Comparison of benefit and mortality of implantable cardioverter-defibrillator therapy in patients aged ≥75 years versus those <75 years

Implantable cardioverter-defibrillator (ICD) therapy decreases arrhythmic and all-cause mortality in patients at high risk of sudden death. However, its clinical benefit in elderly patients is uncertain. The aim of this study was to assess the long-term efficacy of ICD treatment in elderly patients and to identify markers of successful ICD therapy and risk factors of mortality. We performed multivariate analysis of a prospective long-term database from 2 tertiary care centers including 936 consecutive patients with an ICD. Predictors of ICD therapy and risk factors for mortality were assessed in patients ≥75 years old at ICD implantation compared to younger patients. Mean follow-up time was 43 ± 40 months. Rates of ICD therapy were similar in the 2 age groups. No significant predictors of ICD therapy could be identified in older patients. Median estimated survival was 132 months in patients <75 years and 81 months in those ≥75 years old (p = 0.006). Decreased ejection fraction (hazard ratio 1.62 per 10% decrease, p = 0.03) and impaired renal function (hazard ratio 1.57 per 10 ml/kg/m(2) decrease in estimated glomerular filtration rate, p = 0.02) were independent risk factors of mortality in patients ≥75 years old. However, mortality of older patients was similar to that of the age-matched general population irrespective of delivery of ICD therapy. In conclusion, ICD therapy is effective for treatment of life-threatening arrhythmias in all age groups. However, prevention of sudden cardiac death may have limited impact on overall mortality in older patients. Despite a similar rate of appropriate ICD therapies, risk of death is increased 1.6-fold in ICD recipients ≥75 years old compared to younger patients. Patients with decreased ejection fraction and impaired renal function are at highest risk.     

Results of percutaneous radiofrequency ablation of hepatocellular carcinoma in patients with cirrhosis aged 75 years and over

Purpose

The objective of this study was to assess the results and tolerance of radiofrequency ablation in patients with cirrhosis and hepatocellular carcinoma (HCC) older than 75 years.

Patients and methods

Over a period of 9 years from January 2001, 235 patients with cirrhosis and 3 or less HCC ≤ 5 cm of diameter were treated by radiofrequency ablation. Among them, 52 patients older than 75 years were selected for this study.

Results

The mean age was 79.4 ± 3. 5 years. There were 36 males, cirrhosis was classified Child-Pugh class A (n = 52) related to alcohol (n = 13), HCV infection (n = 33), or other causes (n = 6). The mean tumour diameter was 32.5 ± 10,6 mm, and 14 patients had a multifocal HCC. A complete ablation was obtained in 50/52 patients (96%). No severe complication occurred. The estimated overall survival rates were 62%, 52% and 36% at 3 years, 4 years and 5 years, respectively; it was similar to those observed in patients younger than 75 years.

Conclusion

In patients with cirrhosis older than 75 years, radiofrequency ablation of 3 or less HCC ≤ 5 cm is well tolerated and survivals rates are similar to those of younger patients.     

The dark side of laparoscopic surgery for colorectal cancer patients aged 75 years or older

Purpose

The rate of postoperative morbidity and mortality is reportedly high in patients aged ≥?75 years with colorectal cancer (CRC). In such patients, a comparison of the short-term outcome between open method and laparoscopy has not been clearly defined in Taiwan. We aimed to compare postoperative morbidity and mortality parameters after open method and laparoscopy in CRC patients aged ≥?75 years.

Methods

We retrospectively analyzed patients who underwent surgery for CRC from February 2009 to September 2015 at the Linkou Chang Gung Memorial Hospital in Taiwan and analyzed their clinicopathological factors. Postoperative morbidity and mortality were analyzed for evaluating if laparoscopic surgery offers more favorable outcomes than open surgery in the elderly.

Results

A total of 1133 patients were enrolled and analyzed in this study; they were divided into two groups (open method vs. laparoscopy?=?797 vs. 336). The anastomotic leakage rate was significantly higher in the laparoscopy group than in the open method group (3.3 vs. 0.9%, p?=?0.003). Overall postoperative morbidity and mortality rates showed no significant difference between these two groups. Postoperative hospital stay was significantly shorter in the laparoscopy group than in the open method group (10.4?±?8.7 vs. 13.8?±?13.5 days, p?<?0.001).

Conclusions

Our results suggest that laparoscopy in patients aged ≥?75 years with CRC had higher anastomosis leakage rate compared with open surgery but is acceptable and offers the benefit of a shorter hospital stay over open surgery.

     

Comparison of platelet reactivity and clopidogrel response in patients ≤ 75 Years Versus > 75 years undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndrome

Specific data about the clopidogrel response in elderly patients are lacking. The present study was performed to compare the platelet reactivity and clopidogrel response between patients aged > 75 years and < 75 years undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndrome. A total of 689 patients were enrolled, including 162 patients aged > 75 years and 527 younger patients. All patients received a loading dose of 600 mg clopidogrel followed by 150 mg/day. Post-treatment platelet reactivity was assessed by adenosine diphosphate 10 μmol/L-induced platelet aggregation and the specific pharmacologic response to clopidogrel by the platelet reactivity index vasoactive stimulated phosphoprotein. High post-treatment platelet reactivity was defined as adenosine diphosphate 10 μmol/L-induced platelet aggregation >70%. Clinical events were recorded during 1 month of follow-up. The patients > 75 years old had a greater rate of both ischemic and bleeding complications (p = 0.04 and p = 0.03, respectively). The post-treatment platelet reactivity in response to both the loading and the maintenance clopidogrel dose was greater in patients > 75 years old than in the younger patients: 50 ± 17% versus 45 ± 17% (p = 0.002) and 57 ± 15% versus 53 ± 16% (p = 0.0005), respectively. The rate of high post-treatment platelet reactivity was significantly greater in patients aged > 75 years after 600 mg and 150 mg clopidogrel: 14% versus 9% (p = 0.04) and 23% versus 15% (p = 0.02), respectively. In contrast, the pharmacologic response to clopidogrel was not impaired in patients > 75 years after loading and maintenance doses: 43 ± 21% versus 46 ± 21% (p = 0.17) and 38 ± 18% versus 39 ± 18% (p = 0.55), respectively. In conclusion, patients aged > 75 years have an impaired prognosis after acute coronary syndrome. They display greater post-treatment platelet reactivity. However, this greater platelet reactivity does not seem to be related to an impaired specific response to clopidogrel.     

Comparison of outcomes in patients aged <75, 75 to 84, and ≥ 85 years with ST-elevation myocardial infarction (from the ACTION Registry-GWTG)

ST-segment elevation myocardial infarction (STEMI) is common in older adults and has high age-related mortality. We describe contemporary STEMI care using the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Network Registry-Get With The Guidelines (ACTION-GWTG) database. Patients with STEMI (n = 30,188) from 285 ACTION-GWTG sites from January 1, 2007 to June 30, 2008 were grouped by age (<75, 75 to 84, and ≥ 85 years) to compare baseline characteristics, reperfusion, and in-hospital outcomes. In this population, 79.7% (24,070) were <75 years old, 14.2% (4,273) were 75 to 84 years old, and 6.1% (1,845) were ≥ 85 years old (the oldest old). Compared to younger patients, the oldest-old patients (median age 88 years, interquartile range 86 to 91) were more often women, had more hypertension, and end-organ co-morbidity (heart failure and stroke, p <0.0001 for all). More than 42% of the oldest old were also cited as having contraindications to reperfusion, but with absolute or relative contraindications noted in only 10%, and patient preference was the most common reason indicated (45%). Even in reperfusion-eligible patients, the oldest old were less likely to receive it. Although patients who received reperfusion had better outcomes than those who did not, this was significant only for younger patients (< 75 years old, odds ratio 0.58, confidence interval 0.40 to 0.84). In conclusion, > 42% of the oldest old have reported contraindications to reperfusion, with neither mortality benefit nor harm in those who receive it. Disparities in process of care and co-morbidity may explain these observational findings. Whether efforts to optimize patient selection and initiate reperfusion therapy can improve outcomes in the oldest old with STEMI is unknown.     

Comparison of efficacy and safety of a standard versus a loading dose of clopidogrel for acute myocardial infarction in patients ≥ 75 years of age (from the FAST-MI registry)

Data are lacking on the efficacy and safety of a loading dose (LD) of clopidogrel in elderly patients with acute myocardial infarction (AMI). FAST-MI is a nationwide registry that was carried out over a 1-month period in 2005 and included consecutive patients with AMI admitted to intensive care units <48 hours from symptom onset in 223 participating centers. We assessed the impact of a clopidogrel LD (≥300 mg) compared to a conventional dose (<300 mg) on bleeding, need for blood transfusion, and 30-day and 12-month survivals in 791 elderly patients (≥75 years old, mean age 81 ± 4 years, 48% women, 35% with ST-segment elevation MI) included in this registry. Fifty-nine percent (466 patients) received a clopidogrel LD. Follow-up was >99% complete. Major bleeding and blood transfusions were not significantly different in patients who received a clopidogrel LD (3.2% vs 3.7%, p = 0.72; 5.4% vs 6.2%, p = 0.64, respectively). Early mortality was also not significantly different (10.1 vs 10.8, p = 0.76). Using multivariate analyses, clopidogrel LD did not significantly affect major bleeding or transfusion (odds ratio 1.03, 95% confidence interval 0.49 to 2.17, p = 0.94) and 12-month mortality (hazard ratio 1.00, 95% confidence interval 0.72 to 1.40, p = 0.98). In conclusion, the present data showed that in elderly patients admitted for AMI, use of a LD of clopidogrel compared to a conventional dose was not associated with increased in-hospital bleeding, need for transfusion, or mortality. Large-scale randomized trials are still needed to identify the optimal LD of clopidogrel for elderly patients admitted for AMI.     

Validation of the CORB75 (confusion,oxygen saturation,respiratory rate,blood pressure,and age ≥75 years) as a simpler pneumonia severity rule

Purpose

This study compares the ability of two simpler severity rules (classical CRB65 vs. proposed CORB75) in predicting short-term mortality in elderly patients with community-acquired pneumonia (CAP).

Methods

A population-based study was undertaken involving 610 patients ≥65 years old with radiographically confirmed CAP diagnosed between 2008 and 2011 in Tarragona, Spain (350 cases in the derivation cohort, 260 cases in the validation cohort). Severity rules were calculated at the time of diagnosis, and 30-day mortality was considered as the dependent variable. The area under the receiver operating characteristic curves (AUC) was used to compare the discriminative power of the severity rules.

Results

Eighty deaths (46 in the derivation and 34 in the validation cohorts) were observed, which gives a mortality rate of 13.1 % (15.6 % for hospitalized and 3.3 % for outpatient cases). After multivariable analyses, besides CRB (confusion, respiration rate ≥30/min, systolic blood pressure <90 mmHg or diastolic ≤60 mmHg), peripheral oxygen saturation (≤90 %) and age ≥75 years appeared to be associated with increasing 30-day mortality in the derivation cohort. The model showed adequate calibration for the derivation and validation cohorts. A modified CORB75 scoring system (similar to the classical CRB65, but adding oxygen saturation and increasing the age to 75 years) was constructed. The AUC statistics for predicting mortality in the derivation and validation cohorts were 0.79 and 0.82, respectively. In the derivation cohort, a CORB75 score ≥2 showed 78.3 % sensitivity and 65.5 % specificity for mortality (in the validation cohort, these were 82.4 and 71.7 %, respectively).

Conclusions

The proposed CORB75 scoring system has good discriminative power in predicting short-term mortality among elderly people with CAP, which supports its use for severity assessment of these patients in primary care.     

Is routine use of stentless aortic prostheses justified in an elderly (aged > or =75 years) population?

BACKGROUND AND AIM OF THE STUDY: Stentless prostheses in the aortic position produce a superior hemodynamic profile in comparison to that with stented valves. To determine whether routine use of stentless valves in an elderly population is justified, a 10-year retrospective review was performed of a consecutive series of patients aged > or =75 years undergoing stentless aortic valve replacement (AVR). METHODS: Demographic, operative and mortality data were obtained retrospectively. Survivors were interviewed by telephone according to a defined protocol. Univariate and multivariate analysis was used to identify independent predictors of 30-day and overall medium-term mortality. Definitions and analyses were in accordance with joint STS/AATS guidelines. RESULTS: A total of 103 patients (57 males, 46 females; mean age 79.8 years; range: 75-91 years) underwent AVR with a either a Toronto stentless porcine valve (size range: 21-29 mm; n = 74) or an aortic homograft (n = 29). Twenty-eight patients (27%) had either urgent/emergency surgery, 12 (11%) underwent redo surgery, and in 54 cases (52%), the preoperative left ventricular function was significantly impaired (ejection fraction <50%). Forty patients (39%) also underwent concomitant coronary artery bypass grafting. The mean cross-clamp and cardiopulmonary bypass times were 105+/-22 min and 144+/-47 min, respectively. The overall 30-day mortality was 11.6% (n = 12). The 30-day mortality for all elective cases was 5.3%, but for isolated elective AVR was only 2.5%. Using a multivariate model, the only independent predictor of 30-day mortality and medium-term overall mortality was increasing age. The mean follow up period was 3.6 years (range: 0.1-9.3 years), and the Kaplan-Meier actuarial five-year survival was 52%. At follow up, 92% of patients were in NYHA functional classes I and II. CONCLUSION: Stentless AVR in elderly patients is associated with excellent functional and survival outcome in the medium term. Furthermore, in elective cases, age alone should not be a deterrent to the routine use of stentless aortic valves.     

The future of gastroenterology—The next 25 years

Summary Gastroenterology frequently has been considered a backward, undeveloped specialty of clinical medicine, albeit one that deals with many and frequently occurring diseases and has many interested practitioners. In the past few years increasing numbers of young basic medical scientists have turned with keen interest to this almost virgin clinical field and have brought with them the techniques of their respective disciplines. Research in gastroenterology, which has lagged until now, is also receiving increasing pecuniary support. One can predict that in the next 25 years the development of scientific knowledge of the gastrointestinal tract and of diagnosis and therapeutic measures will move on apace.The development of means to quantitate many of the functions of the gastrointestinal tract in health and disease and the use of newer techniques, such as those offered by anatomic, biochemical, and physiologic scientists, should help greatly to expand our knowledge of diseases of the alimentary system. The electron microscope, the determination of the amounts and kinds of enzymes in the blood and cells, studies of motor function and standardization of results, newer techniques of biopsy of liver and intestinal mucosa, and clear definitions and understanding of absorption are all among the factors that will influence and develop this specialty.Ways to control acid and enzyme secretion, how to govern the motor activity of the gastrointestinal tract, development of a better understanding of parenteral nutrition and of the relation of nutritional disturbances to disease of the liver—these are some of the boons to therapy that can be looked for in the quarter-century ahead.The clinical gastroenterologist in the future will stand on an increasingly firm foundation of scientific medicine. The need for a carefully taken history and of a sympathetic and understanding physician who can properly interpret what the scientific studies of his patient have shown will in fact be as great as if not greater than before.     

Wireless capsule video endoscopy:Three years of experience

AIM:To review and summerize the current literatueregarding M2A wireless capsule endoscopy.METHODS:Peer reviewed publications regarding the useof capsule endoscopy as well as our personal experiencewere reviewed.RESULTS:Review of the literature dearly showed that capsuleendoscopy was superior to enteroscopy,small bowel followthrough and computerized tomography in patients withobscure gastrointestinal bleeding,iron deficiency anemia,or suspected Crohn's disease.It was very sensitive for thediagnosis of small bowel tumors and for survailance of smallbowel pathology in patients with Gardner syndrome orfamilial adenomatous polyposis syndrome.Its role in celiacdisease and in patients with known Crohn's disease wascurrently being investigated.CONCLUSION:Capsule video endoscopy is a superior andmore sensitive diagnostic tool than barium follow through,enteroscopy and entero-CT in establishing the diagnosis ofmany small bowel pathologies.     

Wireless capsule video endoscopy：Three years of experience

AIM:To review and summerize the current literatue regarding M2A wireless capsule endoscopy.METHODS:Peer reviewed publications regarding the use of capsule endoscopy as well as our personal experience were reviewed.RESULTS:Review of the literature dearly showed that capsule endoscopy was superior th enteroscopy,small bowel follow through and computerized tomography in aptients with obscure qastrointestinal bleeding,iron deficiency anemia,or suspected Crohn‘s disease.It was very sensitive for the diagnosis of small bowel tumors and for survailance of small bowel pathology in patients with Gardner syndrome or familial adenomatous polyposeis syndrome.Its role in celiac disease and in patients with kmown Crohn‘s disease was currently being investigated.CONGLUSION:Capsule video endoscopy is a superior and more sensitive diagnostic tool than barium follow through,enteroscopy and entero-CT in establishing the diagnosis of many small bowel pathologyes.     

Primary percutaneous coronary intervention for acute myocardial infarction in the elderly aged ≥75 years

Objectives : We aimed to see whether primary percutaneous coronary intervention (PCI) benefits for ST‐segment elevation myocardial infarction (STEMI) in the aged could be validated. Background : Primary PCI benefits in elderly patients with STEMI remain uncertain. Methods : We reviewed 947 consecutive patients treated with primary PCI for STEMI: 331 were aged ≥75 years (older) and 616 <75 years (younger). Results : The older group had higher percentage of renal insufficiency (7.9% vs. 3.1%, P = 0.0010), prior stroke (9.4% vs. 3.9%, P = 0.0006), 30‐day mortality rate (7.6% vs. 3.9%, P = 0.015), and cardiac mortality rate (6.6% vs. 3.7%, P = 0.045). Successful reperfusion rates were similarly high in both groups (90.0% and 92.7%, P = 0.16), despite the higher proportion of patients with door‐to‐balloon time >90 min (15% vs. 8.4%, P = 0.0016) in older patients. Successful compared with unsuccessful PCI significantly decreased 30‐day mortality rates in the older group (6.0% vs. 21%, P = 0.0018) and in the younger group (2.8% vs. 18%, P < 0.0001). When reperfusion was successful, cardiac mortality rate in older patients was not significantly greater than in younger patients (5.4% vs. 2.8%, P = 0.057). By multivariate analysis, unsuccessful reperfusion independently predicted 30‐day mortality (odds ratio, 4.04; 95% confidence interval, 1.79–9.12; P = 0.0008), whereas age ≥75 years (odds ratio, 1.00; 95% confidence interval, 0.41–2.41; P = 0.99) and door‐to‐balloon time >90 min (odds ratio, 1.78; 95% confidence interval, 0.76–4.20; P = 0.19) did not. Conclusions : Pre‐existing comorbidities characterize older patients developing STEMI. Aggressive PCI in older patients improves prognosis, and short door‐to‐balloon time is an important parameter conditioning the prognosis. © 2011 Wiley Periodicals, Inc.