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IMPACT OF AN INVASIVE STRATEGY ON IN-HOSPITAL OUTCOMES IN NONAGENARIANS WITH ACUTE CORONARY SYNDROME: INSIGHTS FROM THE AMI-OPTIMA STUDY
Abstracts
rates of the primary outcome (5.3% versus 11.8%, respectively; p<0.001). There was no significant heterogeneity in the treatment effect of pharmacoinvasive strategy on the primary outcome (p heterogeneity¼0.73) or the incidence of death or re-infarction at one year (p heterogeneity¼0.64) (figure). Patient with renal dysfunction had higher rates of major bleeding compared to patients with eGFR 60 ml/min (7.7% versus 4.3%, respectively; p¼0.004); however, the effect of pharmacoinvasive strategy on bleeding did not vary in relation to eGFR on presentation (p heterogeneity¼0.67). After adjusting for the interaction between TIMI risk score and treatment assignment (p interaction <0.001), there was no significant interaction between treatment assignment and eGFR as a categorical (p interaction¼0.40) or continuous variable (p interaction¼0.18). CONCLUSION: Renal impairment is associated with increased rates of ischemic and bleeding events in STEMI patients treated with fibrinolysis. However, the safety and superior efficacy of pharmacoinvasive strategy following fibrinolysis does not vary in relation to renal function on presentation.
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80e89, and 202 (4.4%) were 90. Compared to younger patients, nonagerians had fewer comorbidities and received less optimal medical therapy at hospital’s discharge. Nonagerians had higher in-hospital mortality compared to patients less than 70 years old (24.0% vs 1.3%, p<0.001). We defined invasive strategy as coronary angiogram with/without coronary intervention. We used inverse probability weighting to adjust for potential confounders between the patients who underwent invasive treatment versus those who were treated conservatively. After inverse probability weighting, the invasive strategy was associated with reduced in-hospital mortality in all age groups: 1.1% vs 3.7% in patients <70 years old (RRR 70%, 95% CI 51-80%; NNT 38), 2.9% vs 9.0% in septuagenarians (RRR 68%, 95% CI 47-78%; NNT 16), 6.2% vs 15% in octogenarians (RRR 59%, 95% CI 35-67%; NNT 11) and 17% vs 26% in nonagerians (RRR 34%, 95% CI 0-42%; NNT 11). The invasive strategy was associated with marked reductions in both cardiovascular mortality and total mortality. Invasive strategy was associated with reductions ranged from 70% to 30% in patients younger than 70 years and nonagerians, respectively (Figure 1). However, compared to the conservative strategy, the invasive strategy was associated with increased in TIMI major bleedings in the nonagerians (9.6% vs 2.0 %, p<0.001; NNH 13) but not in other age groups. CONCLUSIONS: Nonagerians with ACS have high rates of inhospital mortality, and while an invasive strategy was associated with improved survival, at the expense of increased risks for major bleeding.
Table 1. Ischemic and Bleeding Outcomes According to the Revascularization Strategy
004 IMPACT OF AN INVASIVE STRATEGY ON IN-HOSPITAL OUTCOMES IN NONAGENARIANS WITH ACUTE CORONARY SYNDROME: INSIGHTS FROM THE AMI-OPTIMA STUDY E Couture, P Farand, M Nguyen, C Allard, J Afilalo, M Afilalo, E Schampaert, M Eisenberg, M Montigny, S Mansour, S Kouz, J Tardif, T Huynh
Unadjusted Rate
Inverse Probability Weighted
In-Hospital Outcome
Age Group, yrs
P Conservative Invasive Value
Conservative Invasive Odds (%) (%) Ratio
Population
<70 70-79 80-89 ≥90
184 (7.7%) 175 (17%) 437 (46%) 162 (80%)
2210 (92%) 856 (83%) 505 (54%) 40 (20%)
<0.001 <0.001 <0.001 <0.001
2331 (49%) 1016 (50%) 953 (50%) 202 (51%)
2393 (51%) 1032 (50%) 951 (50%) 197 (49%)
Death
<70 70-79 80-89 ≥90
7 (3.8%) 13 (7.4%) 67 (15%) 41 (25%)
24 (1.1%) 23 (2.7%) 28 (5.5%) 7 (18%)
0.002 0.002 <0.001 0.30
3.7 9.0 15 26
CV death
<70 70-79 80-89 ≥90
6 (3.3%) 8 (4.6%) 53 (12%) 34 (21%)
20 (0.9%) 16 (1.9%) 25 (5%) 5 (13%)
0.003 0.03 <0.001 0.22
aStroke
<70 70-79 80-89 ≥90
0 (0%) 2 (1.1%) 6 (1.4%) 3 (1.9%)
6 (0.3%) 1 (0.1%) 7 (1.4%) 1 (2.5%)
TIMI major
<70 70-79 80-89 ≥90
6 (3.3%) 6 (3.4%) 13 (3.0%) 3 (1.9%)
68 (3.1%) 41 (4.8%) 25 (5%) 3 (7.5%)
Sherbrooke, Québec BACKGROUND:
Nonagerians constitute a growing proportion of the patients with acute coronary syndromes (ACS). Currently, little is known about the characteristics, prognosis and management of these patients. We aim to describe the characteristics, management and the impact of an invasive strategy in nonagerians hospitalized for ACS. METHODS AND RESULTS: The AMI-OPTIMA study was a cluster randomized study of knowledge translation to improve discharge medications in patients admitted with ACS at 24 Québec hospitals during two calendar years: 2009 (N¼2371) and 2012 (N¼2198). Of 4,569 patients, 2395 (52%) were <70 years old, 1031 (23%) were 70e79, 941 (21%) were
95% CI
P Value
-
-
0.61 1.00 0.68 0.68
1.1 2.9 6.2 17
0.30 0.30 0.37 0.60
0.190.46 0.200.46 0.270.50 0.370.98
<0.001 <0.001 <0.001 0.04
3.3 6.2 12 21
0.9 2.1 5.7 13
0.28 0.32 0.44 0.54
0.170.44 0.190.52 0.310.61 0.310.92
<0.001 <0.001 <0.001 0.02
0.48 0.02 0.99 0.79
0 1.5 1.6 1.5
0.6 0.1 1.4 2.5
0.07 0.87 1.72
0.010.49 0.411.83 0.417.29
0.03 <0.001 0.85 0.50
0.89 0.43 0.12 0.06
3.6 4.5 2.7 2.0
3.1 4.8 4.4 9.6
0.87 1.07 1.65 5.26
0.631.19 0.711.62 1.012.71 1.7515-74
0.37 0.73 0.05 0.001
TIMI = Thrombolysis in Myocardial Infarction bleeding criteria. CV Death = Cardiovascular Death.
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Canadian Journal of Cardiology Volume 32 2016
remains undefined and there is currently insufficient evidence to support its routine use. Future studies of DAPT in T2MI are needed to optimize the management of these patients. Baseline characteristics and management of T1MI and T2MI patients ACS T1MI (Observational T2MI (Observational (RCT) N=188,347 Studies) N=18,752 Studies) N=3,636
005 DUAL ANTIPLATELET THERAPY IN TYPE 1 AND TYPE 2 MYOCARDIAL INFARCTIONS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES C Reid, A AlTurki, N Danchin, A Yan, S Goodman, J Tanguay, S Mehta, T Huynh Montréal, Québec BACKGROUND:
In 2007, the Task Force for the Universal Definition of Myocardial Infarction defined Type 2 Myocardial Infarction (T2MI) as infarction secondary to causes other than atherosclerotic plaque rupture. The benefit of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, prasugrel, or ticagrelor has been well established for patients with acute coronary syndromes (ACS). It remains unclear however, whether DAPT has been evaluated in T2MI. We aim to determine whether DAPT has been studied in patients with T2MI in randomized controlled trials (RCTs) and observational studies and to summarize our findings. METHODS: We conducted a systematic review of all RCTs of DAPT in ACS cited in Medline, Embase, and Science Direct up to May 2015. We reviewed all RCTs to determine if they included patients with T2MI. We also conducted another systematic search for all observational studies of patients with T2MI. We reviewed and summarized the baseline characteristics, as well as management of patients with Type 1 Myocardial Infarctions (T1MI) and T2MI in these studies. RESULTS: We retrieved 57 RCTs enrolling a total of 188,347 patients. All of these RCTs exclusively enrolled patients with ACS and excluded patients with T2MI. We identified 20 observational studies enrolling 45,621 patients, of which 18,752 were identified with T1MI and 3,636 with T2MI. Patients with T2MI were older and more often female compared with T1MI patients. T2MI was associated with high in-hospital mortality (4-14%) as well as high mortality during follow up (5-49%). Only 6 observational studies assessed the use of DAPT in patients with T2MI (14%-89%) which was lower compared to patients with T1MI (61%97%). None of the observational studies reported the effectiveness and safety of DAPT use in patients with T2MI. CONCLUSION: The efficacy, effectiveness, and safety of DAPT in T2MI have not been formally evaluated in RCTs and observational studies. Thus, the role of DAPT in T2MI
Mean age (years) 55-79
60-72
Female (%)
16-52
22-50
61-76 34-64
Diabetes Mellitus (%)
8-65
13-51
22-51
Hypertension (%) 15-95
48-90
59-86
DAPT (%)
Not Applicable
61-97
14-89
Mortality-In Hospital (%)
1-8
4-11
4-14
5-26
5-49
Mortality-Within3 1-10 years (%)
006 REAL TIME PHYSICIAN OVERSIGHT OF PREHOSPITAL STEMI ACTIVATION ASSOCIATED WITH REDUCED RATE OF INAPPROPRIATE CATHETERIZATION LABORATORY ACTIVATION R Allen-Lefebvre, A Matteau, F Gobeil, S Mansour, A Lebrun, A Kokis, É Quan, I Sareault, M Montigny, BJ Potter Montréal, Québec
automated pre-hospital BACKGROUND: “Physician-less” STEMI diagnosis and cardiac catheterization laboratory (CCL) activation has been shown to provide consistently short door-to-balloon (D2B) times and an acceptably low rate of inappropriate activations (IA). However, as human error accounts for up to 70% of IA with this system, real-time physician oversight might improve system performance further. Herein, we compare the performance of a “physicianless” pre-hospital CCL activation system in terms of the rates of IA and false positive (FP) activations to an otherwise identical system with real-time emergency physician oversight. METHODS: Two health regions in the Greater Montréal Area have opted for alternate pre-hospital STEMI activation protocols. Health Region A opted for a “physician-less” system. Health Region B invested in transmission equipment in order to ensure real-time emergency room physician oversight of all pre-hospital CCL activations. ECG’s were performed by firstresponders in the field for all patients with a complaint of chest pain or dyspnea. An electrographic diagnosis of STEMI (“Acute Myocardial Infarction”, Zoll Medical Corporation) resulted automatically in CCL activation and direct transfer without physician interpretation of the ECG in Health Region A, whereas, in Health Region B, the ECG was transmitted electronically to the emergency physician in the nearest hospital for approval before activating the CCL. Patients with hemodynamic instability, left bundle branch block, or tachycardia in excess of 140bpm were excluded from the prehospital activation algorithm. Patient data were collected for all pre-hospital CCL activations between February 2012 and August 2015 in both Health Regions. IA was defined as any activation resulting from a non-diagnostic ECG (No STelevation). FP activation was defined as any ECG-appropriate
rates of the primary outcome (5.3% versus 11.8%, respectively; p<0.001). There was no significant heterogeneity in the treatment effect of pharmacoinvasive strategy on the primary outcome (p heterogeneity¼0.73) or the incidence of death or re-infarction at one year (p heterogeneity¼0.64) (figure). Patient with renal dysfunction had higher rates of major bleeding compared to patients with eGFR 60 ml/min (7.7% versus 4.3%, respectively; p¼0.004); however, the effect of pharmacoinvasive strategy on bleeding did not vary in relation to eGFR on presentation (p heterogeneity¼0.67). After adjusting for the interaction between TIMI risk score and treatment assignment (p interaction <0.001), there was no significant interaction between treatment assignment and eGFR as a categorical (p interaction¼0.40) or continuous variable (p interaction¼0.18). CONCLUSION: Renal impairment is associated with increased rates of ischemic and bleeding events in STEMI patients treated with fibrinolysis. However, the safety and superior efficacy of pharmacoinvasive strategy following fibrinolysis does not vary in relation to renal function on presentation.
S69
80e89, and 202 (4.4%) were 90. Compared to younger patients, nonagerians had fewer comorbidities and received less optimal medical therapy at hospital’s discharge. Nonagerians had higher in-hospital mortality compared to patients less than 70 years old (24.0% vs 1.3%, p<0.001). We defined invasive strategy as coronary angiogram with/without coronary intervention. We used inverse probability weighting to adjust for potential confounders between the patients who underwent invasive treatment versus those who were treated conservatively. After inverse probability weighting, the invasive strategy was associated with reduced in-hospital mortality in all age groups: 1.1% vs 3.7% in patients <70 years old (RRR 70%, 95% CI 51-80%; NNT 38), 2.9% vs 9.0% in septuagenarians (RRR 68%, 95% CI 47-78%; NNT 16), 6.2% vs 15% in octogenarians (RRR 59%, 95% CI 35-67%; NNT 11) and 17% vs 26% in nonagerians (RRR 34%, 95% CI 0-42%; NNT 11). The invasive strategy was associated with marked reductions in both cardiovascular mortality and total mortality. Invasive strategy was associated with reductions ranged from 70% to 30% in patients younger than 70 years and nonagerians, respectively (Figure 1). However, compared to the conservative strategy, the invasive strategy was associated with increased in TIMI major bleedings in the nonagerians (9.6% vs 2.0 %, p<0.001; NNH 13) but not in other age groups. CONCLUSIONS: Nonagerians with ACS have high rates of inhospital mortality, and while an invasive strategy was associated with improved survival, at the expense of increased risks for major bleeding.
Table 1. Ischemic and Bleeding Outcomes According to the Revascularization Strategy
004 IMPACT OF AN INVASIVE STRATEGY ON IN-HOSPITAL OUTCOMES IN NONAGENARIANS WITH ACUTE CORONARY SYNDROME: INSIGHTS FROM THE AMI-OPTIMA STUDY E Couture, P Farand, M Nguyen, C Allard, J Afilalo, M Afilalo, E Schampaert, M Eisenberg, M Montigny, S Mansour, S Kouz, J Tardif, T Huynh
Unadjusted Rate
Inverse Probability Weighted
In-Hospital Outcome
Age Group, yrs
P Conservative Invasive Value
Conservative Invasive Odds (%) (%) Ratio
Population
<70 70-79 80-89 ≥90
184 (7.7%) 175 (17%) 437 (46%) 162 (80%)
2210 (92%) 856 (83%) 505 (54%) 40 (20%)
<0.001 <0.001 <0.001 <0.001
2331 (49%) 1016 (50%) 953 (50%) 202 (51%)
2393 (51%) 1032 (50%) 951 (50%) 197 (49%)
Death
<70 70-79 80-89 ≥90
7 (3.8%) 13 (7.4%) 67 (15%) 41 (25%)
24 (1.1%) 23 (2.7%) 28 (5.5%) 7 (18%)
0.002 0.002 <0.001 0.30
3.7 9.0 15 26
CV death
<70 70-79 80-89 ≥90
6 (3.3%) 8 (4.6%) 53 (12%) 34 (21%)
20 (0.9%) 16 (1.9%) 25 (5%) 5 (13%)
0.003 0.03 <0.001 0.22
aStroke
<70 70-79 80-89 ≥90
0 (0%) 2 (1.1%) 6 (1.4%) 3 (1.9%)
6 (0.3%) 1 (0.1%) 7 (1.4%) 1 (2.5%)
TIMI major
<70 70-79 80-89 ≥90
6 (3.3%) 6 (3.4%) 13 (3.0%) 3 (1.9%)
68 (3.1%) 41 (4.8%) 25 (5%) 3 (7.5%)
Sherbrooke, Québec BACKGROUND:
Nonagerians constitute a growing proportion of the patients with acute coronary syndromes (ACS). Currently, little is known about the characteristics, prognosis and management of these patients. We aim to describe the characteristics, management and the impact of an invasive strategy in nonagerians hospitalized for ACS. METHODS AND RESULTS: The AMI-OPTIMA study was a cluster randomized study of knowledge translation to improve discharge medications in patients admitted with ACS at 24 Québec hospitals during two calendar years: 2009 (N¼2371) and 2012 (N¼2198). Of 4,569 patients, 2395 (52%) were <70 years old, 1031 (23%) were 70e79, 941 (21%) were
95% CI
P Value
-
-
0.61 1.00 0.68 0.68
1.1 2.9 6.2 17
0.30 0.30 0.37 0.60
0.190.46 0.200.46 0.270.50 0.370.98
<0.001 <0.001 <0.001 0.04
3.3 6.2 12 21
0.9 2.1 5.7 13
0.28 0.32 0.44 0.54
0.170.44 0.190.52 0.310.61 0.310.92
<0.001 <0.001 <0.001 0.02
0.48 0.02 0.99 0.79
0 1.5 1.6 1.5
0.6 0.1 1.4 2.5
0.07 0.87 1.72
0.010.49 0.411.83 0.417.29
0.03 <0.001 0.85 0.50
0.89 0.43 0.12 0.06
3.6 4.5 2.7 2.0
3.1 4.8 4.4 9.6
0.87 1.07 1.65 5.26
0.631.19 0.711.62 1.012.71 1.7515-74
0.37 0.73 0.05 0.001
TIMI = Thrombolysis in Myocardial Infarction bleeding criteria. CV Death = Cardiovascular Death.
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Canadian Journal of Cardiology Volume 32 2016
remains undefined and there is currently insufficient evidence to support its routine use. Future studies of DAPT in T2MI are needed to optimize the management of these patients. Baseline characteristics and management of T1MI and T2MI patients ACS T1MI (Observational T2MI (Observational (RCT) N=188,347 Studies) N=18,752 Studies) N=3,636
005 DUAL ANTIPLATELET THERAPY IN TYPE 1 AND TYPE 2 MYOCARDIAL INFARCTIONS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES C Reid, A AlTurki, N Danchin, A Yan, S Goodman, J Tanguay, S Mehta, T Huynh Montréal, Québec BACKGROUND:
In 2007, the Task Force for the Universal Definition of Myocardial Infarction defined Type 2 Myocardial Infarction (T2MI) as infarction secondary to causes other than atherosclerotic plaque rupture. The benefit of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, prasugrel, or ticagrelor has been well established for patients with acute coronary syndromes (ACS). It remains unclear however, whether DAPT has been evaluated in T2MI. We aim to determine whether DAPT has been studied in patients with T2MI in randomized controlled trials (RCTs) and observational studies and to summarize our findings. METHODS: We conducted a systematic review of all RCTs of DAPT in ACS cited in Medline, Embase, and Science Direct up to May 2015. We reviewed all RCTs to determine if they included patients with T2MI. We also conducted another systematic search for all observational studies of patients with T2MI. We reviewed and summarized the baseline characteristics, as well as management of patients with Type 1 Myocardial Infarctions (T1MI) and T2MI in these studies. RESULTS: We retrieved 57 RCTs enrolling a total of 188,347 patients. All of these RCTs exclusively enrolled patients with ACS and excluded patients with T2MI. We identified 20 observational studies enrolling 45,621 patients, of which 18,752 were identified with T1MI and 3,636 with T2MI. Patients with T2MI were older and more often female compared with T1MI patients. T2MI was associated with high in-hospital mortality (4-14%) as well as high mortality during follow up (5-49%). Only 6 observational studies assessed the use of DAPT in patients with T2MI (14%-89%) which was lower compared to patients with T1MI (61%97%). None of the observational studies reported the effectiveness and safety of DAPT use in patients with T2MI. CONCLUSION: The efficacy, effectiveness, and safety of DAPT in T2MI have not been formally evaluated in RCTs and observational studies. Thus, the role of DAPT in T2MI
Mean age (years) 55-79
60-72
Female (%)
16-52
22-50
61-76 34-64
Diabetes Mellitus (%)
8-65
13-51
22-51
Hypertension (%) 15-95
48-90
59-86
DAPT (%)
Not Applicable
61-97
14-89
Mortality-In Hospital (%)
1-8
4-11
4-14
5-26
5-49
Mortality-Within3 1-10 years (%)
006 REAL TIME PHYSICIAN OVERSIGHT OF PREHOSPITAL STEMI ACTIVATION ASSOCIATED WITH REDUCED RATE OF INAPPROPRIATE CATHETERIZATION LABORATORY ACTIVATION R Allen-Lefebvre, A Matteau, F Gobeil, S Mansour, A Lebrun, A Kokis, É Quan, I Sareault, M Montigny, BJ Potter Montréal, Québec
automated pre-hospital BACKGROUND: “Physician-less” STEMI diagnosis and cardiac catheterization laboratory (CCL) activation has been shown to provide consistently short door-to-balloon (D2B) times and an acceptably low rate of inappropriate activations (IA). However, as human error accounts for up to 70% of IA with this system, real-time physician oversight might improve system performance further. Herein, we compare the performance of a “physicianless” pre-hospital CCL activation system in terms of the rates of IA and false positive (FP) activations to an otherwise identical system with real-time emergency physician oversight. METHODS: Two health regions in the Greater Montréal Area have opted for alternate pre-hospital STEMI activation protocols. Health Region A opted for a “physician-less” system. Health Region B invested in transmission equipment in order to ensure real-time emergency room physician oversight of all pre-hospital CCL activations. ECG’s were performed by firstresponders in the field for all patients with a complaint of chest pain or dyspnea. An electrographic diagnosis of STEMI (“Acute Myocardial Infarction”, Zoll Medical Corporation) resulted automatically in CCL activation and direct transfer without physician interpretation of the ECG in Health Region A, whereas, in Health Region B, the ECG was transmitted electronically to the emergency physician in the nearest hospital for approval before activating the CCL. Patients with hemodynamic instability, left bundle branch block, or tachycardia in excess of 140bpm were excluded from the prehospital activation algorithm. Patient data were collected for all pre-hospital CCL activations between February 2012 and August 2015 in both Health Regions. IA was defined as any activation resulting from a non-diagnostic ECG (No STelevation). FP activation was defined as any ECG-appropriate