- Email: [email protected]
The role of angioplasty in octogenarian patients with Acute Coronary Syndrome
International Journal of Cardiology 202 (2016) 430–432
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
The role of angioplasty in octogenarian patients with Acute Coronary Syndrome Rahul Potluri a,⁎, Jennifer Reynolds b, Paul Carter c, Mudassar Baig d, Amir Aziz e, Siri Potluri f, Noman Ali g, Hardeep Uppal a, Suresh Chandran h a
ACALM Study Unit in collaboration with Aston Medical School, School of Medical Sciences, Aston University, Birmingham, UK Birmingham Medical School, Birmingham, UK Royal Free London NHS Trust, London, UK d Department of Cardiology, Manchester Royal Infirmary, Manchester, UK e Division of Cardiology, University of Birmingham, Birmingham, UK f School of Medicine, Cardiff University, Cardiff, UK g Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK h Department of Acute Medicine, North Western Deanery, Manchester, UK b c
a r t i c l e
i n f o
Article history: Received 31 August 2015 Accepted 21 September 2015 Available online 25 September 2015 Keywords: Angioplasty Acute Coronary Syndrome Mortality Octogenarians
Dear Editor, The introduction of Percutaneous Coronary Intervention (PCI), commonly referred to as angioplasty, has drastically improved outcomes for patients with Acute Coronary Syndrome (ACS) [1–4]. However, in certain groups of patients with ACS uncertainty remains regarding the long-term benefits versus hazards of angioplasty [1,5–7]. There is no clear consensus on the use of angioplasty in patients over the age of 80 years. In some pockets of evidence, angioplasty has been shown to be beneficial in older individuals with acute myocardial infarction [8], and, data from USA describes procedural success of over 90% in patients aged 90 + and a similar mortality rate for age-matched controls [9]. One school of thought suggests that despite overall increased hospital mortality compared to younger patients, the elderly may benefit more when treated with angioplasty [10]. Other clinicians believe this ⁎ Corresponding author at: Aston Medical School, Aston University, Birmingham B4 7ET, UK. E-mail address: [email protected] (R. Potluri).
http://dx.doi.org/10.1016/j.ijcard.2015.09.080 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
aggressive approach in the elderly is dangerous [11]. Driving the lack of evidence is the fact that clinical trials are seldom performed in patients of this age group [11,12]. Furthermore, there is substantial comorbidity in these patients, making the decision to treat with angioplasty difficult [11]. This is particularly worrying as Ischemic Heart Disease is the most common worldwide cause of death in patients greater than 65 years old and in the western world there is an ageing population with a continually growing number of patients with heart disease [11,13]. Clear consensus on the benefits and risks of angioplasty in UK patients with ACS over the age of 80 is required. In this study, we aimed to evaluate the impact of angioplasty on allcause mortality in patients aged 80 or over presenting with ACS in North West England, UK from 2000–2012. We examined mortality in patients ≥80 suffering from ACS, who did and did not undergo angioplasty, using completely anonymous data of adult patients admitted across three multi-ethnic general hospitals in the North West England between 2000 and 2012. We used the ACALM (Algorithm of Comorbidities, Associations, Length of Stay and Mortality) study protocol [14–27]. The ACALM protocol uses ICD-10 diagnosis and OPCS-4 procedure codes to trace patients. All patients aged ≥80 diagnosed with ACS by senior clinicians and consecutively admitted for hospital treatment during the study period were included (n = 1536). All ICD-10 codes that covered the spectrum of ACS such as Myocardial Infarction and Unstable Angina, but not stable angina, were included. Whether patients were treated with angioplasty was traced by OPCS-4 codes for angioplasty procedures (codes K491–K494, K498–K501, K751–K754 and K758). Vital status (alive or decreased) at the end of the study period (30th June 2012) was determined by record linkage to the NHS strategic tracing service. All-cause mortality was determined from the vital status on 30th June 2012 with follow-up beginning on the date of index admission. Multivariate logistic regression accounted for variations in age, gender, ethnicity and identified comorbidities which impacted on mortality. The comorbidities analysed were those which most influence the decision to evaluate if a patient is fit for angioplasty and those which impact mortality (see results) and these were all traced by ICD-10 codes. Data analysis was performed using SPSS version 20.0
Correspondence
431
(SPSS Inc. Chicago, IL) and all p-values were calculated as two-tailed analyses; p b 0.05 was taken as significant. Of 12,227 patients with ACS there were 1536 (12.6%) patients aged ≥80. Of these, 111 (7.2%) patients underwent angioplasty. Full basic demographics of ACS patients aged ≥80 years are shown in Table 1. Mean age was not different between +/−angioplasty. Although patients who did not undergo angioplasty had higher prevalence of various comorbidities (Table 1) only previous ACS, comorbid hypertension and AF were statistically significant (p b 0.05). Multivariate logistic regression analysis accounting for variations in age, gender, ethnic group and co-morbidities revealed Chronic Kidney Disease Stage 3 (Relative Risk (RR) 2.26; 95% Confidence Interval (CI) 1.23–4.15), Heart Failure (RR 2.39; 95% CI 1.67–3.43), Ischaemic Stroke (RR 5.70; 95% CI 2.35–13.84), Atrial Fibrillation (RR 1.51; 95% CI 1.07– 2.13) as significant predictors of worsened all-cause mortality in this patient group. Angioplasty (RR 4.29; 95% CI 2.73–6.76) and previous ACS (RR 1.86; 95% CI 1.35–2.56) conferred improved all–cause mortality in this patient group. Fig. 1 shows the 1-year and 5-year survival curves +/−angioplasty in these ACS patients aged ≥80. Patients treated with angioplasty have better survival than the group without angioplasty. 76.6% of patients who were treated with angioplasty were still alive by the end of the study period compared to 43.2% of patients who were not treated with angioplasty in this group (Table 1). The mean survival in the patients with angioplasty was lower than those without angioplasty (1217 days vs 1423 days). The length of stay for patients who underwent angioplasty was significantly lower compared to patients who did not have angioplasty (7.81 days vs 9.08 days; Table 1). The results of our study suggest that angioplasty confers a four-fold improvement in all-cause mortality following ACS in patients aged 80 or over. Some pockets of evidence suggest angioplasty is associated with improved outcomes in this age group [8,11,12,28,29], but we are the first group in the UK to show this real life impact of angioplasty on allcause mortality. It could be argued that patients who undergo angioplasty are healthier and therefore pre-selected to have improved mortality anyway [10–13]. It is therefore notable that although there was a trend for reduced comorbidities in the angioplasty group in our study, only Atrial Table 1 Characteristics of patients aged 80 years or more with Acute Coronary Syndrome.
Total sample (n) Mean age (years) Male Female Caucasian South Asian Afro-Caribbean Other Heart failure Chronic kidney disease (total) Chronic kidney disease stage 3 Chronic kidney disease stage 4 Chronic kidney disease stage 5 Ischaemic stroke Previous ACS Peripheral vascular disease Carotid artery disease Anaemia Atrial fibrillation Haemorrhagic stroke Hypertension Type 2 diabetes mellitus Hyperlipidaemia Mean length of stay (days) Alive Deceased Mean survival (days) ⁎ Denotes statistical significance, p b 0.05.
Angioplasty
No angioplasty
111 (7.2) 83.9 61 (55) 50 (45) 90 (81.1) 3 (2.7) 0 (0.0) 18 (16.2) 22 (19.8) 4 (3.6) 3 (2.7) 1 (0.9) 0 (0.0) 1 (0.9) 27 (24.3) 4 (3.6) 9 (8.1) 5 (4.5) 17 (15.3) 0 (0.0) 49 (44.1) 20 (18.0) 31 (27.9)⁎ 7.81 85 (76.6) 26 (23.4) 1217
1425 (92.8) 85.1 677 (47.5)⁎ 748 (52.5)⁎ 1211 (85.0)⁎ 26 (1.8) 18 (1.3) 170 (11.9)⁎ 302 (21.2) 107 (7.5) 85 (5.9) 15 (1.1) 7 (0.5) 66 (4.6) 1002 (70.3)⁎ 63 (4.4) 8 (0.6) 125 (8.8) 288 (20.2)⁎ 4 (0.3) 731 (51.3)⁎ 219 (15.4) 205 (14.4) 9.08⁎ 616 (43.2)⁎ 809 (56.8)⁎ 1423⁎
Fig. 1. a shows the 1-year survival in Acute Coronary Syndrome patients aged 80 or over managed +/−angioplasty. As clearly evident, the angioplasty group have significantly improved survival. b shows the 5-year survival in Acute Coronary Syndrome patients aged 80 or over managed +/−angioplasty. As clearly evident, the angioplasty group have significantly improved survival.
Fibrillation, hypertension and previous ACS were statistically significant. Other comorbidities which confer higher mortality risk such as heart failure and chronic kidney disease were not significant. As we analysed the most clinically relevant co-morbidities that influence the decision to send a patient for angioplasty our study offers justified and fairly robust evidence about the role of angioplasty in the management of these patients. The shorter survival time we have demonstrated in patients who have had angioplasty, compared to those who did not, probably reflects the fact that these patients were treated with angioplasty later than those treated medically and therefore have shorter follow-up period by the censoring date of 30th June 2012. This may reflect increased use of angioplasty in this group of patients more recently and the fact that PCI techniques have improved [9,28,29]. We have shown that angioplasty confers improved all-cause mortality in the management of ACS in patients aged ≥80 years whilst accounting for differences in co-morbidities. Caution should be exercised when
432
Correspondence
applying these findings to guide clinical practice in patients and further extension of this study to other centres and in a prospective randomised controlled study would be of clinical relevance and importance. Nevertheless, the findings of this study highlight the need for clinicians to conscientiously think about the individual benefits and risks of angioplasty for every patient. In view of the lack of clinical trials in patients of these age groups, studies such as this one should be the cornerstone of any clinical guidelines. Contributorship RP performed the literature search, acquired and processed the data, performed the analysis, drafted the manuscript and is a guarantor. HU acquired and processed the data, performed the analysis, provided critical appraisal of the manuscript and is a guarantor. MB, AA, PC, JR, SP and SC assisted in the literature search, data analysis, and critical revision of manuscript. All authors approved the final, submitting version of the manuscript. Conflict of interest statement No authors have any conflict of interest to declare. No competing interests by any of the authors. Funding No specific funding was received in relation to this article. Acknowledgments We would like to thank those who have indirectly helped in this research. References [1] K.A. Fox, T.C. Clayton, P. Damman, et al., Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data, J. Am. Coll. Cardiol. 55 (2010) 2435–2445. [2] P.A. McCullough, W.W. O'Neill, M. Graham, et al., A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial, J. Am. Coll. Cardiol. 32 (1998) 596–605. [3] W.E. Boden, R.A. O'Rourke, M.H. Crawford, et al., Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affair Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators, N. Engl. J. Med. 338 (1998) 1785–1792. [4] C.P. Cannon, W.S. Weintraub, L.A. Demopoulos, et al., TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy) — thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban, N. Engl. J. Med. 344 (2001) 1879–1887. [5] J.P. Bassand, C.W. Hamm, D. Ardissino, et al., Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes, Eur. Heart J. 28 (2007) 1598–1660.
[6] A.A. Bavry, D.J. Kumbhani, A.N. Rassi, et al., Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials, J. Am. Coll. Cardiol. 48 (2006) 1319–1325. [7] R. Qayyum, M.R. Khalid, J. Adomaityte, et al., Systematic review: comparing routine and selective invasive strategies for the acute coronary syndrome, Ann. Intern. Med. 148 (2008) 186–196. [8] M.J. de Boer, J.P. Ottervanger, A.W. van't Hof, et al., Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy, J. Am. Coll. Cardiol. 39 (2002) 1723–1728. [9] A.M. From, C.S. Rihal, R.J. Lennon, et al., Temporal trends and improved outcomes of percutaneous coronary revascularization in nonagenarians, JACC Cardiovasc. Interv. 1 (2008) 692–698. [10] A.H. Skolnick, K.P. Alexander, A.Y. Chen, et al., Characteristics, management, and outcomes of 5557 patients age N or =90 years with acute coronary syndromes: results from the CRUSADE initiative, J. Am. Coll. Cardiol. 49 (2007) 1790–1797. [11] D. Ferrera, A. Shroff, Percutaneous coronary intervention in the very elderly: do nonagenarians have the most to gain or the most to lose? J. Invasive Cardiol. 23 (2011) 12. [12] T.Y. Wang, A. Gutierrez, E.D. Peterson, Percutaneous coronary intervention in the elderly, Nat. Rev. Cardiol. 8 (2011) 79–90. [13] K.P. Alexander, L.K. Newby, C.P. Cannon, et al., Acute coronary care in the elderly, part I: non-ST segment elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology, Circulation 115 (2007) 2549–2569. [14] P. Carter, G. Rai, A. Aziz, et al., Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK, Int. J. Cardiol. 173 (2014) 573–574. [15] P. Carter, J. Mann, J. Sangha, et al., The burden of cardiovascular disease amongst psychiatric patients, Int. J. Cardiol. 169 (2013) 65–66. [16] S. Shan, O. McConnell, J. Khan, et al., The impact of ethnicity on the prevalence and length of hospital stay in patients with mitral regurgitation, Int. J. Cardiol. 195 (2015) 15–16. [17] R. Gorantla, M. Nimmagadda, S. Potluri, et al., Ethnic variations in length of hospital stay in patients with atrial fibrillation, Int. J. Cardiol. 187 (2015) 542–544. [18] N. Khouw, M. Wasim, A. Aziz, et al., Length of hospital stay is shorter in South Asian patients with myocardial infarction, Int. J. Cardiol. 171 (2014) 54–55. [19] R. Potluri, M. Wasim, B. Markandey, et al., Length of hospital stay is shorter in South Asian patients with ischaemic stroke, Int. J. Cardiol. 187 (2015) 190–191. [20] C. Thakker, N. Gollop, P. Carter, et al., Prevalence and length of hospital stay in patients with aortic valve disease is lower amongst South Asians, Int. J. Cardiol. 177 (2014) 34–36. [21] B. Green, N. Gollop, M. Baig, et al., Prolonged length of hospital stay in Far-East Asian and Afro-Caribbean patients with cardiomyopathy, Int. J. Cardiol. 176 (2014 Sep) 230–231. [22] R. Ciputra, Y. Sembiring, O. Prawoto, et al., Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery, Int. J. Cardiol. 172 (2014) 434–435. [23] D. Rasoul, S. Potluri, S. Wong, et al., Psychiatric co-morbidities in patients with dilated cardiomyopathy, Int. J. Cardiol. 191 (2015) 71–73. [24] L. Yssennagger, N. Gollop, R. Gorantla, et al., Increasing burden of psychiatric comorbidities amongst patients with Ischaemic Heart Disease, Int. J. Cardiol. 186 (2015) 200–201. [25] R. Teo, N. Gollop, M. Baig, et al., The burden and trends of psychiatric co-morbidities amongst patients with cardiomyopathy, Int. J. Cardiol. 174 (2014) 298–399. [26] R. Potluri, M. Baig, J. Mavi, et al., The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting, Int. J. Cardiol. 176 (2014) 760–763. [27] D. Lavu, H. Uppal, A. Katragadda, et al., Effect of ethnicity on live birth rates after in vitro fertilisation or intracytoplasmic sperm injection treatment: possible explanations and further observations, BJOG. 121 (2014) 1576–1577. [28] S.H. McKellar, M.L. Brown, R.L. Frye, et al., Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis, Nat. Clin. Pract. Cardiovasc. Med. 5 (2008) 738–746. [29] I. Teplitsky, A. Assali, E. Lev, et al., Results of percutaneous coronary interventions in patients N or =90 years of age, Catheter. Cardiovasc. Interv. 70 (2007) 937–943.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
The role of angioplasty in octogenarian patients with Acute Coronary Syndrome Rahul Potluri a,⁎, Jennifer Reynolds b, Paul Carter c, Mudassar Baig d, Amir Aziz e, Siri Potluri f, Noman Ali g, Hardeep Uppal a, Suresh Chandran h a
ACALM Study Unit in collaboration with Aston Medical School, School of Medical Sciences, Aston University, Birmingham, UK Birmingham Medical School, Birmingham, UK Royal Free London NHS Trust, London, UK d Department of Cardiology, Manchester Royal Infirmary, Manchester, UK e Division of Cardiology, University of Birmingham, Birmingham, UK f School of Medicine, Cardiff University, Cardiff, UK g Division of Cardiovascular and Diabetes Research, University of Leeds, Leeds, UK h Department of Acute Medicine, North Western Deanery, Manchester, UK b c
a r t i c l e
i n f o
Article history: Received 31 August 2015 Accepted 21 September 2015 Available online 25 September 2015 Keywords: Angioplasty Acute Coronary Syndrome Mortality Octogenarians
Dear Editor, The introduction of Percutaneous Coronary Intervention (PCI), commonly referred to as angioplasty, has drastically improved outcomes for patients with Acute Coronary Syndrome (ACS) [1–4]. However, in certain groups of patients with ACS uncertainty remains regarding the long-term benefits versus hazards of angioplasty [1,5–7]. There is no clear consensus on the use of angioplasty in patients over the age of 80 years. In some pockets of evidence, angioplasty has been shown to be beneficial in older individuals with acute myocardial infarction [8], and, data from USA describes procedural success of over 90% in patients aged 90 + and a similar mortality rate for age-matched controls [9]. One school of thought suggests that despite overall increased hospital mortality compared to younger patients, the elderly may benefit more when treated with angioplasty [10]. Other clinicians believe this ⁎ Corresponding author at: Aston Medical School, Aston University, Birmingham B4 7ET, UK. E-mail address: [email protected] (R. Potluri).
http://dx.doi.org/10.1016/j.ijcard.2015.09.080 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
aggressive approach in the elderly is dangerous [11]. Driving the lack of evidence is the fact that clinical trials are seldom performed in patients of this age group [11,12]. Furthermore, there is substantial comorbidity in these patients, making the decision to treat with angioplasty difficult [11]. This is particularly worrying as Ischemic Heart Disease is the most common worldwide cause of death in patients greater than 65 years old and in the western world there is an ageing population with a continually growing number of patients with heart disease [11,13]. Clear consensus on the benefits and risks of angioplasty in UK patients with ACS over the age of 80 is required. In this study, we aimed to evaluate the impact of angioplasty on allcause mortality in patients aged 80 or over presenting with ACS in North West England, UK from 2000–2012. We examined mortality in patients ≥80 suffering from ACS, who did and did not undergo angioplasty, using completely anonymous data of adult patients admitted across three multi-ethnic general hospitals in the North West England between 2000 and 2012. We used the ACALM (Algorithm of Comorbidities, Associations, Length of Stay and Mortality) study protocol [14–27]. The ACALM protocol uses ICD-10 diagnosis and OPCS-4 procedure codes to trace patients. All patients aged ≥80 diagnosed with ACS by senior clinicians and consecutively admitted for hospital treatment during the study period were included (n = 1536). All ICD-10 codes that covered the spectrum of ACS such as Myocardial Infarction and Unstable Angina, but not stable angina, were included. Whether patients were treated with angioplasty was traced by OPCS-4 codes for angioplasty procedures (codes K491–K494, K498–K501, K751–K754 and K758). Vital status (alive or decreased) at the end of the study period (30th June 2012) was determined by record linkage to the NHS strategic tracing service. All-cause mortality was determined from the vital status on 30th June 2012 with follow-up beginning on the date of index admission. Multivariate logistic regression accounted for variations in age, gender, ethnicity and identified comorbidities which impacted on mortality. The comorbidities analysed were those which most influence the decision to evaluate if a patient is fit for angioplasty and those which impact mortality (see results) and these were all traced by ICD-10 codes. Data analysis was performed using SPSS version 20.0
Correspondence
431
(SPSS Inc. Chicago, IL) and all p-values were calculated as two-tailed analyses; p b 0.05 was taken as significant. Of 12,227 patients with ACS there were 1536 (12.6%) patients aged ≥80. Of these, 111 (7.2%) patients underwent angioplasty. Full basic demographics of ACS patients aged ≥80 years are shown in Table 1. Mean age was not different between +/−angioplasty. Although patients who did not undergo angioplasty had higher prevalence of various comorbidities (Table 1) only previous ACS, comorbid hypertension and AF were statistically significant (p b 0.05). Multivariate logistic regression analysis accounting for variations in age, gender, ethnic group and co-morbidities revealed Chronic Kidney Disease Stage 3 (Relative Risk (RR) 2.26; 95% Confidence Interval (CI) 1.23–4.15), Heart Failure (RR 2.39; 95% CI 1.67–3.43), Ischaemic Stroke (RR 5.70; 95% CI 2.35–13.84), Atrial Fibrillation (RR 1.51; 95% CI 1.07– 2.13) as significant predictors of worsened all-cause mortality in this patient group. Angioplasty (RR 4.29; 95% CI 2.73–6.76) and previous ACS (RR 1.86; 95% CI 1.35–2.56) conferred improved all–cause mortality in this patient group. Fig. 1 shows the 1-year and 5-year survival curves +/−angioplasty in these ACS patients aged ≥80. Patients treated with angioplasty have better survival than the group without angioplasty. 76.6% of patients who were treated with angioplasty were still alive by the end of the study period compared to 43.2% of patients who were not treated with angioplasty in this group (Table 1). The mean survival in the patients with angioplasty was lower than those without angioplasty (1217 days vs 1423 days). The length of stay for patients who underwent angioplasty was significantly lower compared to patients who did not have angioplasty (7.81 days vs 9.08 days; Table 1). The results of our study suggest that angioplasty confers a four-fold improvement in all-cause mortality following ACS in patients aged 80 or over. Some pockets of evidence suggest angioplasty is associated with improved outcomes in this age group [8,11,12,28,29], but we are the first group in the UK to show this real life impact of angioplasty on allcause mortality. It could be argued that patients who undergo angioplasty are healthier and therefore pre-selected to have improved mortality anyway [10–13]. It is therefore notable that although there was a trend for reduced comorbidities in the angioplasty group in our study, only Atrial Table 1 Characteristics of patients aged 80 years or more with Acute Coronary Syndrome.
Total sample (n) Mean age (years) Male Female Caucasian South Asian Afro-Caribbean Other Heart failure Chronic kidney disease (total) Chronic kidney disease stage 3 Chronic kidney disease stage 4 Chronic kidney disease stage 5 Ischaemic stroke Previous ACS Peripheral vascular disease Carotid artery disease Anaemia Atrial fibrillation Haemorrhagic stroke Hypertension Type 2 diabetes mellitus Hyperlipidaemia Mean length of stay (days) Alive Deceased Mean survival (days) ⁎ Denotes statistical significance, p b 0.05.
Angioplasty
No angioplasty
111 (7.2) 83.9 61 (55) 50 (45) 90 (81.1) 3 (2.7) 0 (0.0) 18 (16.2) 22 (19.8) 4 (3.6) 3 (2.7) 1 (0.9) 0 (0.0) 1 (0.9) 27 (24.3) 4 (3.6) 9 (8.1) 5 (4.5) 17 (15.3) 0 (0.0) 49 (44.1) 20 (18.0) 31 (27.9)⁎ 7.81 85 (76.6) 26 (23.4) 1217
1425 (92.8) 85.1 677 (47.5)⁎ 748 (52.5)⁎ 1211 (85.0)⁎ 26 (1.8) 18 (1.3) 170 (11.9)⁎ 302 (21.2) 107 (7.5) 85 (5.9) 15 (1.1) 7 (0.5) 66 (4.6) 1002 (70.3)⁎ 63 (4.4) 8 (0.6) 125 (8.8) 288 (20.2)⁎ 4 (0.3) 731 (51.3)⁎ 219 (15.4) 205 (14.4) 9.08⁎ 616 (43.2)⁎ 809 (56.8)⁎ 1423⁎
Fig. 1. a shows the 1-year survival in Acute Coronary Syndrome patients aged 80 or over managed +/−angioplasty. As clearly evident, the angioplasty group have significantly improved survival. b shows the 5-year survival in Acute Coronary Syndrome patients aged 80 or over managed +/−angioplasty. As clearly evident, the angioplasty group have significantly improved survival.
Fibrillation, hypertension and previous ACS were statistically significant. Other comorbidities which confer higher mortality risk such as heart failure and chronic kidney disease were not significant. As we analysed the most clinically relevant co-morbidities that influence the decision to send a patient for angioplasty our study offers justified and fairly robust evidence about the role of angioplasty in the management of these patients. The shorter survival time we have demonstrated in patients who have had angioplasty, compared to those who did not, probably reflects the fact that these patients were treated with angioplasty later than those treated medically and therefore have shorter follow-up period by the censoring date of 30th June 2012. This may reflect increased use of angioplasty in this group of patients more recently and the fact that PCI techniques have improved [9,28,29]. We have shown that angioplasty confers improved all-cause mortality in the management of ACS in patients aged ≥80 years whilst accounting for differences in co-morbidities. Caution should be exercised when
432
Correspondence
applying these findings to guide clinical practice in patients and further extension of this study to other centres and in a prospective randomised controlled study would be of clinical relevance and importance. Nevertheless, the findings of this study highlight the need for clinicians to conscientiously think about the individual benefits and risks of angioplasty for every patient. In view of the lack of clinical trials in patients of these age groups, studies such as this one should be the cornerstone of any clinical guidelines. Contributorship RP performed the literature search, acquired and processed the data, performed the analysis, drafted the manuscript and is a guarantor. HU acquired and processed the data, performed the analysis, provided critical appraisal of the manuscript and is a guarantor. MB, AA, PC, JR, SP and SC assisted in the literature search, data analysis, and critical revision of manuscript. All authors approved the final, submitting version of the manuscript. Conflict of interest statement No authors have any conflict of interest to declare. No competing interests by any of the authors. Funding No specific funding was received in relation to this article. Acknowledgments We would like to thank those who have indirectly helped in this research. References [1] K.A. Fox, T.C. Clayton, P. Damman, et al., Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data, J. Am. Coll. Cardiol. 55 (2010) 2435–2445. [2] P.A. McCullough, W.W. O'Neill, M. Graham, et al., A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial, J. Am. Coll. Cardiol. 32 (1998) 596–605. [3] W.E. Boden, R.A. O'Rourke, M.H. Crawford, et al., Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affair Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators, N. Engl. J. Med. 338 (1998) 1785–1792. [4] C.P. Cannon, W.S. Weintraub, L.A. Demopoulos, et al., TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy) — thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban, N. Engl. J. Med. 344 (2001) 1879–1887. [5] J.P. Bassand, C.W. Hamm, D. Ardissino, et al., Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes, Eur. Heart J. 28 (2007) 1598–1660.
[6] A.A. Bavry, D.J. Kumbhani, A.N. Rassi, et al., Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials, J. Am. Coll. Cardiol. 48 (2006) 1319–1325. [7] R. Qayyum, M.R. Khalid, J. Adomaityte, et al., Systematic review: comparing routine and selective invasive strategies for the acute coronary syndrome, Ann. Intern. Med. 148 (2008) 186–196. [8] M.J. de Boer, J.P. Ottervanger, A.W. van't Hof, et al., Reperfusion therapy in elderly patients with acute myocardial infarction: a randomized comparison of primary angioplasty and thrombolytic therapy, J. Am. Coll. Cardiol. 39 (2002) 1723–1728. [9] A.M. From, C.S. Rihal, R.J. Lennon, et al., Temporal trends and improved outcomes of percutaneous coronary revascularization in nonagenarians, JACC Cardiovasc. Interv. 1 (2008) 692–698. [10] A.H. Skolnick, K.P. Alexander, A.Y. Chen, et al., Characteristics, management, and outcomes of 5557 patients age N or =90 years with acute coronary syndromes: results from the CRUSADE initiative, J. Am. Coll. Cardiol. 49 (2007) 1790–1797. [11] D. Ferrera, A. Shroff, Percutaneous coronary intervention in the very elderly: do nonagenarians have the most to gain or the most to lose? J. Invasive Cardiol. 23 (2011) 12. [12] T.Y. Wang, A. Gutierrez, E.D. Peterson, Percutaneous coronary intervention in the elderly, Nat. Rev. Cardiol. 8 (2011) 79–90. [13] K.P. Alexander, L.K. Newby, C.P. Cannon, et al., Acute coronary care in the elderly, part I: non-ST segment elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology, Circulation 115 (2007) 2549–2569. [14] P. Carter, G. Rai, A. Aziz, et al., Trends of cardiovascular disease amongst psychiatric patients between 2001 and 2012 in Greater Manchester, UK, Int. J. Cardiol. 173 (2014) 573–574. [15] P. Carter, J. Mann, J. Sangha, et al., The burden of cardiovascular disease amongst psychiatric patients, Int. J. Cardiol. 169 (2013) 65–66. [16] S. Shan, O. McConnell, J. Khan, et al., The impact of ethnicity on the prevalence and length of hospital stay in patients with mitral regurgitation, Int. J. Cardiol. 195 (2015) 15–16. [17] R. Gorantla, M. Nimmagadda, S. Potluri, et al., Ethnic variations in length of hospital stay in patients with atrial fibrillation, Int. J. Cardiol. 187 (2015) 542–544. [18] N. Khouw, M. Wasim, A. Aziz, et al., Length of hospital stay is shorter in South Asian patients with myocardial infarction, Int. J. Cardiol. 171 (2014) 54–55. [19] R. Potluri, M. Wasim, B. Markandey, et al., Length of hospital stay is shorter in South Asian patients with ischaemic stroke, Int. J. Cardiol. 187 (2015) 190–191. [20] C. Thakker, N. Gollop, P. Carter, et al., Prevalence and length of hospital stay in patients with aortic valve disease is lower amongst South Asians, Int. J. Cardiol. 177 (2014) 34–36. [21] B. Green, N. Gollop, M. Baig, et al., Prolonged length of hospital stay in Far-East Asian and Afro-Caribbean patients with cardiomyopathy, Int. J. Cardiol. 176 (2014 Sep) 230–231. [22] R. Ciputra, Y. Sembiring, O. Prawoto, et al., Length of stay in hospital is longer in ethnic minority patients after coronary artery bypass surgery, Int. J. Cardiol. 172 (2014) 434–435. [23] D. Rasoul, S. Potluri, S. Wong, et al., Psychiatric co-morbidities in patients with dilated cardiomyopathy, Int. J. Cardiol. 191 (2015) 71–73. [24] L. Yssennagger, N. Gollop, R. Gorantla, et al., Increasing burden of psychiatric comorbidities amongst patients with Ischaemic Heart Disease, Int. J. Cardiol. 186 (2015) 200–201. [25] R. Teo, N. Gollop, M. Baig, et al., The burden and trends of psychiatric co-morbidities amongst patients with cardiomyopathy, Int. J. Cardiol. 174 (2014) 298–399. [26] R. Potluri, M. Baig, J. Mavi, et al., The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting, Int. J. Cardiol. 176 (2014) 760–763. [27] D. Lavu, H. Uppal, A. Katragadda, et al., Effect of ethnicity on live birth rates after in vitro fertilisation or intracytoplasmic sperm injection treatment: possible explanations and further observations, BJOG. 121 (2014) 1576–1577. [28] S.H. McKellar, M.L. Brown, R.L. Frye, et al., Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis, Nat. Clin. Pract. Cardiovasc. Med. 5 (2008) 738–746. [29] I. Teplitsky, A. Assali, E. Lev, et al., Results of percutaneous coronary interventions in patients N or =90 years of age, Catheter. Cardiovasc. Interv. 70 (2007) 937–943.