Percutaneous Coronary Intervention in Older Patients with ST-Elevation Myocardial Infarction and Cardiogenic Shock

Background: Older adults ≥75 years of age carry an increased risk of mortality after ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock. Objectives: To examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality. Methods: We used a large publicly available all-payer inpatient health care database sponsored by AHRQ between 1999 to 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS). Results: Of the 317,728 encounters with STEMI and shock in the U.S., 111,901 (35%) were adults ≥75 years. Of these, 53% were females and 83% were Caucasians. The median [IQR] number of chronic conditions was 8 [6,10]. The (1999: 27% vs 2013: 56%, p <0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%, p <0.001). Utilizing PS matching methods, PCI was associated with lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel OR: 0.48, 95% CI 0.45– 0.51). This reduction in hospital mortality risk was seen across the 4 different United States census bureau regions (Adjusted OR: Northeast: 0.41, 95% CI 0.36–0.47; Midwest: 0.49, 95% CI 0.42– 0.57; South: 0.51, 95% CI 0.46–0.56; West: 0.46, 95% CI 0.41–0.53). Conclusions: This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. While clinical judgement is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications. Condensed Abstract The influence of percutaneous coronary intervention (PCI) in adults ≥ 75 years of age with STEMI and cardiogenic shock was examined since the publication of the SHOCK trial. Using propensity score methods, treatment with PCI appears to be associated with significant improvement in hospital mortality in older patients, but the risk is higher in patients with multiple coexisting conditions or high weight of disease burden. From a public health perspective, early revascularization should be considered for older adults in the absence of absolute contraindications (i.e. active bleeding, severe neurocognitive decline, and very limited life expectancy with end-stage disease processes). mellitus, hypertension, obesity, perivascular vascular disease, pulmonary circulation disorder, chronic lung disease, renal failure, liver disease, coagulopathy, weight loss, electrolyte and fluid disorder, blood and alcohol Presentation: This work is part of a Ph.D. thesis for Dr. Damluji at Johns Hopkins University’ GTPCI program. It was presented as an oral presentation at the American College of Cardiology (Geriatric Cardiology Section) 66th Annual Scientific Session, Washington, D.C. The study received best clinical research award at the National Claude D. Pepper Older Americans Independence Centers funded by the National Institute on Aging, National Institutes of Health.