Trends and Impact of Door-to-Balloon Time on Clinical Outcomes in Patients Aged <75, 75 to 84, and ≥85 Years With ST-Elevation Myocardial Infarction.

Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. The impact of timely reperfusion on clinical outcomes in patients aged 75-84 and ≥85 years is uncertain. We analysed 2,972 consecutive STEMI patients who underwent primary percutaneous coronary intervention from the Melbourne Interventional Group Registry (2005-2014). Patients aged <75 years were included in the younger group, those aged 75-84 years were in the elderly group and those ≥85 years were in the very elderly group. The primary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). 2,307 (77.6%) patients were <75 years (mean age 59 ± 9 years), 495 (16.7%) were 75-84 years and 170 (5.7%) were ≥85 years. There has been a significant decrease in DTBT over 10 years in younger and elderly patients (p-for-trend <0.01 and 0.03) with a trend in the very elderly (p-for-trend 0.08). Compared to younger and elderly patients, the very elderly had higher 12-month mortality (3.6% vs 10.7% vs. 29.4%; p = 0.001) and MACE (10.8% vs 20.6% vs 33.5%; p = 0.001). DTBT ≤90 minutes was associated with improved outcomes on univariate analysis but was not an independent predictor of improved 12-month mortality (OR 0.84, 95% CI 0.54-1.31) or MACE (OR 0.89, 95% CI 0.67-1.16). In conclusion, over a 10-year period, there was an improvement in DTBT in patients aged <75 years and 75-84 years however DTBT ≤90 minutes was not an independent predictor of 12-month outcomes. Thus assessing whether patients aged ≥85 years are suitable for invasive management does not necessarily translate to worse clinical outcomes.

Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction.

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.