strategies in frail, older patients with NSTEMI at 1 year. Design, Setting, and Participants: This multicenter randomized clinical trial was conducted at 13 Spanish hospitals between July 7, 2017, and January 9, 2021, and included 167 older adult (≥70 years) patients with frailty (Clinical Frailty Scale score ≥4) and NSTEMI. Data analysis was performed from April 2022 to June 2022. Interventions: Patients were randomized to routine invasive (coronary angiography and revascularization if feasible; n = 84) or conservative (medical treatment with coronary angiography for recurrent ischemia; n = 83) strategy. Main Outcomes and Measures: The primary end point was the number of days alive and out of the hospital (DAOH) from discharge to 1 year. The coprimary end point was the composite of cardiac death, reinfarction, or postdischarge revascularization. Results: The study was prematurely stopped due to the COVID-19 pandemic when 95% of the calculated sample size had been enrolled. Among the 167 patients included, the mean (SD) age was 86 (5) years, and mean (SD) Clinical Frailty Scale score was 5 (1). While not statistically different, DAOH were about 1 month (28 days; 95% CI, -7 to 62) greater for patients managed conservatively (312 days; 95% CI, 289 to 335) vs patients managed invasively (284 days; 95% CI, 255 to 311; P = .12). A sensitivity analysis stratified by sex did not show differences. In addition, we found no differences in all-cause mortality (hazard ratio, 1.45; 95% CI, 0.74-2.85; P = .28). There was a 28-day shorter survival in the invasive vs conservatively managed group (95% CI, -63 to 7 days; restricted mean survival time analysis). Noncardiac reasons accounted for 56% of the readmissions. There were no differences in the number of readmissions or days spent in the hospital after discharge between groups. Neither were there differences in the coprimary end point of ischemic cardiac events (subdistribution hazard ratio, 0.92; 95% CI, 0.54-1.57; P = .78). Conclusions and Relevance: In this randomized clinical trial of NSTEMI in frail older patients, there was no benefit to a routine invasive strategy in DAOH during the first year. Based on these findings, a policy of medical management and watchful observation is recommended for older patients with frailty and NSTEMI. Trial Registration: ClinicalTrials.gov Identifier: NCT03208153.
Subject(s)
COVID-19 , Frailty , Myocardial Infarction , Non-ST Elevated Myocardial Infarction , ST Elevation Myocardial Infarction , Humans , Aged , Aged, 80 and over , Non-ST Elevated Myocardial Infarction/mortality , Non-ST Elevated Myocardial Infarction/therapy , Myocardial Infarction/mortality , Conservative Treatment , Aftercare , Pandemics , Angina, Unstable/therapy , Patient Discharge , Coronary AngiographyABSTRACT
Resumen En este texto repasamos algunos de los principales trabajos relacionados con el diagnóstico y tratamiento de las enfermedades cardiovasculares más prevalentes en el paciente mayor publicados durante el último año, a la vez que se resalta también la importancia de una adecuada prevención, tanto primaria como secundaria. De igual modo, merecen especial atención entidades tan prevalentes como la cardiopatía isquémica, la fibrilación auricular o la insuficiencia cardiaca, entre otras, y se destaca el papel de la rehabilitación cardiaca en los pacientes mayores, dado su impacto pronóstico al permitir abordar en gran medida algunos de los síndromes geriátricos presentes en esta población. Por último, repasamos algunos aspectos importantes en la situación de pandemia actual de COVID-19 y algunos de los trabajos liderados por la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología. In this text we review some of the main studies related to the diagnosis and treatment of the most prevalent cardiovascular diseases in older patients published during the last year, also highlighting the importance of adequate prevention, both primary and secondary. Similarly, prevalent entities such as ischemic heart disease, atrial fibrillation or heart failure, among others, deserve special attention, as well as the role of cardiac rehabilitation in older patients, given its benefits and prognostic impact regarding it addresses to a large extent some of the common geriatric syndromes in this population. Finally, we review some important aspects in the current COVID-19 pandemic and some of the works led by the Geriatric Cardiology Section of the Spanish Society of Cardiology.
ABSTRACT
SARS-CoV-2 infection, also known as COVID-19 (coronavirus infectious disease-19), was first identified in December 2019. In Spain, the first case of this infection was diagnosed on 31 January, 2020 and, by 15 April 2020, has caused 18 579 deaths, especially in the elderly. Due to the rapidly evolving situation regarding this disease, the data reported in this article may be subject to modifications. The older population are particularly susceptible to COVID-19 infection and to developing severe disease. The higher morbidity and mortality rates in older people have been associated with comorbidity, especially cardiovascular disease, and frailty, which weakens the immune response. Due to both the number of affected countries and the number of cases, the current situation constitutes an ongoing pandemic and a major health emergency. Because Spain has one of the largest older populations in the world, COVID-19 has emerged as a geriatric emergency. This document has been prepared jointly between the Section on Geriatric Cardiology of the Spanish Society of Cardiology and the Spanish Society of Geriatrics and Gerontology.
ABSTRACT
Resumen Durante el último año se han publicado numerosos trabajos centrados en el paciente mayor con enfermedad cardiovascular. En este texto repasamos algunos de los principales trabajos relacionados con el abordaje del paciente mayor con cardiopatía, incluyendo escenarios clínicos tan complejos como la situación de la pandemia de enfermedad por coronavirus de 2019 (COVID-19) que vivimos. Hemos querido resaltar y prestar especial atención a aspectos de gran relevancia clínica, dado su impacto pronóstico, como son los síndromes geriátricos y la comorbilidad, entidades prevalentes en el paciente mayor con cardiopatía, y que conviene conocer para mejorar la atención que proporcionamos a nuestros pacientes en distintos ámbitos (urgencias, hospitalización, ambulatorio). Analizamos también algunos de los principales estudios y trabajos impulsados desde la Sección de Cardiología Geriátrica de la Sociedad Española de Cardiología. During last year several papers focusing on elderly patients with cardiovascular disease have been published. In this article, we review some of the most important studies focused on the management of elderly patients with heart disease, also including complex clinical scenarios such as the COVID-19 pandemic. We highlight some aspects of great clinical relevance, given their prognostic impact, such as geriatric syndromes and comorbidity, all of them prevalent in the elderly. We also emphasize on how to improve the care we provide to our patients in different scenarios (emergency, hospitalization, outpatients). Finally, we analyze some of the main studies promoted by the Geriatric Cardiology Section of the Spanish Society of Cardiology.
Subject(s)
Cardiovascular Diseases , Coronavirus , Melatonin , Aged , Emergency Service, Hospital , HumansABSTRACT
OBJECTIVES: Initial data on COVID-19 infection has pointed out a special vulnerability of older adults. DESIGN: We performed a meta-analysis with available national reports on May 7, 2020 from China, Italy, Spain, United Kingdom, and New York State. Analyses were performed by a random effects model, and sensitivity analyses were performed for the identification of potential sources of heterogeneity. SETTING AND PARTICIPANTS: COVID-19-positive patients reported in literature and national reports. MEASURES: All-cause mortality by age. RESULTS: A total of 611,1583 subjects were analyzed and 141,745 (23.2%) were aged ≥80 years. The percentage of octogenarians was different in the 5 registries, the lowest being in China (3.2%) and the highest in the United Kingdom and New York State. The overall mortality rate was 12.10% and it varied widely between countries, the lowest being in China (3.1%) and the highest in the United Kingdom (20.8%) and New York State (20.99%). Mortality was <1.1% in patients aged <50 years and it increased exponentially after that age in the 5 national registries. As expected, the highest mortality rate was observed in patients aged ≥80 years. All age groups had significantly higher mortality compared with the immediately younger age group. The largest increase in mortality risk was observed in patients aged 60 to 69 years compared with those aged 50 to 59 years (odds ratio 3.13, 95% confidence interval 2.61-3.76). CONCLUSIONS AND IMPLICATIONS: This meta-analysis with more than half million of COVID-19 patients from different countries highlights the determinant effect of age on mortality with the relevant thresholds on age >50 years and, especially, >60 years. Older adult patients should be prioritized in the implementation of preventive measures.