Heart and Vessels

, Volume 29, Issue 1, pp 15–20

Impact of advanced age on myocardial perfusion, distal embolization, and mortality patients with ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb–IIIa inhibitors

  • Giuseppe De Luca
  • Arnoud W. J. van’t Hof
  • Kurt Huber
  • C. Michael Gibson
  • Francesco Bellandi
  • Hans-Richard Arntz
  • Mauro Maioli
  • Marko Noc
  • Simona Zorman
  • Gioel Gabrio Secco
  • Uwe Zeymer
  • H. Mesquita Gabriel
  • Ayse Emre
  • Donald Cutlip
  • Tomasz Rakowski
  • Maryann Gyongyosi
  • Dariusz Dudek
Original Article

Abstract

Despite mechanical reperfusion, the outcome is still unsatisfactory in elderly patients with ST-segment elevation myocardial infarction (STEMI). The vast majority of studies have been conducted without extensive use of glycoprotein (Gp) IIb–IIIa inhibitors, which have been associated with improved perfusion and survival. Thus the aim of the current study was to evaluate the impact of age on the angiographic and clinical outcome patients with STEMI undergoing primary angioplasty with Gp IIb–IIIa inhibitors. Our population is represented by a total of 1,662 patients undergoing primary angioplasty for STEMI included in 11 randomized trials comparing early versus late administration of Gp IIb–IIIa inhibitors. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. A total of 231 (13.9 %) patients were older than 75 years. Elderly patients showed a larger prevalence of female gender, hypertension, and diabetes, more advanced Killip class at presentation and longer time to treatment, but a smaller prevalence of smoking. All patients were treated with GP IIb–IIIa inhibitors. Elderly patients showed a significantly impaired postprocedural thrombolysis in myocardial infarction (TIMI) flow (TIMI 0–2: 17.7 vs 10.3 %, P = 0.002) and myocardial perfusion (myocardial blush grade 0–1: 38.3 vs 26.5 %, P = 0.001), and higher prevalence of distal embolization (19.2 vs 9.8 %, P < 0.001), whereas no difference was observed in terms of ST-segment resolution. At follow-up, elderly patients showed a significantly higher mortality (3.2 vs 11.0 %, hazard ratio (HR) (95 % confidence interval (CI)) = 3.78 (2.31–6.16), P < 0.001), which was confirmed after adjustment for baseline confounding factors (HR (95 % CI) = 5.01 (2.63–9.55), P < 0.0001). This study showed that among patients with STEMI undergoing primary angioplasty, advanced age is an independent predictor of mortality after primary angioplasty. Higher rates of distal embolization and poor myocardial perfusion, in addition to the worse risk profile, contribute toward explaining the impact of aging on mortality.

Keywords

Primary angioplasty Perfusion Elderly Mortality 

References

  1. 1.
    Holmes DR, White HD, Pieper KS, Ellis SG, Califf RM, Topol EJ (1999) Effects of age on outcome with primary angioplasty versus thrombolysis. J Am Coll Cardiol 33:412–419PubMedCrossRefGoogle Scholar
  2. 2.
    Golderberg RJ, McCormick D, Gurwitz JH, Yarzebski J, Lessard D, Gore JM (1998) Age-related trends in short- and long-term survival after myocardial infarction: a 20-year population-based perspective (1975–1995). Am J Cardiol 82:1311–1317CrossRefGoogle Scholar
  3. 3.
    DeGeare VS, Stone GW, Grines L, Brodie BR, Cox DA, Garcia E, Wharton TP, Boura JA, O’Neill WW, Grines CL (2000) Angiographic and clinical characteristics associated with increased in-hospital mortality in elderly patients with acute myocardial infarction undergoing percutaneous intervention (a pooled analysis of the Primary Angioplasty in Myocardial Infarction Trials). Am J Cardiol 86:30–34PubMedCrossRefGoogle Scholar
  4. 4.
    Klein LW, Block P, Brindis RG, McKay CR, McCallister BD, Wolk M, Weintraub W, ACC-NCDR Registry (2002) Percutaneous coronary interventions in octogenarians in the American College of Cardiology National Cardiovascular Data Registry. J Am Coll Cardiol 40:394–402PubMedCrossRefGoogle Scholar
  5. 5.
    van’t Hof A, Liem A, Suryapranata H, Hoorntje JC, de Boer MJ, Zijlstra F (1998) Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction. Myocardial Blush Grade. Circulation 97:2302–2306Google Scholar
  6. 6.
    De Luca G, van’t Hof AW, Ottervanger JP, Hoorntje JC, Gosselink AT, Dambrink JH, de Boer MJ, Suryapranata H (2005) Ageing, impaired myocardial perfusion, and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Eur Heart J 26:662–666Google Scholar
  7. 7.
    Ikeda N, Nakajima R, Utsunomiya M, Hori M, Itaya H, Makino K, Ono T, Yamamoto M, Nemoto N, Iijima R, Hara H, Takagi T, Hara H, Nakamura M, Sugi K (2001) Higher body mass index at the time of acute myocardial infarction is associated with a favorable long-term prognosis (8-year follow-up). Heart Vessels 26:495–501CrossRefGoogle Scholar
  8. 8.
    Matsue Y, Matsumura A, Abe M, Ono M, Seya M, Nakamura T, Iwatsuka R, Mizukami A, Setoguchi M, Nagahori W, Ohno M, Suzuki M, Hashimoto Y (2013) Prognostic implications of chronic kidney disease and anemia after percutaneous coronary intervention in acute myocardial infarction patients. Heart Vessels 28:19–26PubMedCrossRefGoogle Scholar
  9. 9.
    Neumann FJ, Blasini R, Schmitt C, Alt E, Dirschinger J, Gawaz M, Kastrati A, Schömig A (1998) Effect of glycoprotein IIb/IIIa receptor blockade on recovery of coronary flow and left ventricular function after the placement of coronary-artery stents in acute myocardial infarction. Circulation 98:2695–2701PubMedCrossRefGoogle Scholar
  10. 10.
    De Luca G, Suryapranata H, Stone GW, Antoniucci D, Tcheng JE, Neumann FJ, Van de Werf F, Antman EM, Topol EJ (2005) Abciximab as adjunctive therapy to reperfusion in acute ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. JAMA 293:1759–1765PubMedCrossRefGoogle Scholar
  11. 11.
    De Luca G, Gibson CM, Bellandi F, Murphy S, Maioli M, Noc M, Zeymer U, Dudek D, Arntz HR, Zorman S, Gabriel HM, Emre A, Cutlip D, Biondi-Zoccai G, Rakowski T, Gyongyosi M, Marino P, Huber K, van’t Hof AW (2008) Early glycoprotein IIb–IIIa inhibitors in primary angioplasty (EGYPT) cooperation: an individual patient data meta-analysis. Heart 94:1548–1558Google Scholar
  12. 12.
    De Luca G, Cassetti E, Marino P (2009) Percutaneous coronary intervention-related time delay, patient’s risk profile, and survival benefits of primary angioplasty vs lytic therapy in ST-segment elevation myocardial infarction. Am J Emerg Med 27:712–719PubMedCrossRefGoogle Scholar
  13. 13.
    De Luca G, Biondi-Zoccai G, Marino P (2008) Transferring patients with ST-segment elevation myocardial infarction for mechanical reperfusion: a meta-regression analysis of randomized trials. Ann Emerg Med 52:665–676PubMedCrossRefGoogle Scholar
  14. 14.
    Feng Y, Shen C, Ma G, Wang J, Chen Z, Dai Q, Zhi H, Yang C, Fu Q, Shang G, Guan Y (2010) Prolonged pain to hospital time is associated with increased plasma advanced oxidation protein products and poor prognosis in patients with percutaneous coronary intervention for ST-elevation myocardial infarction. Heart Vessels 25:374–378PubMedCrossRefGoogle Scholar
  15. 15.
    De Luca G, Parodi G, Sciagrà R, Venditti F, Bellandi B, Vergara R, Migliorini A, Valenti R, Antoniucci D (2012) Time-to-treatment and infarct size in STEMI patients undergoing primary angioplasty. Int J Cardiol (Epub ahead of print)Google Scholar
  16. 16.
    De Luca G, van’t Hof AW, Ottervanger JP, Hoorntje JC, Gosselink AT, Dambrink JH, Zijlstra F, de Boer MJ, Suryapranata H (2005) Unsuccessful reperfusion in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Am Heart J 150:557–562Google Scholar
  17. 17.
    Kloner RA, Ganote CE, Jennings RB (1974) The ‘no reflow’ phenomenon after temporary coronary occlusion in the dog. J Clin Invest 54:1496–1508PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Prasad A, Stone GW, Aymong E, Zimetbaum PJ, McLaughlin M, Mehran R, Garcia E, Tcheng JE, Cox DA, Grines CL, Gersh BJ; CADILLAC trial (2004) Impact of ST-segment resolution after primary angioplasty on outcomes after myocardial infarction in elderly patients: an analysis from the CADILLAC trial. Am Heart J 147:669–675Google Scholar
  19. 19.
    Ataka K, Chen D, Levitsky S, Jimenez E, Feinberg H (1992) Effect of aging on intracellular Ca2+, pHi, and contractility during ischemia and reperfusion. Circulation 86(Suppl.):II 371–II 376Google Scholar
  20. 20.
    Headrick JP (1998) Aging impairs functional, metabolic and ionic recovery from ischemia–reperfusion and hypoxia–reoxygenation. J Mol Cell Cardiol 30:1415–1430PubMedCrossRefGoogle Scholar
  21. 21.
    McCully JD, Tsukube T, Ataka K, Krukenkamp IB, Feinberg H, Levitsky S (1994) Myocardial cytosolic calcium accumulation during ischemia/reperfusion: the effects of aging and cardioplegia. J Card Surg 9(Suppl.):449–452Google Scholar
  22. 22.
    Singh N, Prasad S, Singer DR, MacAllister RJ (2002) Aging is associated with impairment of nitric oxide and prostanoid dilator pathways in the human forearm. Clin Sci 102:595–600PubMedCrossRefGoogle Scholar
  23. 23.
    Jugdutt BI, Jelani A, Palaniyappan A, Idikio H, Uweira RE, Menon V, Jugdutt CE (2010) Aging-related early changes in markers of ventricular and matrix remodeling after reperfused ST-segment elevation myocardial infarction in the canine model: effect of early therapy with an angiotensin II type 1 receptor blocker. Circulation 27(122):341–351CrossRefGoogle Scholar
  24. 24.
    Boengler K, Schulz R, Heusch G (2009) Loss of cardioprotection with ageing. Cardiovasc Res 83:247–261PubMedCrossRefGoogle Scholar
  25. 25.
    Taniyama Y, Ito H, Iwakura K, Nishikawa N, Masuyama T, Kuzuya T, Hori M, Higashino Y, Fujii K, Minamino T (1997) Beneficial effect of intracoronary verapamil on microvascular and myocardial salvage in patients with acute myocardial infarction. J Am Coll Cardiol 30:1193–1199PubMedCrossRefGoogle Scholar
  26. 26.
    Marzilli M, Orsini E, Marraccini P, Testa R (2000) Beneficial effects of intracoronary adenosine as an adjunct to primary angioplasty in acute myocardial infarction. Circulation 101:2154–2159PubMedCrossRefGoogle Scholar
  27. 27.
    Kobatake R, Sato T, Fujiwara Y, Sunami H, Yoshioka R, Ikeda T, Saito H, Ujihira T (2011) Comparison of the effects of nitroprusside versus nicorandil on the slow/no-reflow phenomenon during coronary interventions for acute myocardial infarction. Heart Vessels 26:379–384PubMedCrossRefGoogle Scholar
  28. 28.
    Batchelor WB, Anstrom KJ, Muhlbaier LH, Grosswald R, Weintraub WS, O’Neill WW, Peterson ED (2000) Contemporary outcome trends in the elderly undergoing percutaneous coronary interventions: results in 7472 octogenarians. National Cardiovascular Network Collaboration. J Am Coll Cardiol 36:723–730PubMedCrossRefGoogle Scholar
  29. 29.
    Henriques JP, Zijlstra F, Ottervanger JP, de Boer MJ, van’t Hof AW, Hoorntje JC, Suryapranata H (2002) Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J 23:1112–1117Google Scholar
  30. 30.
    Gremmel T, Steiner S, Seidinger D, Koppensteiner R, Panzer S, Kopp CW (2010) Adenosine diphosphate-inducible platelet reactivity shows a pronounced age dependency in the initial phase of antiplatelet therapy with clopidogrel. J Thromb Haemost 8:37–42PubMedCrossRefGoogle Scholar
  31. 31.
    Ikarugi H, Yamashita T, Aoki R, Ishii H, Kanki K, Yamamoto J (2003) Impaired spontaneous thrombolytic activity in elderly and in habitual smokers, as measured by a new global thrombosis test. Blood Coagul Fibrinolysis 14:781–784PubMedCrossRefGoogle Scholar
  32. 32.
    De Luca G, Dudek D, Sardella G, Marino P, Chevalier B, Zijlstra F (2008) Adjunctive manual thrombectomy improves myocardial perfusion and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials. Eur Heart J 29:3002–3010PubMedCrossRefGoogle Scholar
  33. 33.
    Galiuto L, Lombardo A, Maseri A, Santoro L, Porto I, Cianflone D, Rebuzzi AG, Crea F (2003) Temporal evolution and functional outcome of no reflow: sustained and spontaneously reversible patterns following successful coronary recanalisation. Heart 89:731–737PubMedCrossRefGoogle Scholar
  34. 34.
    Hoffmann R, Haager P, Arning J, Christott P, Radke P, Blindt R, Ortlepp J, Lepper W, Hanrath P (2003) Usefulness of myocardial blush grade early and late after primary coronary angioplasty for acute myocardial infarction in predicting left ventricular function. Am J Cardiol 92:1015–1019PubMedCrossRefGoogle Scholar

Copyright information

© European Union 2013

Authors and Affiliations

  • Giuseppe De Luca
    • 1
  • Arnoud W. J. van’t Hof
    • 2
  • Kurt Huber
    • 3
  • C. Michael Gibson
    • 4
  • Francesco Bellandi
    • 5
  • Hans-Richard Arntz
    • 6
  • Mauro Maioli
    • 5
  • Marko Noc
    • 7
  • Simona Zorman
    • 7
  • Gioel Gabrio Secco
    • 1
  • Uwe Zeymer
    • 8
  • H. Mesquita Gabriel
    • 9
  • Ayse Emre
    • 10
  • Donald Cutlip
    • 11
  • Tomasz Rakowski
    • 12
  • Maryann Gyongyosi
    • 13
  • Dariusz Dudek
    • 12
  1. 1.Division of Cardiology“Maggiore della Carità” Hospital, Eastern Piedmont UniversityNovaraItaly
  2. 2.Division of CardiologyHospital “De Weezenlanden”ZwolleThe Netherlands
  3. 3.Department of Medicine (Cardiology and Emergency Medicine)WilhelminenspitalViennaAustria
  4. 4.TIMI Study Group, Cardiovascular DivisionBrigham and Women’s HospitalBostonUSA
  5. 5.Division of CardiologyPrato HospitalPratoItaly
  6. 6.Medizinische Klinik II, Kardiologie/Pulmologie, CharitéBerlinGermany
  7. 7.Center for Intensive Internal MedicineUniversity Medical CenterLjubljanaSlovenia
  8. 8.Division of CardiologyHerzzentrum LudwigshafenLudwigshafenGermany
  9. 9.Division of CardiologyHospital de Santa MariaLisbonPortugal
  10. 10.Siyami Ersek Thoracic and Cardiovascular Surgery CenterIstanbulTurkey
  11. 11.Interventional Cardiology SectionBeth Israel Deaconess Medical CenterBostonUSA
  12. 12.Second Department of CardiologyInstitute of Cardiology, Jagiellonian UniversityKrakowPoland
  13. 13.Department of CardiologyMedical University of ViennaViennaAustria

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