- Email: [email protected]
Complications of Acute Myocardial Infarction in Patients ≥90 Years of Age
required transfusions. Unsuccessful procedures were due to inability to pass the guidewire through the graft, and occurred in patients with older occlusions. The high event rate at 1 year reflects the very ill population studied, as well as the high rates of restenosis previously reported in vein grafts,10,13 and is comparable to the findings in ROBUST. Event-free survival was greatest in patients with successful procedures, with minimal residual narrowing. Only minimal efforts were taken to achieve a small residual narrowing, for fear of embolization. With the advent of abciximab, as well as evidence suggesting that stents may be placed safely immediately after TEC,11 we have recently performed immediate stenting after TEC under intravascular ultrasound guidance in 2 patients in an effort to maintain better long-term patency. Both were performed in recently occluded grafts (,1 month), without embolization or other incidents after 3 months. In summary, our results suggest that the use of TEC in totally occluded saphenous vein grafts is at least as safe and effective as overnight urokinase, and may be a reasonable approach for patients who are poor candidates for repeat coronary artery bypass grafting. The number of patients presented here is small, and further study is necessary to define patient selection more clearly and refine current techniques. We expect that new devices and novel approaches with established devices addressing this complex vascular problem will continue to improve outcomes, and catheter-based recanalization of totally occluded saphenous vein grafts may develop into a more commonly used alternative. 1. Smith SH, Geer JC. Morphology of saphenous vein-coronary artery bypass grafts: 7–116 months postoperative. Arch Pathol Lab Med 1983;107:13–25.
2. Fitzgibbon GM, Leach AJ, Kafka JP, Keon WJ. Coronary bypass graft fate: long-term angiographic study. J Am Coll Cardiol 1991;17:1075–1080. 3. Sergeant PT, Blackstone EH, Lasaffre E, Flameng W, Kirklin JW. Incremental risks for reintervention after the CABG operation. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac Surgery. 2nd ed. New York: Churchill-Livingstone, 1993:335– 336. 4. Foster E, Fisher L, Kaiser G, Myers W. Comparison of operative mortality and morbidity for initial and repeat coronary bypass grafting: the Coronary Artery Surgery Study (CASS) Registry experience. Ann Thorac Surg 1993; 38:563–570. 5. Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanglu S, Kolff JW, Wilansky S, Moore WH. Transmyocardial laser revascularization: clinical experience with twelve month follow-up. J Thorac Cardiovasc Surg 1996;111:791–799. 6. Kriett JM, Kaye MP. The registry of the International Society for Heart Transplantation: seventh annual report–1990. J Heart Transplant 1990; 9:323–350. 7. Hartmann JR, McKeever LS, Stamato NJ, Bufalino VJ, Marek JC, Brown AS, Goodwin MJ, Cahill JM, Enger EL. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts by extended infusion of urokinase: initial results and short-term clinical follow-up. J Am Coll Cardiol 1991;18:1517– 1523. 8. Hartmann JR, McKeever LS, O’Neill WW, White CJ, Whitlow PL, Gilmore PS, Doorey AJ, Galichia JP, Enger EL. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts with long-term, low dose direct infusion of urokinase (ROBUST): a serial trial. J Am Coll Cardiol 1996;27:60 – 66. 9. Taylor MA, Santoian EC, Aji J, Eldredge J, Cha SD, Dennis CA. Intracerebral hemorrage complicating urokinase infusion into an occluded aortocoronary bypass graft. Cathet Cardiovasc Diagn 1994;31:206 –210. 10. Sullebarger JT, Puleo J. Extraction atherectomy for the recanalization of totally occluded aortocoronary saphenous vein grafts. Cathet Cardiovasc Diagn 1995;36:399 –343. 11. DeFeyter PJ, Serruys P, Van den Brand M, Meester H, Beatt K, Suryapranata H. Percutaneous transluminal angioplasty of a totally occluded venous bypass graft: a challenge that should be resisted. Am J Cardiol 1989;64:88 – 90. 12. Safian RD, Grines CL, May MA, Lichtenberg A, Juran N, Schreiber TL, Pavlides G, Meany TB, Savas V, O’Neill WW. Clinical and angiographic results of transluminal extraction coronary atherectomy in saphenous vein bypass grafts. Circulation 1994;89:302–312. 13. Kaplan BM, Safian RD, Grines CL, Goldstein JA, Mersalese DL, Ajluni S, O’Neill WW. Usefulness of adjunctive angioscopy and extraction atherectomy before stent implantation in high-risk aortocoronary saphenous vein grafts. Am J Cardiol 1995;76:822– 824. 14. Lytle B, Loop F, Cosgrove D. Fifteen hundred coronary reoperations: results and determinants of early and late survival. J Thorac Cardiovasc Surg 1987;93: 847– 859. 15. Popma JJ, Leon MB, Mintz GS, Kent KM, Satler LF, Garrand TJ, Pichard AD. Results of coronary angioplasty using the transluminal extraction catheter. Am J Cardiol 1992;70:1526 –1532.
Complications of Acute Myocardial Infarction in Patients >90 Years of Age Michael L. Malone,
MD,
Leon B. Rosen,
ospitalization for acute myocardial infarction (AMI) in the 90-year old encompasses a range H of negative experiences and outcomes that are gen-
MD,
and James S. Goodwin,
MD
erally not considered or well documented when one is describing the consequences of an AMI. Indeed, in a review of 14 recent studies1–14 of the clinical course and outcomes of AMI in older persons, we could find no mention of in-hospital delirium as well as no mention of the use of restraints. Major
efforts in recent years have focused on decreasing mortality in older persons by use of thrombolytic agents, b blockers, and aspirin. Review articles of AMI in older persons call for enhancing or maintaining the functional capacity as well as preserving independence,15–17 yet there is a paucity of data documenting these outcomes. This study describes the hospital experience of persons $90 years of age with AMI.
From Sinai Samaritan Medical Center and St. Luke’s Medical Center, Milwaukee, Wisconsin. Dr. Malone’s address is: 1020 N. 12 Street, 3rd Floor, Milwaukee, Wisconsin 53233. Manuscript received July 28, 1997; revised manuscript received and accepted November 25, 1997.
A retrospective review was performed of patients aged $90 years who were discharged with the primary diagnosis of AMI (ICD-9 codes 410.0 through 410.9) from January 1, 1992, to December 31, 1994.
•••
638
©1998 by Excerpta Medica, Inc. All rights reserved.
0002-9149/98/$19.00 PII S0002-9149(97)00986-7
TABLE I Patient Characteristics Max. Length Admit Total Concurrent CHF Do Not Coronary Age Female Survived of Stay Prehospital to CK CK-MB on Rescusitate Thrombolytic Angiography Case (yr) Gender Hospitalization (d) Residence CCU (U/L)* (ng/ml)† Admit. Orders Agent Given Performed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
91 96 92 91 90 97 91 95 97 90 94 90 90 94 94 90 90 92 92 92 91 95 92 90 91 93 92 91 90 93 95 93 94 92 91 90 95 90 94 94
0 1 0 1 1 1 1 0 1 1 1 1 1 0 1 1 0 1 1 1 1 0 1 0 0 1 1 1 1 1 0 0 1 0 0 0 1 1 1 1
1 0 1 1 1 1 0 1 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 0 1 1 0 0
3 4 50 6 14 2 3 18 7 6 4 11 14 3 10 19 15 11 4 5 6 7 17 6 2 7 13 12 10 11 8 9 21 2 16 13 9 8 1 16
GH Home GH GH Home GH NH NH NH Home Home Home Home Home GH Home Home Home Home Home NH Home NH GH Home NH NH NH NH NH Home NH Home NH Home Home Home NH NH NH
0 1 1 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 1 1 0 0
343 842 458 775 283 327 3,929 323 2 604 214 207 597 4,158 3,211 425 493 301 519 685 1,153 32 2,590 2,397 622 761 3,399 618 26 2,337 547 1,026 590 1,298 731 — 2,939 20 492 152
24.2 78.5 1.6 6.2 12.9 31.9 337.8 16.0 2 44.8 16.5 10.4 29.0 300.0 31.1 21.2 15.8 10.5 18.0 20.8 146.0 6.6 116.4 207.5 23 5.3 20.2 99.7 3 217.8 82.7 72.2 21.2 118 23.8 — 264.6 2.1 73.2 14.8
1 0 1 1 1 0 0 1 1 0 0 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 1 1 1 0 1 1 1 1 0 0 1 1 1 1
1 2 0 0 1 1 0 2 1 1 0 0 2 2 1 2 1 1 1 1 1 0 0 0 2 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
*Normal 5 0 to 200 U/L. † Normal #5.0, borderline 5.1 to 10. Admit. 5 admittance; CHF 5 congestive heart failure; CK 5 creatine phosphokinase; CK-MB 5 creatine phosphokinase-muscle band; GH 5 group home; Max. 5 maximal; NH 5 nursing home.
The setting was 2 community teaching hospitals in Milwaukee, Wisconsin. Cases were excluded if (1) there was no mention of AMI in the discharge summary (n 5 26), (2) the chart was not available during the study period (n 5 1), and (3) the hospital stay was ,24 hours (n 5 3). Three trained abstractors collected data from each chart. Congestive heart failure was considered present if any one of rales, S3, or jugular venous distention were present, or if the radiologist’s interpretation of heart failure was noted in the admission chest x-ray report. We defined codes status as: full code, do not resuscitate, other or not recorded. Use of restraints was defined as any mention by nursing staff of wrist restraint, vest restraint, or mitten restraint. Orders for major tranquilizers included any order for thiorid-
azine, haloperidol, thorazine, thiothixene, or trifluoperazine. Orders for benzodiazepines included any order for lorazepam, alprezolam, buspirone, or oxazepam. Formal minimental status examination within 48 hours from admission was defined as any written mental status description .2 lines on the chart or having a numerical score recorded from a minimental status examination. Delirium was defined as any mention in the progress notes of delirium, lethargy, agitation, or disorientation. The database was entered into dBase III Plust (Ashton-Tate, Torrance, California) software program and transferred to Epi 5 for statistical analysis. Noncardiac complications in those with AMI were compared with a control group of 26 90-year-old patients with no mention of AMI in their discharge summary by using chi-square analysis. BRIEF REPORTS
639
TABLE II Complications of Acute Myocardial Infarction AMI (n 5 40)
Condition Hypotension in first 48 hours* Heart block in first 72 hours Cardiogenic shock Ventricular tachycardia Delirium, lethargy, agitation, disorientation mentioned in physician/nurse progress notes Other indirect indicators of delirium Restraints applied to patients‡ Orders for as-needed major tranquilizer Pulling on nasogastric or urine catheters Pressure ulcers Fever $101 after day 3 of hospitalization Positive blood culture Positive urine culture
11 7 1 5 11
No AMI (n 5 26)
(28%) 7 (18%)† 1 (3%) 2 (13%) 1 (28%) 10
p Value
(27%) (4%) (8%) (4%) (38%)
0.96 0.10 0.32 0.23 0.35
11 (28%) 8 (20%)
10 (38%) 7 (27%)
0.35 0.51
11 (28%)
6 (23%)
0.68
8 (21%) 4 (10%)
5 (19%) 4 (15%)
0.93 0.51
1 (3%) 2 (5%)
0 (0%) 3 (12%)
0.41 0.31
*Systolic blood pressure ,90 mm Hg as recorded in nursing vital signs. † One case of heart block required the use of a temporary pacemaker. All other cases of heart block were first-degree atrioventricular block. ‡ Mean duration of restraining 6.4 days.
an AMI was no different than the control group of 26 patients without AMI. The overall in-hospital death rate of patients $90 years of age with AMI was 25%. Seventy percent of those who were discharged alive went to a nursing home. The median length of stay for all patients was 8.5 days (25th intraquartile 4.5 days, 75th intraquartile 13.5 days). The average length of stay among patients who were physically restrained was longer than the stay among patients who were not restrained, although this difference was not statistically significant (13.9 vs 8.4 days, p 5 0.19). Similarly, patients who had progress notes indicating delirium did not spend a longer time in the hospital than those without delirium (12.6 vs 8.9 days, p 5 0.70). The median length of stay for those who died was 3.5 days (25th intraquartile 2 days, 75th intraquartile 6 days). Twenty percent of the patients who survived hospitalization were discharged with a chronic urinary catheter. None of the 40 patients had a urinary catheter before hospitalization. Three patients received a percutaneous gastrostomy tube during hospitalization, whereas another was discharged with a nasogastric tube. •••
•••
Table I describes the pertinent characteristics of the 40 patients. These 90-year-old patients often had the complication of delirium during their hospitalization. In 28% of the patients, delirium or agitation was directly mentioned in the physicians’ or nurses’ progress notes (Table II). Because delirium is often not appropriately diagnosed,18 –20 we looked for indirect indicators of delirium as well. We found frequent indirect indicators of delirium, such a restraint applied to patients (28%) and orders for use of ‘‘as-needed’’ major tranquilizers (20%). The average duration of physical restraint use was 6.4 days (mean 6 SD 4.8 days). A total of 50% of the patients had either delirium noted in the progress notes or received a physical restraint or an order for an as-needed major tranquilizer. On review of the hospital itemized billing data, we found that 7 of the 40 patients received haloperidol or another major tranquilizer during their stay. Of these, 6 patients received this medication as an asneeded order, whereas 1 patient was given haloperidol on a daily basis. Patients with AMI were no more likely to have experienced these noncardiac complications than a control group of 90-year-old patients without AMI (Table II). No patient was able to ambulate independently at the time of their discharge. Forty-seven percent of the survivors required minimal assistance for ambulation, 43% required moderate assistance, and 10% were bedridden. Thirty-eight percent of the patients had received physical therapy or therapeutic exercise during their hospital stay (mean number of visits 4.5, range 1 to 14). Twenty-one percent of the patients developed pressure ulcers during their hospitalization. The ambulatory status at discharge of those who had 640 THE AMERICAN JOURNAL OF CARDIOLOGYT
VOL. 81
In very old patients, the negative consequences of hospitalization, of bed rest, of being restrained or confused, and of existence in an intensive care unit may equal or exceed the negative consequences of the specific illness that precipitated the hospitalization. We would draw 2 general conclusions from this reasoning. First, any study of diagnostic or therapeutic modalities involving hospitalized elderly must evaluate the total spectrum of consequences of that modality, e.g., whether the use of a given monitoring device might indirectly lead to more frequent utilization of restraints. Second, new approaches must be developed for the care of the very old with an acute medical illness. There are no a priori reasons to assume that a model of acute care medicine that has evolved based largely on the care of younger patients would be appropriate for 90-year-old patients. What is the appropriate model? Would the very old patient with an AMI have better outcomes managed carefully with a physiatrist during hospitalization? Is the routine prescription of decreased physical activity after AMI a good idea (e.g., bed rest, or bed rest with bathroom privileges as occurred in 86% of these patients)? Given the exponential growth in the population of men and women aged $90 years, it is imperative that the special vulnerabilities of this population to adverse outcomes of hospitalization be addressed in studies designed to improve the experience of hospitalization of the very old. There were several limitations to this study that should be pointed out. First, it is a retrospective review of a relatively small number of patients. The nursing staff of these 2 hospitals had no instrument to document the functional status of these older patients before their AMI. The description of a poor ambulatory status at the end of the hospitalization does not MARCH 1, 1998
give us proof that a deterioration in status occurred during hospitalization. In conclusion, the in-hospital rate of common geriatric syndromes (delirium, pressure ulcers, and restraint use) was very high in this group of oldest patients with AMI. Attention to preventing the noncardiac problems that arise during hospitalization may be as important as attempts to prevent cardiac complications. Acknowledgment: We thank Lynda Czekay for her secretarial assistance in preparing this manuscript; Zehar Naqvi, MD, Mohammed Samara, MD, Kapil Davar, Mike Wenzel, and Anna Stefka for their assistance in chart abstraction, and Robert McNutt, MD, for his comments on the manuscript.
1. Gray D, Keating N, Skene AM, Hampton JR. Myocardial infarction in patients
over 75, 1982–1990. Quar J Med 1992;84:659 – 669. 2. Day JJ, Bayer AJ, Pathy MSJ. Acute myocardial infarction: diagnostic diffi-
culties and outcome in advanced old age. Age Ageing 1987;16:239 –243. 3. Teng JK, Lin LJ, Tsai LM, Kwan CM, Chen JH. Acute myocardial infarction in young and very old Chinese adults: clinical characteristics and therapeutic implications. Int J Cardiol 1994;44:29 –36. 4. Fleming C, D’Agostino RB, Selker HP. Is coronary-care-unit admission restricted for elderly patients? A multicenter study. Am J Public Health 1991; 81:1121–1126. 5. Malone ML, Sial SH, Battiola RJ, Nachodsky JP, Solomon DJ, Goodwin JS. Age-related differences in the utilization of therapies post acute myocardial infarction. J Am Geratr Soc 1995;43:627– 633. 6. Devlin W, Cragg D, Jacks M, Friedman H, O’Neill W, Grines C. Comparison of outcome in patients with acute myocardial infarction aged .75 years with that in younger patients. Am J Cardiol 1995;75:573–576.
7. Pashos CL, Newhouse JP, McNeil BJ. Temporal changes in the care and outcomes of elderly patients with acute myocardial infarction, 1987 through 1990. JAMA 1993;27:1832–1836. 8. Lew AS, Hod H, Cescek B, Shah PK, Ganz W. Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase. Am J Cardiol 1987;59:1–5. 9. Sagie A, Rotenberg Z, Weinberger I, Fuchs J, Agmon J. Acute transmural myocardial infarction in elderly patients hospitalized in the coronary care unit versus the general medical ward. J Am Geriatr Soc 1987;35:915–919. 10. Udvarhely IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the medicare population, process of care and clinical outcomes. JAMA 1992;268:2530 –2536. 11. Krumholz HM, Radford MJ, Ellerbeck EF, Hennen J, Meehan TP, Petrillo M, Wang Y, Jencks SF. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med 1996; 124:292–298. 12. The ISAM Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction—mortality, morbidity, and infarct size at 21 days. N Engl J Med 1986;314:1465–1471. 13. Greenland P, Reicher-Reiss H, Goldbourt U, Behar S, and the Israeli SPRINT Investigators. In-hospital and 1-year mortality in 1524 women after acute myocardial infarction. Comparison with 4315 men. Circulation 1991; 83:484 – 491. 14. The International Study Group. In hospital mortality and clinical course of 20891 patients with suspected acute myocardial infarction randomized between alteplase and streptokinase with or without heparin. Lancet 1990;336: 71–75. 15. Wenger NK. Coronary disease in elderly patients: myocardial infarction and myocardial revascularization. Heart Dis Stroke 1994;3:401– 406. 16. Yusuf S, Furberg CD. Are we biased in our approach to treating elderly patients with heart disease? Am J Cardiol 1991;68:954 –956. 17. Duncan AK, Vittone J, Felming KC, Smith HC. Cardiovascular disease in elderly patients. Mayo Clini Proc 1996;71:184 –196. 18. Bross MH, Tatum NO. Delirium in the elderly patient. Am Fam Physician 1994;50:1325–1332. 19. Weinrich S, Sarna L. Delirium in the older person with cancer. Cancer 1994;74(suppl 7):2079 –2091. 20. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278 –288.
Safety of Intracoronary Ultrasound Imaging in Patients With Acute Myocardial Infarction Wolfgang Bocksch, MD, Michael Schartl, MD, Stephan Beckmann, Stefan Dreysse, MD, and Eckart Fleck, MD ultrasound (ICUS) is an invasive technique to get high-resolution cross-sectional images Iof ntracoronary normal and diseased coronary arteries in vivo. 1
Until now, it has been applied to patients undergoing elective diagnostic coronary angiography or transcatheter therapy.2,3 The reported incidence of serious complication is low in experienced hands of single centers as well as in retrospective multicenter series.2,3 In smaller, selected patient series, ICUS was performed in order to analyze plaque morphology and angioplasty mechanisms in patients with unstable angina and acute myocardial infarction (AMI).4 The following single-center study was performed to analyze the From the Cardiac Catheterization Laboratory, Division of Cardiology, Virchow Klinikum and German Heart Institute Berlin, Humboldt Universitaet Berlin, Berlin, Germany. Dr. Bocksch’s address is: Cardiac Catheterization Laboratory, Division of Cardiology, Virchow Klinikum and German Heart Institute Berlin, Humboldt Universitaet Berlin, Augustenburger Platzl, 13 353 Berlin, Germany. Manuscript received July 22, 1997; revised manuscript received and accepted November 25, 1997. ©1998 by Excerpta Medica, Inc. All rights reserved.
MD,
safety and time consumption of additional ICUS imaging in 103 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) for AMI. •••
One hundred three selected patients with AMI underwent coronary angiography and subsequent PTCA of the infarct artery within 12 hours after the onset of chest pain. All of these patients, who gave informed consent for emergency transcatheter therapy including intravascular ultrasound, had an occlusion or a highgrade stenosis in the proximal or midsegments of the infarct artery, with a proximal reference diameter of .2.5 mm (left anterior descending coronary artery, 52 patients; left circumflex coronary artery, 10 patients right coronary artery, 41 patients). Exclusion criteria for ICUS were cardiogenic shock, significant left main disease, diffuse 3-vessel disease, extreme tortuous coronary anatomy, reinfarction, acute graft closure, acute closure after PTCA, or stenting. After diagnostic coronary angiography, ICUS was performed before and after PTCA using a 3.5Fr mechanical ultrasound 0002-9149/98/$19.00 PII 0002-9149(97)00989-2
641
2. Fitzgibbon GM, Leach AJ, Kafka JP, Keon WJ. Coronary bypass graft fate: long-term angiographic study. J Am Coll Cardiol 1991;17:1075–1080. 3. Sergeant PT, Blackstone EH, Lasaffre E, Flameng W, Kirklin JW. Incremental risks for reintervention after the CABG operation. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac Surgery. 2nd ed. New York: Churchill-Livingstone, 1993:335– 336. 4. Foster E, Fisher L, Kaiser G, Myers W. Comparison of operative mortality and morbidity for initial and repeat coronary bypass grafting: the Coronary Artery Surgery Study (CASS) Registry experience. Ann Thorac Surg 1993; 38:563–570. 5. Cooley DA, Frazier OH, Kadipasaoglu KA, Lindenmeir MH, Pehlivanglu S, Kolff JW, Wilansky S, Moore WH. Transmyocardial laser revascularization: clinical experience with twelve month follow-up. J Thorac Cardiovasc Surg 1996;111:791–799. 6. Kriett JM, Kaye MP. The registry of the International Society for Heart Transplantation: seventh annual report–1990. J Heart Transplant 1990; 9:323–350. 7. Hartmann JR, McKeever LS, Stamato NJ, Bufalino VJ, Marek JC, Brown AS, Goodwin MJ, Cahill JM, Enger EL. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts by extended infusion of urokinase: initial results and short-term clinical follow-up. J Am Coll Cardiol 1991;18:1517– 1523. 8. Hartmann JR, McKeever LS, O’Neill WW, White CJ, Whitlow PL, Gilmore PS, Doorey AJ, Galichia JP, Enger EL. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts with long-term, low dose direct infusion of urokinase (ROBUST): a serial trial. J Am Coll Cardiol 1996;27:60 – 66. 9. Taylor MA, Santoian EC, Aji J, Eldredge J, Cha SD, Dennis CA. Intracerebral hemorrage complicating urokinase infusion into an occluded aortocoronary bypass graft. Cathet Cardiovasc Diagn 1994;31:206 –210. 10. Sullebarger JT, Puleo J. Extraction atherectomy for the recanalization of totally occluded aortocoronary saphenous vein grafts. Cathet Cardiovasc Diagn 1995;36:399 –343. 11. DeFeyter PJ, Serruys P, Van den Brand M, Meester H, Beatt K, Suryapranata H. Percutaneous transluminal angioplasty of a totally occluded venous bypass graft: a challenge that should be resisted. Am J Cardiol 1989;64:88 – 90. 12. Safian RD, Grines CL, May MA, Lichtenberg A, Juran N, Schreiber TL, Pavlides G, Meany TB, Savas V, O’Neill WW. Clinical and angiographic results of transluminal extraction coronary atherectomy in saphenous vein bypass grafts. Circulation 1994;89:302–312. 13. Kaplan BM, Safian RD, Grines CL, Goldstein JA, Mersalese DL, Ajluni S, O’Neill WW. Usefulness of adjunctive angioscopy and extraction atherectomy before stent implantation in high-risk aortocoronary saphenous vein grafts. Am J Cardiol 1995;76:822– 824. 14. Lytle B, Loop F, Cosgrove D. Fifteen hundred coronary reoperations: results and determinants of early and late survival. J Thorac Cardiovasc Surg 1987;93: 847– 859. 15. Popma JJ, Leon MB, Mintz GS, Kent KM, Satler LF, Garrand TJ, Pichard AD. Results of coronary angioplasty using the transluminal extraction catheter. Am J Cardiol 1992;70:1526 –1532.
Complications of Acute Myocardial Infarction in Patients >90 Years of Age Michael L. Malone,
MD,
Leon B. Rosen,
ospitalization for acute myocardial infarction (AMI) in the 90-year old encompasses a range H of negative experiences and outcomes that are gen-
MD,
and James S. Goodwin,
MD
erally not considered or well documented when one is describing the consequences of an AMI. Indeed, in a review of 14 recent studies1–14 of the clinical course and outcomes of AMI in older persons, we could find no mention of in-hospital delirium as well as no mention of the use of restraints. Major
efforts in recent years have focused on decreasing mortality in older persons by use of thrombolytic agents, b blockers, and aspirin. Review articles of AMI in older persons call for enhancing or maintaining the functional capacity as well as preserving independence,15–17 yet there is a paucity of data documenting these outcomes. This study describes the hospital experience of persons $90 years of age with AMI.
From Sinai Samaritan Medical Center and St. Luke’s Medical Center, Milwaukee, Wisconsin. Dr. Malone’s address is: 1020 N. 12 Street, 3rd Floor, Milwaukee, Wisconsin 53233. Manuscript received July 28, 1997; revised manuscript received and accepted November 25, 1997.
A retrospective review was performed of patients aged $90 years who were discharged with the primary diagnosis of AMI (ICD-9 codes 410.0 through 410.9) from January 1, 1992, to December 31, 1994.
•••
638
©1998 by Excerpta Medica, Inc. All rights reserved.
0002-9149/98/$19.00 PII S0002-9149(97)00986-7
TABLE I Patient Characteristics Max. Length Admit Total Concurrent CHF Do Not Coronary Age Female Survived of Stay Prehospital to CK CK-MB on Rescusitate Thrombolytic Angiography Case (yr) Gender Hospitalization (d) Residence CCU (U/L)* (ng/ml)† Admit. Orders Agent Given Performed 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
91 96 92 91 90 97 91 95 97 90 94 90 90 94 94 90 90 92 92 92 91 95 92 90 91 93 92 91 90 93 95 93 94 92 91 90 95 90 94 94
0 1 0 1 1 1 1 0 1 1 1 1 1 0 1 1 0 1 1 1 1 0 1 0 0 1 1 1 1 1 0 0 1 0 0 0 1 1 1 1
1 0 1 1 1 1 0 1 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 0 1 1 0 0
3 4 50 6 14 2 3 18 7 6 4 11 14 3 10 19 15 11 4 5 6 7 17 6 2 7 13 12 10 11 8 9 21 2 16 13 9 8 1 16
GH Home GH GH Home GH NH NH NH Home Home Home Home Home GH Home Home Home Home Home NH Home NH GH Home NH NH NH NH NH Home NH Home NH Home Home Home NH NH NH
0 1 1 0 0 1 1 0 0 1 0 0 0 1 0 0 0 0 0 0 1 0 1 1 1 0 0 1 1 0 1 0 0 0 0 0 1 1 0 0
343 842 458 775 283 327 3,929 323 2 604 214 207 597 4,158 3,211 425 493 301 519 685 1,153 32 2,590 2,397 622 761 3,399 618 26 2,337 547 1,026 590 1,298 731 — 2,939 20 492 152
24.2 78.5 1.6 6.2 12.9 31.9 337.8 16.0 2 44.8 16.5 10.4 29.0 300.0 31.1 21.2 15.8 10.5 18.0 20.8 146.0 6.6 116.4 207.5 23 5.3 20.2 99.7 3 217.8 82.7 72.2 21.2 118 23.8 — 264.6 2.1 73.2 14.8
1 0 1 1 1 0 0 1 1 0 0 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 1 1 1 0 1 1 1 1 0 0 1 1 1 1
1 2 0 0 1 1 0 2 1 1 0 0 2 2 1 2 1 1 1 1 1 0 0 0 2 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
*Normal 5 0 to 200 U/L. † Normal #5.0, borderline 5.1 to 10. Admit. 5 admittance; CHF 5 congestive heart failure; CK 5 creatine phosphokinase; CK-MB 5 creatine phosphokinase-muscle band; GH 5 group home; Max. 5 maximal; NH 5 nursing home.
The setting was 2 community teaching hospitals in Milwaukee, Wisconsin. Cases were excluded if (1) there was no mention of AMI in the discharge summary (n 5 26), (2) the chart was not available during the study period (n 5 1), and (3) the hospital stay was ,24 hours (n 5 3). Three trained abstractors collected data from each chart. Congestive heart failure was considered present if any one of rales, S3, or jugular venous distention were present, or if the radiologist’s interpretation of heart failure was noted in the admission chest x-ray report. We defined codes status as: full code, do not resuscitate, other or not recorded. Use of restraints was defined as any mention by nursing staff of wrist restraint, vest restraint, or mitten restraint. Orders for major tranquilizers included any order for thiorid-
azine, haloperidol, thorazine, thiothixene, or trifluoperazine. Orders for benzodiazepines included any order for lorazepam, alprezolam, buspirone, or oxazepam. Formal minimental status examination within 48 hours from admission was defined as any written mental status description .2 lines on the chart or having a numerical score recorded from a minimental status examination. Delirium was defined as any mention in the progress notes of delirium, lethargy, agitation, or disorientation. The database was entered into dBase III Plust (Ashton-Tate, Torrance, California) software program and transferred to Epi 5 for statistical analysis. Noncardiac complications in those with AMI were compared with a control group of 26 90-year-old patients with no mention of AMI in their discharge summary by using chi-square analysis. BRIEF REPORTS
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TABLE II Complications of Acute Myocardial Infarction AMI (n 5 40)
Condition Hypotension in first 48 hours* Heart block in first 72 hours Cardiogenic shock Ventricular tachycardia Delirium, lethargy, agitation, disorientation mentioned in physician/nurse progress notes Other indirect indicators of delirium Restraints applied to patients‡ Orders for as-needed major tranquilizer Pulling on nasogastric or urine catheters Pressure ulcers Fever $101 after day 3 of hospitalization Positive blood culture Positive urine culture
11 7 1 5 11
No AMI (n 5 26)
(28%) 7 (18%)† 1 (3%) 2 (13%) 1 (28%) 10
p Value
(27%) (4%) (8%) (4%) (38%)
0.96 0.10 0.32 0.23 0.35
11 (28%) 8 (20%)
10 (38%) 7 (27%)
0.35 0.51
11 (28%)
6 (23%)
0.68
8 (21%) 4 (10%)
5 (19%) 4 (15%)
0.93 0.51
1 (3%) 2 (5%)
0 (0%) 3 (12%)
0.41 0.31
*Systolic blood pressure ,90 mm Hg as recorded in nursing vital signs. † One case of heart block required the use of a temporary pacemaker. All other cases of heart block were first-degree atrioventricular block. ‡ Mean duration of restraining 6.4 days.
an AMI was no different than the control group of 26 patients without AMI. The overall in-hospital death rate of patients $90 years of age with AMI was 25%. Seventy percent of those who were discharged alive went to a nursing home. The median length of stay for all patients was 8.5 days (25th intraquartile 4.5 days, 75th intraquartile 13.5 days). The average length of stay among patients who were physically restrained was longer than the stay among patients who were not restrained, although this difference was not statistically significant (13.9 vs 8.4 days, p 5 0.19). Similarly, patients who had progress notes indicating delirium did not spend a longer time in the hospital than those without delirium (12.6 vs 8.9 days, p 5 0.70). The median length of stay for those who died was 3.5 days (25th intraquartile 2 days, 75th intraquartile 6 days). Twenty percent of the patients who survived hospitalization were discharged with a chronic urinary catheter. None of the 40 patients had a urinary catheter before hospitalization. Three patients received a percutaneous gastrostomy tube during hospitalization, whereas another was discharged with a nasogastric tube. •••
•••
Table I describes the pertinent characteristics of the 40 patients. These 90-year-old patients often had the complication of delirium during their hospitalization. In 28% of the patients, delirium or agitation was directly mentioned in the physicians’ or nurses’ progress notes (Table II). Because delirium is often not appropriately diagnosed,18 –20 we looked for indirect indicators of delirium as well. We found frequent indirect indicators of delirium, such a restraint applied to patients (28%) and orders for use of ‘‘as-needed’’ major tranquilizers (20%). The average duration of physical restraint use was 6.4 days (mean 6 SD 4.8 days). A total of 50% of the patients had either delirium noted in the progress notes or received a physical restraint or an order for an as-needed major tranquilizer. On review of the hospital itemized billing data, we found that 7 of the 40 patients received haloperidol or another major tranquilizer during their stay. Of these, 6 patients received this medication as an asneeded order, whereas 1 patient was given haloperidol on a daily basis. Patients with AMI were no more likely to have experienced these noncardiac complications than a control group of 90-year-old patients without AMI (Table II). No patient was able to ambulate independently at the time of their discharge. Forty-seven percent of the survivors required minimal assistance for ambulation, 43% required moderate assistance, and 10% were bedridden. Thirty-eight percent of the patients had received physical therapy or therapeutic exercise during their hospital stay (mean number of visits 4.5, range 1 to 14). Twenty-one percent of the patients developed pressure ulcers during their hospitalization. The ambulatory status at discharge of those who had 640 THE AMERICAN JOURNAL OF CARDIOLOGYT
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In very old patients, the negative consequences of hospitalization, of bed rest, of being restrained or confused, and of existence in an intensive care unit may equal or exceed the negative consequences of the specific illness that precipitated the hospitalization. We would draw 2 general conclusions from this reasoning. First, any study of diagnostic or therapeutic modalities involving hospitalized elderly must evaluate the total spectrum of consequences of that modality, e.g., whether the use of a given monitoring device might indirectly lead to more frequent utilization of restraints. Second, new approaches must be developed for the care of the very old with an acute medical illness. There are no a priori reasons to assume that a model of acute care medicine that has evolved based largely on the care of younger patients would be appropriate for 90-year-old patients. What is the appropriate model? Would the very old patient with an AMI have better outcomes managed carefully with a physiatrist during hospitalization? Is the routine prescription of decreased physical activity after AMI a good idea (e.g., bed rest, or bed rest with bathroom privileges as occurred in 86% of these patients)? Given the exponential growth in the population of men and women aged $90 years, it is imperative that the special vulnerabilities of this population to adverse outcomes of hospitalization be addressed in studies designed to improve the experience of hospitalization of the very old. There were several limitations to this study that should be pointed out. First, it is a retrospective review of a relatively small number of patients. The nursing staff of these 2 hospitals had no instrument to document the functional status of these older patients before their AMI. The description of a poor ambulatory status at the end of the hospitalization does not MARCH 1, 1998
give us proof that a deterioration in status occurred during hospitalization. In conclusion, the in-hospital rate of common geriatric syndromes (delirium, pressure ulcers, and restraint use) was very high in this group of oldest patients with AMI. Attention to preventing the noncardiac problems that arise during hospitalization may be as important as attempts to prevent cardiac complications. Acknowledgment: We thank Lynda Czekay for her secretarial assistance in preparing this manuscript; Zehar Naqvi, MD, Mohammed Samara, MD, Kapil Davar, Mike Wenzel, and Anna Stefka for their assistance in chart abstraction, and Robert McNutt, MD, for his comments on the manuscript.
1. Gray D, Keating N, Skene AM, Hampton JR. Myocardial infarction in patients
over 75, 1982–1990. Quar J Med 1992;84:659 – 669. 2. Day JJ, Bayer AJ, Pathy MSJ. Acute myocardial infarction: diagnostic diffi-
culties and outcome in advanced old age. Age Ageing 1987;16:239 –243. 3. Teng JK, Lin LJ, Tsai LM, Kwan CM, Chen JH. Acute myocardial infarction in young and very old Chinese adults: clinical characteristics and therapeutic implications. Int J Cardiol 1994;44:29 –36. 4. Fleming C, D’Agostino RB, Selker HP. Is coronary-care-unit admission restricted for elderly patients? A multicenter study. Am J Public Health 1991; 81:1121–1126. 5. Malone ML, Sial SH, Battiola RJ, Nachodsky JP, Solomon DJ, Goodwin JS. Age-related differences in the utilization of therapies post acute myocardial infarction. J Am Geratr Soc 1995;43:627– 633. 6. Devlin W, Cragg D, Jacks M, Friedman H, O’Neill W, Grines C. Comparison of outcome in patients with acute myocardial infarction aged .75 years with that in younger patients. Am J Cardiol 1995;75:573–576.
7. Pashos CL, Newhouse JP, McNeil BJ. Temporal changes in the care and outcomes of elderly patients with acute myocardial infarction, 1987 through 1990. JAMA 1993;27:1832–1836. 8. Lew AS, Hod H, Cescek B, Shah PK, Ganz W. Mortality and morbidity rates of patients older and younger than 75 years with acute myocardial infarction treated with intravenous streptokinase. Am J Cardiol 1987;59:1–5. 9. Sagie A, Rotenberg Z, Weinberger I, Fuchs J, Agmon J. Acute transmural myocardial infarction in elderly patients hospitalized in the coronary care unit versus the general medical ward. J Am Geriatr Soc 1987;35:915–919. 10. Udvarhely IS, Gatsonis C, Epstein AM, Pashos CL, Newhouse JP, McNeil BJ. Acute myocardial infarction in the medicare population, process of care and clinical outcomes. JAMA 1992;268:2530 –2536. 11. Krumholz HM, Radford MJ, Ellerbeck EF, Hennen J, Meehan TP, Petrillo M, Wang Y, Jencks SF. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med 1996; 124:292–298. 12. The ISAM Study Group. A prospective trial of intravenous streptokinase in acute myocardial infarction—mortality, morbidity, and infarct size at 21 days. N Engl J Med 1986;314:1465–1471. 13. Greenland P, Reicher-Reiss H, Goldbourt U, Behar S, and the Israeli SPRINT Investigators. In-hospital and 1-year mortality in 1524 women after acute myocardial infarction. Comparison with 4315 men. Circulation 1991; 83:484 – 491. 14. The International Study Group. In hospital mortality and clinical course of 20891 patients with suspected acute myocardial infarction randomized between alteplase and streptokinase with or without heparin. Lancet 1990;336: 71–75. 15. Wenger NK. Coronary disease in elderly patients: myocardial infarction and myocardial revascularization. Heart Dis Stroke 1994;3:401– 406. 16. Yusuf S, Furberg CD. Are we biased in our approach to treating elderly patients with heart disease? Am J Cardiol 1991;68:954 –956. 17. Duncan AK, Vittone J, Felming KC, Smith HC. Cardiovascular disease in elderly patients. Mayo Clini Proc 1996;71:184 –196. 18. Bross MH, Tatum NO. Delirium in the elderly patient. Am Fam Physician 1994;50:1325–1332. 19. Weinrich S, Sarna L. Delirium in the older person with cancer. Cancer 1994;74(suppl 7):2079 –2091. 20. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278 –288.
Safety of Intracoronary Ultrasound Imaging in Patients With Acute Myocardial Infarction Wolfgang Bocksch, MD, Michael Schartl, MD, Stephan Beckmann, Stefan Dreysse, MD, and Eckart Fleck, MD ultrasound (ICUS) is an invasive technique to get high-resolution cross-sectional images Iof ntracoronary normal and diseased coronary arteries in vivo. 1
Until now, it has been applied to patients undergoing elective diagnostic coronary angiography or transcatheter therapy.2,3 The reported incidence of serious complication is low in experienced hands of single centers as well as in retrospective multicenter series.2,3 In smaller, selected patient series, ICUS was performed in order to analyze plaque morphology and angioplasty mechanisms in patients with unstable angina and acute myocardial infarction (AMI).4 The following single-center study was performed to analyze the From the Cardiac Catheterization Laboratory, Division of Cardiology, Virchow Klinikum and German Heart Institute Berlin, Humboldt Universitaet Berlin, Berlin, Germany. Dr. Bocksch’s address is: Cardiac Catheterization Laboratory, Division of Cardiology, Virchow Klinikum and German Heart Institute Berlin, Humboldt Universitaet Berlin, Augustenburger Platzl, 13 353 Berlin, Germany. Manuscript received July 22, 1997; revised manuscript received and accepted November 25, 1997. ©1998 by Excerpta Medica, Inc. All rights reserved.
MD,
safety and time consumption of additional ICUS imaging in 103 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) for AMI. •••
One hundred three selected patients with AMI underwent coronary angiography and subsequent PTCA of the infarct artery within 12 hours after the onset of chest pain. All of these patients, who gave informed consent for emergency transcatheter therapy including intravascular ultrasound, had an occlusion or a highgrade stenosis in the proximal or midsegments of the infarct artery, with a proximal reference diameter of .2.5 mm (left anterior descending coronary artery, 52 patients; left circumflex coronary artery, 10 patients right coronary artery, 41 patients). Exclusion criteria for ICUS were cardiogenic shock, significant left main disease, diffuse 3-vessel disease, extreme tortuous coronary anatomy, reinfarction, acute graft closure, acute closure after PTCA, or stenting. After diagnostic coronary angiography, ICUS was performed before and after PTCA using a 3.5Fr mechanical ultrasound 0002-9149/98/$19.00 PII 0002-9149(97)00989-2
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