Echocardiographically determined ejection fraction in the elderly admitted with non-ST-elevation acute coronary syndromes in a spoke hospital with no cath-lab facility and the treatment-risk paradox
Authors: Mantovani F , Guerri E , Manca F , Calzolari M , Colaiori I , Pignatelli G , Musto D"amore S , Guiducci V , Navazio A 
Published: February 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
The elderly with non-ST-elevation coronary syndromes (NSTE-ACS) represents an high risk group and may benefit from early invasive strategy, that may be difficult to achieve in spoke hospitals with no cath-lab facility. Although a strong predictor of mortality in NSTE-ACS, the role of echocardiographically determined left ventricular ejection fraction (EF) in this setting is poorly determined.

Purpose
we aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals according to EF.

Methods
Observational retrospective study of all consecutive NSTE-ACS patients admitted to a spoke hospital, where a same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography was available. Patients were divided in 3 groups according to EF: normal (EF≥55%), mild-moderate (EF 35-55%) and severe reduction (FE &lt; 35%).

Results
from 2013-2017, 181 patients ≥80 years (median 84, IQR 82-89) were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network.
Of these, 66 patients (36%) had normal EF, 79 (44%) had mild-moderate and 36 (20%) had severely EF reduction. GRACE risk score was high (&gt;140) in the whole cohort, increasing with the lowering of EF (165 ± 27 in normal EF, 179 ± 28 in mildly-moderate and 193 ± 31 in severe reduction; p &lt; 0.001). The three groups did not differ in term of age, gender, CV risk factors, known CAD, presence of severe COPD, PAD and atrial fibrillation (all p &gt; 0.1). As expected, clinical signs of heart failure presented more frequently with worsening of EF (2% in normal EF, 8% in mildly-moderate and 56% in severe reduction; p &lt; 0.001) and serum creatinine tended to be higher with worsening of EF (p = 0.05).
Of note, the invasive strategy was chosen less often with worsening of EF (68% in normal EF, 58% in mildly-moderate and 39% in severe reduction (p = 0.1).
When the invasive strategy was chosen, time from admission to cath lab consistently raised with worsening of EF (53 ± 35 hours in normal EF, 68 ± 46 in mildly-moderate and 104 ± 81 in severe reduction; p = 0.001), therefore the proportion of patients reaching the cath lab in &lt;72 hours as recommended from guidelines decreased with worsening of EF (73% in normal EF, 67% in mildly-moderate and 39% in severe reduction; p = 0.03). Table.
However, at 1-year follow-up, the overall survival did not differ across the EF groups (p = 0.26). Figure.

Conclusion
in the elderly admitted with NSTE-ACS in a spoke hospital with no cath lab facility EF may be part of the "treatment-risk paradox": the worse is the EF, the less patients are sent for invasive strategy and when invasive strategy is chosen the more time they have to wait for cath lab. However, in this setting, the impact of classical classification of EF in normal, mildly-moderate and severe reduction on 1-year mortality may not be significant and should not impede the access to invasive strategy in a timely fashion. Abstract Table Abstract Figure